Slide 1

Accurate Blood Pressure Measurement and Documentation Education for Nursing Assistants

Exercise raises BP(This includes walking to the bathroom)

The education for the nursing assistants was presented in an exaggerated, somewhat facetious cartoon style Power Point to increase retention. It was followed by a post-test to further increase retention and provide a measurable outcome compared to the pre-test. I have included some of the cartoons in this final report.

1Inspiration

http://www.zazzle.com/the_good_news_is_we_were_able_to_save_your_leg_card-137636050078193536What should we do when the leg is the only option for measuring BP?

The following clinical scenario inspired this project. An elderly, male dialysis patient could have blood pressures taken only in his lower legs. His blood pressures were regularly out of the normal range and responsive measures were taken by night physician assistants (PAs). These PAs did not know the patient nor were they told that the pressures were taken in his legs. Most of the nurses were not aware of the differences between blood pressures taken in a distal lower limb compared to the upper arm. It took two days for this to be sorted out while the patient was awakened for repeated blood pressure assessments and interventions.

2Accurate blood pressure measurement is imperative to good medical practices.Obese patients, hemodialysis patients with fistulas and those with mastectomies, create room for error by needing an alternative site rather than the gold standard of the upper arm.The ankle measurement is, on average, about 17 mmHg higher than the arm measurement, but could be as much as 33 mmHg higher (Moore, C., Dobson, A., Kinagi, M., Dillon, B., 2008, p83).The forearm measurement falsely elevated the values of blood pressure assessment in obese patients (Pierin, Alavarce, Gusmao, Halpern, & Mion, 2004).Project overview

3Although BP measurement is considered a simple task there are still many errors. False assessments may result from physical factors, such as surroundings, cuff size, arm and body position (Anderson, D., Anderson, M., and Hill, 2010)..

Project Overview cont.

Hi, I am going to take your Blood Pressure and tell you about my pet lion. No talking while assessing BP

4Project goals and objectives

Nursing assistants would be educated on proper technique of assessing blood pressures and why. Education retention will be measured by 90% of NAs passing a post test with a score of 80% or better.Errors related to the technician, equipment, or failure to standardize the technique and the circumstances of measurement can contribute to incorrect blood pressure readings (Netea, Lenders, Smits, & Thien, 2003).Improved accuracy and communication as evidenced by charting of blood pressure location. This will ensure that IV fluids, anti-hypertensive and vasopressor medications are given appropriately, septic shock is caught early and falls due to hypotension are reduced. In addition, it should reduce the unnecessary rechecking of blood pressures increasing patient satisfaction.

Human error is still a large factor in the accuracy of BP assessments. Inaccuracies from cuff size, positioning, talking and active listening are always possible with this vital task (Handler, 2009).

5Creating a culture of quality and safety

Improve the effectiveness of communication among caregivers (Joint Commission, 2014, p 2). Complete charting of the location of blood pressure improves communication .The organization identifies safety risks inherent in its patient population (Joint Commission, 2014, p 2). Patients who cannot have their blood pressure measured in the upper arm are at greater risk for medication errors and misdiagnosis.Improve recognition and response to changes in a patients condition (Joint Commission, 2014, p 2). Minimizing false blood pressure readings due to improper technique improves recognition and therefore response to high and low blood pressures.

This project has met three goals of the 2009 National patent safety goals from the joint commission.

In addition, Providing education for staff improves the system as a whole and does not look to place individual blame. This is One of The goals of quality management to improve systems processes, not to assign blame (Yoder-Wise, 2011, p 392).

694% of the NAs have completed the Power Point and post test. The average test score was 91.25%. This was in comparison to the pre-test average score of 63%.* 100% of those have agreed to chart the location of all blood pressures taken in any location other than the upper arm. On the pretest, the sample group estimated they charted location only 44% of the time. Outcomes and the educational material are being made available to the staff.Process, progress, and completion of project

* The pre-test sample group size was 53% of the total NA staff. 7

Staff being resistant to adding any task to their work load.Staff feeling resentful that they are being educated on a subject they feel they know.Finding convenient times with every NA without disrupting their work flow.Project manager doubting if this education is important enough to overcome first three obstacles.Obstacles and challenges of project

http://facstaff.gpc.edu/~jaliff/anablves.htm

Time availability problems were anticipated from the beginning. It has been awkward finding convenient times with every NA without disrupting their day and feeling like I am adding to their full work load. With that came doubt about my subject matter. The unit educator was helpful in encouraging me.

8Ethical principlesBeneficence- is compassion; taking positive action to help others (Beauchamp, 2009). Nonmaleficence- is the avoidance of harm or hurt which is of course at the heart of nursing ethics (Beauchamp, 2009).

Ethical/professional issues encounteredIssue Adding a task to busy nursing assistants.Solution Begin education with an explanation of how this is an important positive action to avoid harming patients.

The four basic principles of biomedical ethics are: respect for autonomy, beneficence, nonmaleficence and justice (Beauchamp, 2009). Although these sound like grandiose principles they come up in small ways daily and certainly in this project. This is because beneficence and nonmaleficence take extra time in a busy work day. When I approached staff with education to improve their accuracy, most were more concerned with their time constraints and resistant to adding anything to their work day. To counter that, I led with an explanation of the problem and why this put our patients at risk. This was successful for the most part because the nursing assistant staff is truly a compassionate group that wants the best care for their patients. They would never knowingly harm anyone.

9

A full bladder temporarily raises BP

http://www.shutterstock.com/pic-60565813/stock-photo-conceptual-illustration-of-a-man-need-a-pee-waiting-in-front-of-bathroom-sign.html?src=NFAAloSK-fDlA2OWmuFF3Q-1-6http://facstaff.gpc.edu/~jaliff/anablves.htmA patient hold their arm out causes a false reading.

Here two more examples from the project that can temporarily raise blood pressure.10I learned that there are many subtle differences between shifts. I should have had someone on the team who worked day shift and have been willing to delegate to them. They would have understood the daytime workflow and the staff. Collaboration is surprisingly essential. Leadership without collaboration is a dictatorship. Dictatorships do not by nature promote education, mentorship or good two way communication. Mentorship by the unit manager and educator was invaluable. When I doubted whether what I was doing was valuable or just something for school, the educator refreshed my dedication.

Lesson learned as a leader and project manager

I learned that there are many subtle differences between shifts. I realize now at the end of the project, that I should have had someone on the team who worked day shift and have been willing to delegate to them. I recognize that I am guilty of being a bit controlling. However, delegation is a critical skill needed to accomplish a good number of goalsAs an independent learner and person, I found collaboration to be surprisingly essential. Leadership without collaboration is a dictatorship. Dictatorships do not by nature promote education, mentorship or good two way communication. I also found it was reassuring to be mentored by the unit manager and educator who have done these types of projects before. In fact, it was invaluable. When I doubted whether what I was doing was valuable or just something for school, the educator was able to refresh my dedication.

11American Nurses Association, ANA (2010). Nursing scope and standards of practice. (2nd ed) Silver Spring, MD: Author.Anderson, D., Anderson, M., and Hill, P. (2010, Sept-Oct 2010). Location of blood pressure measurement. MedSurg Nursing.Retrieved from: http://0-go.galegroup.com.libcat.ferris.edu/ps/i.do?action=interpret&id=GALE|A239529706&v=2.1&u=lom_ferrissu&it=r&p=ITOF&sw=w&authCount=1Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. (6th ed., pp. 152-153). New York, NY: Oxford University Press. Handler, J., (2009). The importance of accurate blood pressure measurement. The Permanente Journal. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911816/Moore, C., Dobson, A., Kinagi, M., Dillon, B., (2008). Comparison of blood pressure measured at the arm, ankle and calf. Anesthesia, Journal of the Association of Anaesthetists of Great Britain and Ireland. doi: 10 111/j.1365-2044.2008.05633.x. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2008.05633.x/abstract;jsessionid=B1DFA8E3FCA51E3258E48B23E0704926.f01t03References

12Netea, R.T., Lenders, J., Smits, P., & Thien, T. (2003). Influence of body and arm position on blood pressure readings: An overview. Journal of Hypertension. doi: 10.1038/sj.jhh.1001573. Retrieved from: http://www.nature.com/jhh/journal/v17/n7/full/1001573a.htmlPierin, A., Alavarce, D., Gusmao, J., Halpern, A., & Mion, D., Jr. (2004). Blood pressure measurement in obese patients: Comparison between upper arm and forearm measurements. Blood Pressure Monitoring, 9(3), 101-105. Retrieved from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CDcQFjAB&url=http%3A%2F%2Fwww.researchgate.net%2Fpublication%2F8508896_Blood_pressure_measurement_in_obese_patients_comparison_between_upper_arm_and_forearm_measurements%2Ffile%2F72e7e52388a58e872a.pdf&ei=4zVdU57uBoLWyQHT84D4BA&usg=AFQjCNF4OVaUmYH0Ud9bR_NrXdHj8tiExA&sig2=inppxGYr33lYymxakMX9Eg&bvm=bv.65397613,d.aWcThe Joint Commission, (2014). 2014 National patient safety goals. Retrieved from: http://www.jointcommission.org/assets/1/6/NCC_NPSG_Chapter_2014.pdfYoder-Wise, P. S. (2011). Leading and managing in nursing. (5th ed.) St Louis, MO: Mosby

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