GPs do not always realise the effect they have on a patient’s blood pressure. The minutes before and during the taking blood pressure measurements are more important than most of us think. The patient will often want to know what their blood pressure is when they are stressed or unwell. In this case, it is wise to reassure the patient beforehand that the blood pressure may be raised due to these factors and, if so, should be repeated when they are feeling better.
The correct way to take a blood pressure measurement involves a very calm approach by the GP, reassuring the patient that the measurement will be done several times (as blood pressure readings often reduce over a few minutes as the patient relaxes). Ensure the patient has been resting for a few minutes prior to the measurement and, if possible, that the conversation has been pleasant and relaxing prior to the taking of the blood pressure. The arm on which the blood pressure is taken should be at the level of the heart during the measurement (i.e. resting on the consultation table, not hanging down or in their lap, as this raises the reading). The cuff should not be pumped up to the extent that it is painful, unless the blood pressure really is high enough to warrant this.
If the blood pressure is initially raised, ask the patient to close their eyes and imagine something that really relaxes them. It may help to get them to lie down in a quiet place and read a magazine if they are particularly anxious. If using a manual technique, pump the cuff up slowly to avoid appearing to be in a hurry. Arrange the sphygmomanometer so the patient cannot see the display or the dial as it is pumping. Reassure the patient after the first reading that things are ok, even if the patient is initially hypertensive, as this commonly relaxes them and reduces the next few readings.
Always emphasise to a patient who has high blood pressure readings that they need follow-up, and that high readings done on one particular day may not represent true hypertension. It is important to avoid worrying the patient too much, as they will be more anxious next consult. If there is genuine concern about white coat hypertension, 24-hour blood pressure monitoring may help clarify the situation. It helps to empower the patient who is hypertensive. Education about low salt diets1 and the effect of weight loss and exercise on blood pressure is important. Coffee, alcohol intake and the use of certain recreational drugs (cocaine, amphetamines) are also important factors that need consideration if the patient is hypertensive.