What are the guidelines for case workers to accurately monitor blood pressure in adult patients, including proper positioning, cuff size, and actions to take for hypertension (blood pressure greater than 140/90 mmHg) and hypotension (blood pressure less than 90/60 mmHg)?

Blood Pressure Monitoring Guidelines for Case Workers

Case workers must remove all clothing covering the cuff placement site and position the cuff directly on bare skin at heart level—measurements taken over clothing (including sweaters) are invalid and should never be performed. 1

Patient Preparation Protocol

Before any blood pressure measurement, case workers must ensure the following preparation steps are completed:

• Have the patient sit in a chair with feet flat on the floor and back fully supported for more than 5 minutes before taking any measurement 1
• Ensure the patient has emptied their bladder prior to measurement 1
• Verify the patient has avoided caffeine, exercise, and smoking for at least 30 minutes before the measurement 1
• Neither the case worker nor the patient should talk during the rest period or during the actual measurement 1
• Do NOT take measurements with the patient sitting or lying on an examining table—this does not meet proper positioning criteria 1

Proper Positioning and Technique

Arm Positioning (Critical)

• Support the patient's arm on a flat surface (such as a desk or table) 1
• Position the middle of the cuff on the upper arm at the level of the right atrium (the midpoint of the sternum or fourth intercostal space) 1, 2
• The arm must be at heart level regardless of body position—incorrect arm positioning can cause errors of 6-10 mmHg 1, 3, 4

Cuff Selection and Placement

• Use the correct cuff size so that the bladder encircles 80% of the arm circumference 1, 2
• Document if a larger or smaller than normal cuff size is used 1
• Place the cuff on bare skin, 2-3 cm above the antecubital fossa (elbow crease) 2
• Undercuffing (using too small a cuff) accounts for 84% of cuff selection errors and produces falsely elevated readings 2

Measurement Protocol

• Use a validated, calibrated blood pressure device and ensure periodic calibration 1
• At the first visit, measure blood pressure in both arms and use the arm with the higher reading for all subsequent measurements 1
• Take at least 2 readings separated by 1-2 minutes 1
• Average the readings to determine the patient's blood pressure level 1

Documentation Requirements

Case workers must document the following for every blood pressure measurement:

• Record both systolic and diastolic blood pressure to the nearest even number 1
• Note the time of the most recent blood pressure medication taken before measurement 1
• Provide the patient with both verbal and written blood pressure readings 1
• Document any non-standard cuff size used 2

Action Thresholds and Response Protocol

Hypertension (High Blood Pressure)

Blood Pressure ≥180/120 mmHg (Hypertensive Crisis):

• Call 911 immediately if the patient has any of the following symptoms:
  • Severe headache
  • Chest pain
  • Shortness of breath
  • Visual changes or blurred vision
  • Difficulty speaking
  • Weakness or numbness
  • Severe anxiety or confusion
  • Nosebleed that won't stop

Blood Pressure 140-179/90-119 mmHg (Stage 2 Hypertension):

• Contact the patient's healthcare provider the same day
• Recheck blood pressure after 5 minutes of continued rest to confirm the reading
• Document all readings and symptoms

Blood Pressure 130-139/80-89 mmHg (Stage 1 Hypertension):

• Notify the healthcare provider within 1-2 days
• Schedule follow-up blood pressure monitoring
• Document the reading

Hypotension (Low Blood Pressure)

Blood Pressure <90/60 mmHg with symptoms:

• Call 911 if the patient experiences:
  • Dizziness or lightheadedness
  • Fainting or near-fainting
  • Confusion or inability to concentrate
  • Blurred vision
  • Nausea
  • Cold, clammy, pale skin
  • Rapid, shallow breathing
  • Fatigue or weakness
  • Rapid or weak pulse

Blood Pressure <90/60 mmHg without symptoms:

• Contact the healthcare provider the same day
• Have the patient remain seated and monitor for symptom development
• Do not allow the patient to stand quickly

Common Symptoms to Monitor

Hypertension Warning Signs:

• Severe headache (especially occipital)
• Chest pain or pressure
• Shortness of breath
• Visual disturbances
• Nosebleeds
• Severe anxiety

Hypotension Warning Signs:

• Dizziness when standing (orthostatic hypotension)
• Lightheadedness
• Fainting or near-fainting episodes
• Confusion or difficulty concentrating
• Blurred vision
• Fatigue or weakness
• Cold, clammy skin

Critical Pitfalls to Avoid

• Never measure blood pressure over clothing—this was the error that prompted this training and produces inaccurate readings 1
• Never allow the patient's arm to hang unsupported—this can increase readings by 6-10 mmHg 1, 3, 4
• Never rush the preparation period—patients must rest quietly for more than 5 minutes 1
• Never talk during measurement—conversation can elevate blood pressure 1
• Never use a single reading to make clinical decisions—always take at least 2 readings 1
• Never measure immediately after caffeine, exercise, or smoking—wait at least 30 minutes 1

Staff Training and Competency

All case workers must:

• Complete certification in correct blood pressure measurement skills 1
• Undergo documented assessment of correct blood pressure measurement technique 1
• Follow a standardized protocol with checklists for every measurement 1