Sphygmomanometers

 There are three types of sphygmomanometersused to measure

blood pressure: mercury, aneroid, and digital.
 Reading blood pressure by auscultation is considered the gold
standard by the Heart, Lung and Blood Institute of the NIH.

Subject
 Position: supine, seated, standing.
 In seated position, the subject's arm should be flexed.
 The flexed elbow should be at the level of the heart.
 If the subject is anxious, wait a few minutes before taking the
pressure

Procedures
 To begin blood pressure measurement, use a properly sized blood
pressure cuff. The length of the cuff's bladder should be at least
equal to 80% of the circumference of the upper arm.
 Wrap the cuff around the upper arm with the cuff's lower edge one
inch above the antecubital fossa.
 Lightly press the stethoscope's bell over the brachial artery just
below the cuff's edge. Some health care workers have difficulty
using the bell in the antecubital fossa, so we suggest using the bell
or the diaphragm to measure the blood pressure.
 Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a
moderate rate (3mm/sec).
 Listen with the stethoscope and simultaneously observe the
sphygmomanometer. The first knocking sound (Korotkoff) is the
subject's systolic pressure. When the knocking sound disappears,
that is the diastolic pressure (such as 120/80).
 Record the pressure in both arms and note the difference; also
record the subject's position (supine), which arm was used, and the
cuff size (small, standard or large adult cuff).
 If the subject's pressure is elevated, measure blood pressure two
additional times, waiting a few minutes between measurements.
 A BLOOD PRESSURE OF 180/120mmHg OR MORE REQUIRES
IMMEDIATE ATTENTION!
Precautions
 Aneroid and digital manometers may require periodic calibration.
 Use a larger cuff on obese or heavily muscled subjects.
 Use a smaller cuff for pediatric patients.
 For pediatric patients a lower blood pressure may indicate the
presence of hypertension.
 Don't place the cuff over clothing.
 Flex and support the subject's arm.
 In some patients the Korotkoff sounds disappear as the systolic
pressure is bled down. After an interval, the Korotkoff sounds
reappear. This interval is referred to as the "auscultatory gap." This
pathophysiologic occurrence can lead to a marked under-estimation
of systolic pressure if the cuff pressure is not elevated enough. It is
for this reason that the rapid inflation of the blood pressure cuff to
180mmHg was recommended above. The "auscultatory gap" is felt to
be associated with carotid atherosclerosis and a decrease in arterial
compliance in patients with increased blood pressure.

Practice
 Use our aneroid and mercury sphygmomanometers simulators to
practice your blood pressure measurement skills.
 Then take one of our courses that feature blood pressure,
auscultation, and other physical examination skills.
 For pediatric patients, the NIH provides tables which use age, sex
Blood pressure is the force of blood against the walls of the arteries. Blood pressure is
recorded as two numbers, the systolic pressure (the pressure when the heart beats)
over the diastolic pressure (the pressure when the heart relaxes between beats).
We record this with the systolic pressure first (on the top) and the diastolic
pressure second (below). For example, if the systolic pressure is 120 mmHg
(millimetres of mercury) and the diastolic pressure is 80 mmHg, we would describe
the blood pressure as ‘120 over 80’, written 120/80.
All patients must be assessed for fitness before they undergo surgery. As part of this
assessment, it important to measure and record the patient's blood pressure. There are
two reasons for this:

1. It provides an initial recording (a ‘baseline’). If the blood pressure falls

suddenly below this baseline after surgery, we are alerted to the fact that the
patient may be experiencing complications.
2. It allows us to confirm that the patient is fit enough to undergo surgery. A high
blood pressure reading, or indeed a very low blood pressure reading, could
suggest that the patient has other medical problems, e.g. an undiagnosed heart
condition. He or she may need further medical tests and possibly medication to
stabilise the blood pressure before undergoing surgery.

When measuring a patient's blood pressure, the nurse should be aware of factors that
can affect the reading and possibly give a false reading, which could lead to
unnecessary medical investigations. These factors include:

 blood pressure cuff is too small or is placed over clothing

 the patient has recently exercised
 the patient is cold or otherwise uncomfortable (e.g., they may need to use the
toilet first)
 the patient has consumed alcohol or caffeine less than 30 minutes before the
reading
 the patient is anxious or stressed
 the patient is talking during the procedure.
Figure 1. Sphygmomanometer (wall-mounted)

Figure 2. The arm is supported on a level surface. The cuff is around the upper arm and the
stethoscope is over the brachial artery, in the bend of the elbow

Blood pressure may vary according to whether the patient is lying down, sitting or
standing. It is normally recorded with the patient sitting.
You will need
 sphygmo-manometer
 blood pressure cuffs: small, medium, large
 stethoscope
 chair
 patient's care notes or observation chart
 alcohol wipe

Preparation
 Ask whether the patient needs the toilet.
 Ask the patient to sit down. The patient should have rested for 3–5 minutes
before starting the procedure.
 Wash and dry your hands.
 Explain to the patient what you are going to do. This will help reduce their
anxiety.
 Explain the sensation of the cuff tightening on their arm and reassure them that
this is safe.

Method
 Ask the patient to loosen any tight clothing or remove long-sleeved garments so
that it is possible to access the upper arm. Do not use an arm that may have a
medical problem.
 Place the cuff around the upper arm and secure.
 Connect the cuff tubing to the sphygmo-manometer tubing and secure.
 Rest the patient's arm on a surface that is level with their arm.
 Place the stethoscope over the brachial artery (in the bend of the elbow) and
listen to the pulse .
 Pump up the cuff slowly and listen for when the pulse disappears. This is an
indication to stop inflating the cuff.
 Start to deflate the cuff very slowly whilst watching the mercury level in the
sphygmomanometer.
 Note the sphygmomanometer reading (the number the mercury has reached)
when the pulse reappears: record this as the systolic pressure.
 Deflate the cuff further until the pulse disappears: record this reading as the
diastolic pressure.
 Record these two measurements, first the systolic and then the diastolic (e.g.,
120/80), in the patient's notes or chart.
 Tell the patient the blood pressure reading.
 Disinfect the stethoscope drum and ear pieces with the alcohol wipe.
 Wash and dry your hands.
 Report an extremely low or high reading to the clinically qualified person in
charge of the patient's care.