Analyzing Blood Pressure Cues
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To determine relationships among gathered cues from the blood pressure assessment, the nurse connects cues and considers the relevance of cues to the patient’s blood pressure. The following guidelines help assist the nurse in this process.
Determine Relationship Between Cues
Organize and Link Cues
Consider Relevance of Cues
Consider relevance of cues to the patient’s unique situation:
The nurse considers expected findings based upon the patient’s age, the BP measurement site, and the patient’s baseline to determine relevance.
Some BP cues can be related to medical conditions (like hemorrhage [low BP]).
The nurse reviews the medical diagnosis. If the patient has hypertension, the nurse can expect the BP to be high or even within the expected range (if BP medicine is effective).
The nurse reviews the vital signs flow sheet to determine an upward/downward trend. The nurse notices a downward trend of an adult patient’s BP (135/88, 130/83, 125/78, 119/74). The nurse intervenes and measures the oxygen saturation level, reassesses the patient’s circulatory system (not just vital signs), performs a head-to-toe assessment, reviews the patient’s medication to determine if therapeutic or side effects cause the BP to decrease, and/or notifies the health care provider.
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Blood Pressure Hypotheses with Cues
Linking cues correctly allows the nurse to develop an individualized hypothesis. Although the International Classification for Nursing Practice (ICNP) identifies diagnoses for blood pressure as Blood Pressure Within Normal Limits and Altered Blood Pressure, to classify the Altered Blood Pressure, the primary blood pressure alterations (hypertension, hypotension, and orthostatic [postural] hypotension) are the focus.
Organizing/Linking Cues
Cause
ICNP Diagnosis /Hypothesis
History of hypertension
High blood pressure readings
Can be asymptomatic
Blurred vision
Headaches
Nose bleeds
Dizziness
Facial redness
Elevated BP from thickening of arteries, which reduces compliance (elasticity);increasing peripheral resistance, causing the heart to pump harder; retaining fluid
Altered Blood Pressure
Hypertension
Low blood pressure reading
Shock
Hemorrhage
Tachycardia and tachypnea
Thready pulse
Cool, clammy skin
Confusion
Disruption in cardiovascular dynamics from hypovolemia (loss of blood and body fluids), diminished cardiac output, and/or diminished resistance in arteries
Altered Blood Pressure
Hypotension
Systolic blood pressure decreases 20 mm Hg or diastolic 10 mm Hg upon position changes
Dizziness upon position changes
Feels faint upon standing or sitting from a lying position
Taking blood pressure medication
Peripheral vasodilation with no rise in cardiac output or vasoconstriction to compensate for the vasodilation
Altered Blood Pressure
Orthostatic (postural) hypotension
Prioritizing Hypotheses
The nurse prioritizes BP hypotheses to address critical needs first. The nurse uses the following guidelines to determine priority.
Parameter
Description
Example
Life-Threatening
This is always addressed first.
Extremely high or low BP readings are life-threatening, but airway and breathing still take priority.
ABCs
Airway, breathing, and circulation take precedence in that order.
Occluded airway addressed first, then breathing issues, then BP.
Immediate Concern
Address the most urgent/immediate, most serious, or most likely first.
Hypotension is an immediate concern, but airway and breathing still take precedence.
Acute Versus Chronic
Acute takes precedence over chronic.
Hypotension (acute) takes precedence over a person with a history of hypertension (chronic).
Issues Affect Other Hypotheses
If resolved, would the issue affect other hypotheses?
Addressing orthostatic hypotension would resolve or even prevent falls.
Guidelines for Goals, Outcomes, and Solutions
After hypotheses are prioritized, the nurse considers overall goals, outcomes, and solutions.
Overall Goals
Resolve the blood pressure alteration
Return blood pressure to expected ranges
Return the patient to previous level of functioning
Example:
Patient’s blood pressure alteration resolves.
Expected Outcomes
Indicate reversal of the blood pressure alteration/hypothesis
Are written using the SMART (specific, measurable, achievable, relevant, and time-bound) method
Example:
Patient’s blood pressure will return to expected range 2 hours after treatment (timeline may vary depending upon severity of BP).
Solutions
Are guided by the hypothesis and outcomes
Follows goal/outcome development
Must consider the patient’s medical diagnosis and any cultural, spiritual, physical, mental, and emotional aspects that could cause solutions to be contraindicated or avoided
Example:
Lifestyle and dietary changes and antihypertensive medications for a patient with hypertension are possible solutions.
If the patient is pregnant and has hypertension, angiotensin-converting enzyme (ACE) inhibitors (a type of antihypertensive drug) are contraindicated and must be avoided.
Putting It into Practice
Remember
The patient is a 73-year-old male recovering from hip replacement surgery. The patient has been experiencing dizzy spells when sitting up. The nurse assesses the patient’s blood pressure lying down, and it registers 124/85 mm Hg. Then, after sitting up for 1 minute, the blood pressure is 100/70 mm Hg. Ensuring that the patient is secure, the nurse then assesses the BP a third time while standing. This BP is 98/66 mm Hg. During the interview the nurse discovers that the patient has not been eating or drinking regularly since the surgery and that he was immobile for 5 weeks before surgery. Finally, as the nurse reviews the chart, the nurse notices that the patient is taking several new medications.
Update
The patient is diagnosed with orthostatic hypotension.
Using Clinical Judgment
Analyze Cues
Which cues besides the blood pressure readings support the diagnosis of orthostatic hypotension?
It occurs more frequently in older adults (73 years old).
It may be caused by side effects from medications (taking several new medications).
Immobility and dehydration are risk/contributing factors (not eating or drinking regularly and immobile for 5 weeks).
Prioritize Hypotheses
What blood pressure condition can be ruled out as a cause for a status change?
Hypertension (the patient’s BP is decreasing, not increasing).
Generate Solutions
Which actions can you take to minimize risk and promote patient safety?
Institute fall precautions (orthostatic hypotension places the patient at risk for falls).
Remind patient to call for assistance before standing or transferring to chair or ambulating.
