Section 5.2: Blood Pressure & Pain Observation

Blood Pressure & Pain Observation

Blood pressure (BP) is the force exerted by the blood against the walls of the arteries as the heart pumps it through the body. Along with vital signs like temperature and pulse, blood pressure provides critical information about a resident's cardiovascular health. Additionally, monitoring and reporting pain is an essential CNA duty. Because pain can directly affect blood pressure and overall well-being, understanding both concepts is critical for delivering safe and effective patient care.

Blood Pressure Normal and Abnormal Ranges

Blood pressure is recorded as a fraction in millimeters of mercury (mmHg). The top number is the systolic pressure, which represents the pressure in the arteries when the heart contracts (beats). The bottom number is the diastolic pressure, which represents the pressure in the arteries when the heart relaxes between beats.

• Hypertension is high blood pressure. If left untreated, it can lead to stroke, heart attack, or kidney damage.
• Hypotension is low blood pressure. It can cause dizziness, lightheadedness, and fainting (syncope), increasing a resident's risk of falls.
• Orthostatic Hypotension is a sudden drop in blood pressure that occurs when a resident stands up too quickly from a sitting or lying position. To prevent this, have the resident dangle their legs over the side of the bed for a few minutes before standing.

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Blood Pressure Equipment and Measuring Technique

Measuring blood pressure requires two main pieces of equipment: a sphygmomanometer (blood pressure cuff) and a stethoscope.

Cuff Size and Placement

Using the correct cuff size is essential for an accurate reading. If the cuff is too small, the blood pressure reading will be falsely high. If the cuff is too large, the reading will be falsely low. The cuff bladder should encircle at least 80% of the resident's upper arm.

To measure blood pressure, follow these steps:

1. Have the resident sit or lie down comfortably. Ensure their arm is supported at heart level, with the palm facing up.
2. Expose the upper arm. Do not roll up a tight sleeve, as this can act as a tourniquet and cause an inaccurate reading.
3. Locate the brachial artery on the inside of the elbow (antecubital fossa).
4. Place the cuff smoothly around the upper arm, about 1 inch above the antecubital fossa. Align the arrow on the cuff with the brachial artery.

Inflating and Deflating the Cuff

There are two primary methods for determining how high to inflate the cuff: the one-step method and the two-step method.

• Two-Step Method (Standard for Clinical Exams): Locate the radial pulse while inflating the cuff. Note the point where the pulse disappears. Inflate the cuff 30 mmHg beyond this point. Release the air, wait 30 seconds, then place the stethoscope over the brachial artery and inflate again to that target level to take the reading.
• One-Step Method (Common in Practice): If the resident's baseline blood pressure is known, place the stethoscope over the brachial artery and inflate the cuff to 160 mmHg to 180 mmHg (or 30 mmHg above their typical systolic pressure).
• Deflation Technique: Open the valve slowly to deflate the cuff at a steady rate of 2 to 3 mmHg per second.
  • The first sound you hear is the systolic pressure.
  • The point where the sound completely disappears is the diastolic pressure.
  • Deflate the cuff fully, remove it, and record the reading immediately.

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Pain Observation: Subjective vs. Objective Signs

Pain is often called the "fifth vital sign." Although CNAs do not prescribe pain medication, they are responsible for observing, measuring, and reporting a resident's pain to the nurse.

Subjective Signs of Pain

Pain is entirely subjective, meaning it is whatever the resident says it is. You cannot measure pain with a machine, so you must rely on the resident's self-report.

• Subjective reporting includes statements made by the resident, such as "My lower back is throbbing," "It hurts when I breathe," or "I feel a sharp pain in my foot."
• When a resident reports pain, ask them to describe the location, intensity, and quality of the pain. Use the facility-approved Numeric Rating Scale (0 to 10), where 0 is no pain and 10 is the worst possible pain.
• For residents with cognitive impairment (such as advanced dementia) or language barriers, use the Wong-Baker FACES Pain Rating Scale, which uses a series of faces ranging from happy (no hurt) to crying (hurts worst).

Objective Signs of Pain

Many residents, particularly those with dementia or communication deficits, cannot verbally report their pain. In these cases, you must look for objective signs, which are observable and measurable indicators of discomfort.

• Facial expressions: Grimacing, frowning, clenching the jaw, or closing the eyes tightly.

• Body movements: Guarding or protecting a painful body part, bracing, rocking, or pacing.

• Vocalizations: Moaning, groaning, crying, whimpering, or calling out.

• Physiological changes: Elevated blood pressure, increased heart rate, rapid breathing, and sweating (diaphoresis).

• Behavioral changes: Increased agitation, restlessness, withdrawal, or refusing to participate in care.

• Clinical Scenario: Mrs. Miller has moderate Alzheimer's disease and is unable to tell you if she is in pain. While assisting her with morning care, you notice she grimaces and moans when you gently move her left arm, and her heart rate is elevated to 94 bpm (compared to her usual 72 bpm).

• CNA Action: These are objective signs of pain. You must document these observations and report them to the charge nurse immediately so the nurse can assess Mrs. Miller and administer pain medication if appropriate.