Accurate Blood P ressure M easurement and Documentation E ducation for Nursing Assistants

1. Accurate Blood Pressure Measurement and Documentation Education for Nursing Assistants Exercise raises BP(This includes walking to the bathroom)

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

3. Project overview • Accurate 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).

4. Project Overview cont. • Although 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). • . Hi, I am going to take your Blood Pressure and tell you about my pet lion………. No talking while assessing BP

5. Project 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.

6. Creating 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 patient’s 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.

7. Process, progress, and completion of project • 94% 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.

8. Obstacles and challenges of project • 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. http://facstaff.gpc.edu/~jaliff/anablves.htm

9. Ethical principles • Beneficence- 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/professionalissuesencountered • Issue – 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.

10. A full bladder temporarily raises BP A patient hold their arm out causes a false reading. http://facstaff.gpc.edu/~jaliff/anablves.htm 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-1-6

11. Lesson learned as a leader and project manager • I 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.

12. References • American 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=1 • Beauchamp, 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.f01t03

13. References • Netea, 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.html • Pierin, 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.aWc • The Joint Commission, (2014). 2014 National patient safety goals. Retrieved from: http://www.jointcommission.org/assets/1/6/NCC_NPSG_Chapter_2014.pdf • Yoder-Wise, P. S. (2011). Leading and managing in nursing. (5th ed.) St Louis, MO: Mosby