BLOOD PRESSURE MEASUREMENT

DOCUMENT TYPE: PROCEDURESite Applicability

Applicable for use in the Neonatal Intensive Care Unit at BC Women’s Hospital.

Purpose Non-invasive blood pressure (BP) measurement is an essential component of neonatal physical assessment. Correct technique for measuring BP is necessary to ensure accuracy or readings, while enduring minimal discomfort to the patient.

Equipment & SuppliesFor Oscillometric or non-invasive measurement of Arterial Blood Pressure: Cardio-respiratory monitor with blood pressure measurement module Blood pressure cuff of appropriate size Blood pressure cable

ProcedureNon-Invasive Blood Pressure is measured using the oscillometric (electronic) method.

STEPS RATIONALE1. DETERMINE frequencv of measuring Blood Pressure

(BP) based on:a. Prescriber’s orderb. Unit standardc. Nurse’s Clinical judgmentd. As required for a particular procedure or

medication

Blood Pressure values are a basis for diagnostic and therapeutic decisions and BP evaluation is included as part of a complete physical assessment.

The optimal time to obtain blood pressure measurement is 1.5 hours after a feed or medical intervention.

2. PERFORM hand hygiene Routine infection control practices; reduces transmission of microorganisms.

3. IDENTIFY infant and PREPARE infant for BP measurement

Ensures identification mechanism is present to prevent treatments, medications, and procedures to wrong infant.Optimize environmental factors that influence BP such as room temperature, light levels & room noise.

4. DETERMINE which site will be used to measure BP (assess skin integrity of the site chosen prior to cuff application): Arm Calf

The Right upper arm is the site of choice for BP measurement in neonates/infantsTaking BP on an arm with compromised peripheral circulation, intra-arterial catheters, intravenous catheters or peripherally inserted central catheters should be avoided.

5. SELECT appropriate sized cuff: A too small cuff will give significantly higher readings; a too large cuff will give significantly lower readings.Measure the circumference of the arm or calf. Choose the appropriate cuff size based on the manufacturer’s recommendations.

Measurements are performed during routine care to minimize the impact on the infants’ resting and sleeping periods.

C-06-12-60347 Published Date: 11-Sept-2019Page 1 of 4 Review Date: 11-Sept-2021

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BLOOD PRESSURE MEASUREMENT

DOCUMENT TYPE: PROCEDURE6. POSITION infant Infant can be prone or supine.7. APPLY cuff and wrap it smoothly and snugly around

the arm Arm: align the middle of the cuff, indicated by

the manufacturer’s marker over the palpated brachial artery.

Calf: position the middle of the cuff, indicated by the manufacturer’s marker over the palpated posterior tibial or dorsalis pedis artery.

8. LEAVE infant undisturbed for 15 minutes after cuff placement

Measurements obtained are more representative of a true resting blood pressure.

9. CONNECT cuff to BP monitor tubing Ensure tubing is free of kinks Ensure monitor is in neonate mode Ensure infant is in quiet awake state or asleep Contain infant’s limb to reduce artifact Press start to obtain reading

Selecting the correct mode (neonate) prevents unnecessarily high inflation of the cuff.

10.If there is a concern about the BP, repeat the readings 3 times at 2 minute intervals and document the most accurate measurement

BP can vary based on the neonate’s activity during the procedure. Ensure they are settled. In an otherwise well baby, treatment should not be based on BP alone.

11.If a 4 limb BP is required, repeat for remaining limbs and document.

4 limb BP can assist in a comprehensive assessment including coarctation of the aorta or related aortic abnormalities.Compare:Upper and lower limb results Systolic BP in legs may be slightly higher than

systolic BP in the arms, mean BP should be the same.

Systolic preductal (right arm) BP of >/= 15mmHg above lower limb BP is abnormal

Upper limb results A difference in >/= 10mmHg in systolic BP

between upper limbs is abnormal.

NOTE: it is rare to find a difference in 4 limb BP without palpable differences in pulses. If 4 limb BP is abnormal, repeat pulse check of bilateral brachial and femoral pulses for normal, decreased or increased amplitude.

Upper and Lower pulses: Markedly decreased lower limb pulses compared

to upper limb can indicate coarctation.12.REMOVE BP cuff unless frequent monitoring or repeat

reading is required.13.NOTIFY most responsible provider of unexpected or

abnormal readingsC-06-12-60347 Published Date: 11-Sept-2019Page 2 of 4 Review Date: 11-Sept-2021

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

BLOOD PRESSURE MEASUREMENT

DOCUMENT TYPE: PROCEDUREDocumentation

RECORD BP measurement on patient care flowsheet and other documents as appropriate indicating:a) Date and timeb) Systolic/Diastolic and mean blood pressure readingsc) Limb usedd) Infant positione) Infant’s response

ReferencesElsevier Clinical Skills: Blood Pressure Measurement (Pediartic). Retrieved on July 31 from HYPERLINK "http://point-of-

care.elsevierperformancemanager.com/skills/798/quick-sheet?skillId=CCP_061"http://point-of-care.elsevierperformancemanager.com/skills/798/quick-sheet?skillId=CCP_061

Konig, K., Casalaz, D., Burke, E., & Watkins, A. (2012). Accuracy of non-invasive blood pressure monitoring in very preterm infants. Intensive Care Med, 38:670-676.

MacDonald, M., Ramasethu, J., & Rais-Bahrami, K. (2012). Atlas of Procedures in Neonatology, (5th Ed.) Philadelphia; Lippincott, Williams & Wilkens.

Nwankwo, M., Lorenz, J.& Gardiner, J. (1997). A Standard Protocol for Blood Pressure Measurement in the Newborn. Pediatrics, 99 (6).

Developed ByBCW Neonatal Program – Registered Nurse

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN14-Aug-2019 C-06-12-60347 Blood Pressure Measurement Approved at: Neonatal Leadership

Committee

DisclaimerThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.  This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

C-06-12-60347 Published Date: 11-Sept-2019Page 3 of 4 Review Date: 11-Sept-2021

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

BLOOD PRESSURE MEASUREMENT

DOCUMENT TYPE: PROCEDURE

C-06-12-60347 Published Date: 11-Sept-2019Page 4 of 4 Review Date: 11-Sept-2021

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.