Practice Nurse

Routine Tests Part 3

Routine tests and monitoring are key to the day-to-day work of practice nurses and intrinsic to the management of long-term conditions, health screening and promotion, and the management of minor illnesses and injuries. It is therefore important that nurses maintain their practical and clinical skills to the highest standards.

This resource, consisting of five assessment questions at basic level, tests your knowledge of the theory of, and best practice when taking a blood pressure and recording an electrocardiogram (ECG). Complete the resource, including reading the featured articles and undertaking some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.


On completion of this resource, you should be able to:

Understand the importance of the correct selection and use of devices

Appreciate the importance of maintaining equipment appropriately

Understand the importance of patient information and consent

Appreciate the need for ensuring appropriate delegation

Nursing and Midwifery Council. The Code; 2015 (updated 2018). 

Practice Nurse bite-sized learning: Understanding hypertension

Practice Nurse bite-sized learning: Understanding resistant hypertension

On completion of this resource, you should be able to:

Code of professional conduct: standards for conduct, performance and ethics

 Diane Baylis, Medical Protection Society

Overcoming white coat hypertension with ambulatory blood pressure monitoring

Mary, aged 56 and an infrequent attender at the surgery, has come for holiday vaccinations. You notice that she has not had her blood pressure recorded for over 5 years, so you take the opportunity to record it. Which of the following statements about blood pressure (BP) is correct?

Which of the following statements is correct?

Blood pressure (BP) is the force exerted by the blood on the arterial walls, as the blood travels from the heart, via the arteries, to the small blood vessels in the peripheral circulation. The systolic (top) recording is when the pressure of blood in the arteries is at its highest and the diastolic at its lowest.

If you were trying to squirt a liquid from a syringe into a tube, the pressure in the tube would be affected both by the amount of liquid you were trying to eject and the force you were using to drive the syringe, together with the size of the tube it was being forced into. Likewise, the pressure of the blood going round the circulation (measured in the large arteries) is governed by the amount of blood pumped out of the heart with each beat and the strength of heart contraction (cardiac output), together with the difficulty of pushing blood into the smallest vessels (peripheral vascular resistance). BP increases when cardiac output increases and/or peripheral vascular resistance increases. There are a number of mechanisms that affect cardiac output and peripheral vascular resistance, and thereby interact to control blood pressure.

BP may be used as an indicator of risk for other diseases such as cardiovascular disease (CVD) or used to assess the severity of a patient’s condition, as in hypovolaemic shock.

A patient with a persistently raised BP (hypertension) is at much greater risk of CVD especially when this is combined with other lifestyle risk factors and/or multiple diseases; hence it is important to monitor BP, either to make an initial diagnosis or to monitor the effect of any medication. The NICE clinical guideline on hypertension (CG127) sets out guidance on the regularity of monitoring and optimal target levels.

 also recommends that a diagnosis of hypertension is based on ambulatory or home BP measurement, and not solely on the basis of clinic measurements, as many patients have artificially high BP in the surgery (white coat hypertension).

1.Kaplan NM. Kaplan’s clinical hypertension (9th edition). Lippincott Williams and Wilkins, Phildelphia, USA; 2006

2. Beevers G, Lip GYH, O’Brien E (2001). ABC of hypertension. The pathophysiologyof hypertension. BMJ 2001;322:912-6

http://publications.nice.org.uk/hypertension-cg127

Back to basics: assessing cardiovascular risk

Access and read the following link with Blood Pressure information for patients from the British Heart Foundation. Think about how you might use this with your patients.

https://www.bhf.org.uk/informationsupport/risk-factors/high-blood-pressure

Question 1

The healthcare assistant at your surgery reports that she has accidentally dropped a sphygmomanometer, a non-invasive blood pressure (NIBP) aneroid gauge device, on the floor. There is no obvious damage and the machine seems to be functioning as usual. She asks if she may continue to use the machine. She also mentions that she has heard that mercury sphygmomanometers are the best device for measuring and does not understand why there is not one available at the surgery. She is keen to know more about the accuracy of blood pressure recording.

While mercury sphygmomanometers are considered the gold standard for measuring blood pressure environmental concerns about mercury have resulted in subsequent restrictions on their use. Non-invasive blood pressure (NIBP) aneroid gauge or electronic pressure transducer devices are more commonly used.

All devices for measuring blood pressure must be properly validated, maintained and regularly recalibrated according to the manufacturer's instructions.

 However, many manometers fall short of EU guidelines of being accurate to within 3 mmHg. In a study of blood pressure equipment in GP practices in Southwark and Lewisham, 20% of manometers were not accurate to within 3 mmHg. Over half the aneroid sphygmomanometers tested were inaccurate by over 20 mmHg. The investigators pointed out that it is easy for devices to become inaccurate if they are dropped or damaged but staff and patients are not aware of this so individuals could be treated on the basis of inaccurate readings.

All machines differ and it is important to be familiar with the devices you will be using. To reduce the possibility of inaccuracy devices should be calibrated regularly, according to the manufacturer’s instructions.

1. MHRA. Blood pressure measurement devices, 2013 

https://www.gov.uk/government/publications/blood-pressure-measurement-devices

2. NICE NG136. Hypertension: diagnosis and management; 2019 (updated 2023) 

3. Shuttleworth A. Under pressure. Nursing Times 2005;101(42):16-18

The changing role of the healthcare assistant

What devices do you use at your place of work for measuring blood pressure? When were they last calibrated? Where is this information recorded?

Question 2

Mary, aged 56, who has come in for travel immunisations and whose blood pressure has not been recorded for over 5 years, has a Body Mass Index (BMI) of 33.5kg/m

 and it is apparent that her upper arms are big. However, having decided to fit in a BP check before providing her with the immunisations she requested, you are already running short of time. Which of the following statements is correct?

It is very important to ensure the cuff used is of an appropriate size, as wrongly sized cuffs can result in inaccurate measurement, which in turn may result in high blood pressure that is missed, or a false low reading..

The recommended blood pressure cuff sizes are as follows:

Arm circumference less than 23cm: small adult cuff size

Arm circumference 23cm to 33cm: standard adult cuff size

Arm circumference 33cm to 50cm: large adult cuff size

In Sue’s case, it would be wise to measure her arm before selecting the appropriate sized cuff in order to ensure an accurate reading.

NICE NG136. Hypertension: diagnosis and management; 2019 (updated 2023). 

Fonseca-Reyes S, de Alba-Garcia JG, Parra-Carrillo JZ, et al. Effect of standard cuff on blood pressure readings in patients with obese arms. How frequent are arms of a 'large circumference'? Blood Pressure Monitoring 2003;8:101-6

Investigate the cuffs that you have available in your practice. Does each consulting room have all the above cuff sizes available?

Question 3

The doctor has requested that you carry out an Electrocardiogram (ECG) recording on a 72-year-old gentleman who has been found to have an irregular pulse. The patient does not immediately respond to your instructions to undress and lie down.

Patients may not be aware that the procedure will involve some undressing and it is important that the process and procedure are fully explained, with the opportunity for them to ask any questions, and that their privacy and dignity are protected. The patient should be in a recumbent position that allows access to their chest, legs and arms so the electrodes can be placed accurately. Electrodes placement should be as per the Society for Cardiological Science and Technology recommendations.

 On occasion, it may be appropriate to deviate from the standard placements. Should this be the case, it should be recorded on the ECG.

For accurate recording electrodes must have a good contact with the skin. Greasy body lotions, creams or perspiration, together with excess body hair can affect adhesion, and whenever possible, should be removed before the procedure. If you cannot part the hair effectively then you may need to shave the local area. You can only do this with your patient’s consent. Carrying out a procedure without informing the patient what you are going to do, and why, and without first gaining their consent could be deemed in law as assault.

 Once the leads have been placed, ensure the patient is relaxed and quiet, as any movements together with external electrical interference can affect the clarity of the tracing making interpretation more difficult.

The ECG should be labelled with the patient’s details including the date and time the recording was taken together with any supporting information that may be relevant to why it was being undertaken.

1. The Society for Cardiological Science and Technology. Recording and reporting a 12 lead electrocardiogram; 2024 

https://scst.org.uk/revised-standards-recording-and-reporting-12-lead-electrocardiograms/

Bayliss,D. Medico-legal issues: Gaining consent

You can see how to perform an ECG by accessing the following link:

https://www.youtube.com/watch?v=y_P_0ggH4dE&feature=related

Question 4

The healthcare assistant at your surgery has been trained and assessed for competency in undertaking ECGs and she has been given the practice protocol to read through. On a busy morning the doctor has requested you to record an ECG on one of your patients. You delegate the task to your healthcare assistant. You then find out that she not only recorded the ECG but also informed the patient of the automated interpretation of the ECG data. Do you?

Most ECG machines nowadays provide an automated interpretation of the ECG data. While these programs are accurate for providing heart rate and conduction interval information, they tend to over-report abnormalities. It is important that there are have robust systems in place within the practice to facilitate accurate interpretation of ECGs.

Healthcare assistants provide a valuable service in primary care and undertake a variety of clinical skills. It is, however, imperative that their competence be assessed against evidence based protocols. Asking them to read through a protocol is not enough, their understanding of the protocol in practice needs to be established.

Healthcare assistants are not regulated by a professional body such as the Nursing and Midwifery Council (NMC). While they are accountable for their own actions, they should only undertake tasks for which they have been trained and assessed.

When a task is delegated, for example by a Registered Nurse, then it is the responsibility of the delegator to ensure that the principles of delegation are adhered to.

Protocols should also be regularly reviewed and updated.

1. Nursing & Midwifery Council. Delegation and accountability.

https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/delegation-and-accountability-supplementary-information-to-the-nmc-code.pdf

Read through the protocol for ECG recording and interpretation at your practice. When was this last updated?

Routine Tests Part 3

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