A registered nurse (RN), licensed practical nurse (LPN), or unlicensed assistive personnel (UAP) may measure blood pressure (BP). When the BP is taken by the UAP, any variance from previous measures is reported to the licensed caregiver.
BP is measured initially to obtain baseline data to assess general hemodynamic status of each child within the first hour of admission to an acute care setting.
BP is measured to assess response to treatment regimes.
During acute illness, measure BP every 4 to 8 hours or more frequently as clinically indicated.
In neonates, measure BP if renal disease or coarctation of the aorta is suspected or if clinical signs of hypotension are present. Universal screening of neonates is not recommended. Wide variability exists in BP between limbs. Suspicion of coarctation must be followed up with echocardiography.
Do not routinely measure BP in children with osteogenesis imperfecta due to high risk of fractures; measure BP only with a direct order from healthcare prescriber.
For health maintenance, BP should be measured:
When a child older than 3 years of age is seen in a healthcare setting
In a child younger than 3 years of age with history of neonatal condition requiring intensive care; symptoms of hypertension, hypotension, elevated intracranial pressure, recurrent urinary tract infections, and renal or cardiac disease; malignancy or transplant (solid organ, bone marrow); and treatment with medications known to affect BP
Auscultation is the preferred method of measuring BP in children because frequent calibration of automated devices is required and there is a lack of established reference standards for children. Automated devices are acceptable when auscultation is difficult (e.g., in young children) or when frequent measurements are required.
Use the right arm whenever possible for consistency of measurement and comparison with standard norms.
Mercury-gravity or aneroid sphygmomanometer
Automated device that uses oscillometric or Doppler technique
Appropriately sized BP cuff
Assess for signs of hypotension, including weak pulse, diaphoresis, pallor, and dizziness.
Assess for signs of hypertension, including headache, bounding pulse, and flushing.
Explain to the child and family why monitoring is important, how it is done, and equipment used. Use language that is appropriate for developmental level (e.g., “I’m going to see how your heart is working. You will feel like your arm is getting a hug.”).
In nonemergent situations:
Show child equipment and let child handle equipment.
Demonstrate on family member, other staff, or stuffed animal how procedure is done and how equipment is used, as age appropriate.
Measure BP after 5 minutes of rest, when possible, to ensure the most accurate reading because agitation may falsely elevate the results. Position child’s arm (extremity) at heart level during the rest; a level below the heart may cause false high readings, a level above the heart may cause false low readings.