In this assignment I have chosen to discuss a manual blood pressure a clinical skill in which I have become competent in practising. Developing the ability to perform a practical skill safely is necessary for all nursing students (Nursing and Midwifery Council NMC 2008). I will reflect on this skill using a reflective model I will be using the Gibbs model (1998) which consists of five elements description, feelings, evaluation, analysis conclusion and a action plan.
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I have chosen this skill as in all the clinical placements I have been placed in blood pressure monitoring has always been used but the electronic method preferred. While observing other healthcare professionals performing this skill I have encountered different standards and conflicting evidence. Having both the skills and the knowledge of how to take a manual blood pressure is essential for patient safety (NMC 2008). Achieving competence in this area has become more difficult since the introduction of the electronic BP monitors. I have researched the topic of blood pressure monitoring to give myself a greater knowledge.
The patient was an 86 year old gentleman with hypertension (see Profile). High blood pressure is a very common condition in modern society if left undetected can lead to life threatening conditions (British Hypertension Society BHS 2009). It is estimated that 6.5% of patients have been wrongly diagnosed as hypersensitive having their blood pressure taken using an electronic method (Coe and Houghton 2002). Having the skill of taking a manual blood pressure is important for patient’s safety and health.
Description
I was asked by my mentor while in clinical placement to perform a manual blood pressure. The electronic method that was usually used was faulty and an accurate reading could not be obtained. As a student nurse I had been taught the skill in university and practiced on fellow students but not had much opportunity to perform the skill on placement. Following a discussion with my mentor I collected the equipment to make sure it was all available and in working order. I returned to the patient and asked if I could carry out the procedure and washed my hands before starting.
I then assessed the position of the patient to make sure I had access and that he had no restricting clothing on and that he was in a comfortable position. Placing a pillow under his elbow I placed a medium sized blood pressure cuff on the upper arm of the patient. The cuff was centred using the arrow on the cuff over the brachial artery. I then located the brachial pulse and placed my fingers over the pulse. Making sure the valve of the bladder was closed I inflated the blood pressure cuff until I could no longer feel the pulse, this is the estimated systolic pressure I then deflated the cuff.
Leaving for a few seconds before continuing I located the brachial pulse again and placed the diaphragm of the stethoscope over this point. I inflated the cuff again to the estimated systolic I have previously gained adding 30mmhg.
When reaching this point I began to deflate the cuff slowly and listen for the first beat or korotoff sounds. This would give me the systolic pressure and then continued to listen for the last beat which is the diastolic pressure. The last beat was very hard to listen for as the patient in the next bed began to cough so had to inflate the cuff again and listen until I could confirm the reading. After finishing the procedure I left the patient comfortable and went to clean the equipment, to document and report the result to my mentor.
After performing the skill on the patient my mentor asked me to perform the skill on her to give me more practice after explaining to her I had not had much experience. While doing this she advised me on tips that would help me improve practice. She suggested that if the area was noisy that I could watch for a slight flicker on the needle of the sphygmomanometer to identify the first and last beat. Another tip was that I could use the radial artery instead of the brachial artery. My mentor also mentioned to make sure that the patient did not have their legs crossed.
Feelings
After this procedure I felt that I had performed the skill well even though I had not had a lot of practice performing the skill. Being asked to do the manual blood pressure I initially had reservation at whether I was competent at the procedure but think this was just lack of confidence. On reflection I would have had more confidence in myself if I had more opportunity to practice the skill in clinical practice.
Evaluation
A positive outcome is that I now feel more confident to perform the skill of taking a manual blood pressure accurately. Having performed the skill on my mentor after performing on the patient and being given tips that would improve my practice has given me the confidence to perform the skill. I also now have a better knowledge of the evidence based practice of taking a manual blood pressure after reading about the subject and the importance of accurately measuring the blood pressure. This includes different factor that can affect blood pressure and prevent from obtaining an accurate reading. However the negative of the situation is the manual blood pressure monitoring is not widely used in some clinical areas and they are heavily reliant on the electronic method.
Analysis
My mentor asked me to perform the manual blood pressure because the electronic method was not obtaining a reading. Discussing the procedure before with her gave me confidence to perform the skill, and the importance of being able to perform the skill accurately. Having a holistic approach this is one of the skills of looking at the whole patients and not just certain aspects. Being a holistic nurse is having the knowledge and theories behind the skill. Having the evidence based practice knowing what can affect the blood pressure and taking these factors into consideration.
Collecting the equipment before starting the procedure making sure that it is all in working order before hand helps make sure that you are going to obtain a correct reading. Assessing the environment before starting the procedure doing a risk assessment making sure you have adequate access to the patient will help to improve practice.
Gaining consent from the patient before beginning the procedure is following the nursing and midwifery code (2008). Gaining consent from a patient must be done before any clinical procedure is commenced and patients have the right to refuse treatment or care and a nurse must respect the wishes of the patient. Gaining consent helps to ensure the patient understands the procedure that is being performed.
Washing hands before a procedure using the ayliffe technique encourages good practice (World Health Organisation 2002). Using evidence based research it has been discovered that cross infection between patients has reduced with the introduction of the wash your hands campaign (NSPA 2008).
Making sure that the patient does not have any restrictive clothing on the arms and that the arm is supported at heart level. Evidence has show that blood pressure can be 10 — 12 mmhg higher when the blood pressure is taken with the arm dangling giving a false high reading (Mallett & Dougherty 2008).
Using the correct size cuff is very important as using the incorrect cuff can give a false reading (Perry & Potter 2007). Making sure the cuff fits snugly on the upper arm covering about 80% of the arm (BHS 2009). Using the arrow on the cuff help to centre the cuff in the correct place and help to locate the brachial artery which is situated in the crook of the arm. Covering only 80% of the arm also gives enough access to use the stethoscope not doing this may result in the sounds not being able to be heard adequately.
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Locating the brachial pulse and feeling for until it disappears this is the estimated systolic and adding 30mmhg to the pressure when inflated (Baillie 2005) this is so unnecessary pressure is not added to the arm while the skill is being performed. Using the radial artery instead of the brachial artery does give better access and I have found that it is easier to find on most patients.
Using the tips given to me by my mentor I know feel that I have the knowledge to accurately perform a manual blood pressure. Gain supporting evidence from The Royal Marsden Manual (Mallett & Dougherty 2008) and other sources has helped me to improve my practice which has given me more confidence to perform this skill with accuracy and competence.
Conclusion
I am pleased that I was given the opportunity by my mentor to improve my practice in performing the skill of taking a manual blood pressure. I am now more confident in performing the skill and can understand the importance of providing an accurate reading.
The measuring of a manual blood pressure is an important skill and the evidence based practice is also a vital part of the procedure. When checking a blood pressure the most accurate method to use is a manual blood pressure (National Institute for Health and Clinical Excellence NICE 2004)
Action Plan
I am going to take every opportunity where possible to perform manual blood pressure monitoring as I feel that I am confident and competent enough to do so. Having this skill means that if electronic medical devices fail that I have the ability to carry on with my duties and will not affect patient care. The knowledge that I have gained from my mentor about the tips on performing a manual blood pressure I can pass on to my fellow students and other health care professionals and they can also improve their knowledge and performance on taking a manual blood pressure. In doing this I can hopefully improve patient care and make the care more individual to the patent.
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