Lippincott Procedures - Blood pressure assessment, adult Page 1 of 7

Blood pressure assessment, adult

Introduction
Defined as the lateral force exerted by blood on the arterial walls, blood pressure depends on the force of ventricular contractions,
arterial wall elasticity, peripheral vascular resistance, and blood volume and viscosity. Systolic, or maximum, pressure occurs during left
ventricular contraction and reflects the integrity of the heart, arteries, and arterioles. Diastolic, or minimum, pressure occurs during left
ventricular relaxation and directly indicates blood vessel resistance.

Pulse pressure, the difference between systolic and diastolic pressures, varies inversely with arterial elasticity. Rigid vessels, incapable of
distention and recoil, produce high systolic pressure and low diastolic pressure. Normally, systolic pressure exceeds diastolic pressure by
about 40 mm Hg. Narrowed pulse pressure — a difference of less than 30 mm Hg — occurs when systolic pressure falls and diastolic
pressure rises. These changes reflect reduced stroke volume, increased peripheral resistance, or both. Widened pulse pressure — a
difference of more than 50 mm Hg between systolic and diastolic pressures — occurs when systolic pressure rises and diastolic pressure
remains constant, or when systolic pressure rises and diastolic pressure falls. These changes reflect increased stroke volume, decreased
peripheral resistance, or both.

Frequent blood pressure measurement is critical after serious injury, surgery, or anesthesia and during any illness or condition that
threatens cardiovascular stability. (Frequent measurement may be performed with an automated vital signs monitor.) Regular
measurement is indicated for patients with a history of hypertension or hypotension, and annual screening is recommended for all
adults.

Blood pressure should be measured using the recommendations set by the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). Until recently, patients with hypertension were
stratified based on blood pressure readings alone. However, the JNC VII also considers the patient's individual risk factors, meaning that
those with more risk factors are treated more aggressively. (See Classification of blood pressure.)

CLASSIFICATION OF BLOOD PRESSURE

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure recommends that a person's risk factors be considered in the
treatment of hypertension. The patient with more risk factors should be treated more aggressively.

Category Systolic BP mm Hg Diastolic BP mm Hg

Normal < 120 and < 80

Prehypertension 120 to 139 or 80 to 89

Hypertension, stage 1 140 to 159 or 90 to 99

Hypertension, stage 2 > 160 or > 100

Adapted from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. NIH Publication No. 03-5231. Bethesda, Md.: National Institutes
of Health; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program,
May 2003.

Equipment
• Sphygmomanometer (aneroid or digital)
• Stethoscope
• Alcohol pad
• Automated vital signs monitor (if available)

The sphygmomanometer consists of an inflatable compression cuff linked to a manual air pump and a mercury manometer or an aneroid
gauge. The JNC VII recommends using a mercury sphygmomanometer because it is more accurate and requires calibration less
frequently than the aneroid model (note that mercury sphygmomanometers have been removed from usage at UVAHS, due to concerns
over mercury as a hazardous substance). However, a recently calibrated aneroid manometer may be used. To obtain an accurate
reading, you must rest its gauge on a level surface and view the meniscus at eye level; you can rest an aneroid gauge in any position
but must view it directly from the front.

When using a digital sphygmomanometer, the apparatus must be turned off between patients to allow reset. Follow manufacturers’
instructions for use.

Cuffs come in sizes ranging from newborn to extra-large adult. Disposable cuffs and thigh cuffs are available.

The automated vital signs monitor is a noninvasive device that measures pulse rate, systolic and diastolic pressures, and mean arterial
pressure at preset intervals. (See Using an electronic vital signs monitor.)

Preparation of Equipment

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Carefully choose a cuff of appropriate size for the patient; the bladder should encircle at least 80% of the upper arm. Cuff
width should equal approximately 40% of the mid-arm circumference. An excessively narrow cuff may cause a falsely high
pressure reading; an excessively wide one, a falsely low reading. (For information on other situations that can cause false-
high or false-low readings, see Correcting problems of blood pressure measurement . ) If you're not using your own
stethoscope, disinfect the earpieces with an alcohol pad before placing them in your ears to avoid cross-contamination.

To use an automated vital signs monitor, collect the monitor, dual air hose, and pressure cuff. Then make sure the monitor
unit is firmly positioned near the patient's bed.

POSITIONING THE BLOOD PRESSURE CUFF

Palpate the brachial artery. Position the cuff 1" (2.5 cm) above the site of pulsation, center the bladder above the artery
with the cuff fully deflated, and wrap the cuff evenly and snugly around the upper arm.

Implementation
•
• Confirm the patient's identity using two patient identifiers.
• Determine the correct size cuff (bladder covers 80% of arm and width is at least 40% of arm circumference).
• Have the patient rest for at least 5 minutes before measuring his blood pressure. Make sure he hasn't smoked or had
caffeine for at least 30 minutes.
• Tell the patient that you're going to take his blood pressure.
• The preferred position is to have the patient sit erect with the back supported during blood pressure measurement,
with both feet flat on the floor because crossing the legs may increase blood pressure. The arm should be extended at
heart level and well supported. If the artery is below heart level, a false-high reading may be obtained. Make sure the
patient is relaxed and comfortable.
• Wrap the deflated cuff snugly around the upper arm. (See Positioning the blood pressure cuff.)
• If the conventional cuff does not fit properly, see Points to Remember.
• Place the cuff so that the mark for the artery is correctly aligned.
• If necessary, connect the appropriate tube to the rubber bulb of the air pump and the other tube to the manometer.
• Locate the brachial artery by palpation. Center the bell of the stethoscope over the part of the artery where you detect
the strongest beats, and hold it in place with one hand. The bell of the stethoscope transmits low-pitched arterial
blood sounds more effectively than does the diaphragm.
• Using the thumb and index finger of your other hand, turn the thumbscrew on the rubber bulb of the air pump
clockwise to close the valve.

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• Pump up the cuff to the predetermined level. Then insert the stethoscope earpieces into your ears.

• To determine how high to pump the blood pressure cuff, first estimate the systolic blood pressure by palpation. As you
feel the radial artery with your fingers of one hand, inflate the cuff until the radial pulse disappears. Read this pressure
on the manometer and add 30 mm Hg to it. Use this sum as the target inflation to prevent discomfort from
overinflation. Deflate the cuff.

• Carefully open the valve of the air pump, and then slowly deflate the cuff — no faster than 2 to 3 mm Hg/second. While
releasing air, watch the mercury column or aneroid gauge and auscultate for the sound over the artery.

• When you hear the first beat or clear tapping sound, note the pressure on the column or gauge. This is the systolic pressure. (The
beat or tapping sound is the first of five Korotkoff sounds. The second sound resembles a murmur or swish; the third sound, crisp
tapping; the fourth sound, a soft, muffled tone; and the fifth, the last sound heard.)
• Continue to release air gradually while auscultating for the sound over the artery.
• Note the pressure where the sound disappears. This is the diastolic pressure—the fifth Korotkoff sound.
• After you hear the last Korotkoff sound, deflate the cuff slowly for at least another 10 mm Hg to ensure that no further sounds are
audible.
• Rapidly deflate the cuff. Record the pressure, wait 2 minutes, and then repeat the procedure. If the average of the readings is
greater than 5 mm Hg, take the average of two or more readings. After doing so, remove and fold the cuff, and return it to
storage.
• Document your measurements.

Points to Remember:

• Avoid taking blood pressure in the arm on the affected side of a mastectomy because it may decrease already compromised
lymphatic circulation, worsen edema, and damage the arm.

• Avoid taking blood pressure on the same arm of an arteriovenous fistula or hemodialysis shunt because blood flow through the
vascular device may be compromised.

• Standard sized cuffs will not adequately wrap around a very large arm or > 32 cm/12.6 inches. Use a longer cuff.

• Cuffs that are too wide (top to bottom) may give false readings.
• Obtaining blood pressure measurement using the thigh or wrist should only be done when it is not possible to obtain a
measurement using the upper arm.
• To obtain a thigh blood pressure, apply the appropriate-sized cuff to the thigh and auscultate the pulsations over the
popliteal artery.
• To obtain a forearm blood pressure, apply the appropriate-sized cuff to the forearm 5" (13 cm) below the elbow, and
auscultate the pulsations over the radial or ulnar artery.

EQUIPMENT

USING AN ELECTRONIC VITAL SIGNS MONITOR

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An electronic vital signs monitor allows you to track a patient's vital signs continually, without having to reapply a blood
pressure cuff each time. In addition, the patient won't need an invasive arterial line to gather similar data.

Some automated vital signs monitors are lightweight and battery-operated and can be attached to an I.V. pole for continual
monitoring, even during patient transfers. Make sure you know the capacity of the monitor's battery and plug the machine
in whenever possible to keep it charged. Regularly calibrate the monitor to ensure accurate readings.

Before using any monitor, check its accuracy. Determine the patient's pulse rate and blood pressure manually, using the
same arm you'll use for the monitor cuff. Compare your results when you get initial readings from the monitor. If the
results differ, call your supply department or the manufacturer's representative (at UVAHS, contact Clinical Engineering's
Distribution Services for pickup, 2-0937, and/or submit a repair request).

Check the manufacturer's guidelines because most automated monitoring devices are intended for serial monitoring only
and may be inaccurate for a one-time measurement.

Preparing the device

• Explain the procedure to the patient. Describe the alarm system so he won't be frightened if it's triggered.
• Make sure the power switch is off. Then plug the monitor into a properly grounded wall outlet. Secure the dual air
hose to the front of the monitor.
• Connect the pressure cuff's tubing into the other ends of the dual air hose, and tighten connections to prevent air
leaks. Keep the air hose away from the patient to avoid accidental dislodgment.
• Squeeze all air from the cuff, and wrap it loosely around the patient's arm about 1" (2.5 cm) above the antecubital
fossa. Never apply the cuff to a limb that has an I.V. line in place. Position the cuff's "artery" arrow over the palpated
brachial artery. Then secure the cuff for a snug fit.

Selecting parameters

• When you turn on the monitor, it will default to a manual mode. (In this mode, you can obtain vital signs yourself
before switching to the automatic mode.) Press the AUTO/MANUAL button to select the automatic mode. The monitor
will give you baseline data for the pulse rate, systolic and diastolic pressures, and mean arterial pressure.
• Compare your previous manual results with these baseline data. If they match, you're ready to set the alarm
parameters. Press the SELECT button to blank out all displays except systolic pressure.
• Use the HIGH and LOW limit buttons to set the specific parameters for systolic pressure. (These limits range from a
high of 240 to a low of 0.) You'll also do this three more times for mean arterial pressure, pulse rate, and diastolic
pressure. After you've set the parameters for diastolic pressure, press the SELECT button again to display all current
data. Even if you forget to do this last step, the monitor will automatically display current data 10 seconds after you
set the last parameters.

Collecting data

• You also need to program the monitor according to the desired frequency. Press the SET button until you reach the
desired time interval in minutes. If you've chosen the automatic mode, the monitor will display a default cycle time of
3 minutes. You can override the default cycle time to set the interval you prefer.
• You can obtain a set of vital signs at any time by pressing the START button. Also, pressing the CANCEL button will
stop the interval and deflate the cuff. You can retrieve stored data by pressing the PRIOR DATA button. The monitor
will display the last data obtained along with the time elapsed since then. Scrolling backward, you can retrieve data
from the previous 99 minutes.
• Make sure that the patient's vital signs are documented frequently on a vital sign assessment sheet.

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Special Considerations
• If you can't auscultate blood pressure, you may estimate systolic pressure. To do this, first palpate the brachial or radial pulse.
Then inflate the cuff until you no longer detect the pulse. Slowly deflate the cuff and, when you detect the pulse again, record the
pressure as the palpated systolic pressure.
• Palpation of systolic blood pressure also may be important to avoid underestimating blood pressure in patients with an
auscultatory gap. This gap is a loss of sound between the first and second Korotkoff sounds that may be as great as 40 mm Hg.
You may find this in patients with venous congestion or hypotension.
• If your patient is crying or anxious, delay blood pressure measurement, if possible, until the patient becomes calm to avoid falsely
elevated readings.
• Remember that malfunction in an aneroid sphygmomanometer can be identified only by checking it against a mercury manometer
of known accuracy. Be sure to check your aneroid manometer this way periodically. Malfunction in a mercury manometer is
evident in abnormal behavior of the mercury column. Don't attempt to repair either type yourself; instead, send it to the
appropriate service department.
• Measure the blood pressure of patients taking antihypertensive medications while they're in a sitting position to ensure accurate
measurements.
• Occasionally, blood pressure must be measured in both arms or with the patient in two different positions (such as lying and
standing or sitting and standing).
• When measuring blood pressure in both arms, record the two readings noting which arm and the time the reading was
obtained.
• Recording the blood pressure in different positions checks for orthostatic hypotension.

MEASURING FOR ORTHOSTATIC BLOOD PRESSURE

(see also separate UVA procedure for Orthostatic Blood Pressure)

1. Place the patient in a supine position, lying completely flat if possible.

Note – it the bed/table has adjustable height, place it in the lowest position.
Once the patient changes position do not leave him/her unattended. Be alert for signs and
symptoms of fainting and/or hypotension.
Between measurements and particularly at each change of position observe and question the
patient for:
• Dizziness
• Pallor

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• Lightheadedness
• Diaphoresis
• Syncope
2. Have the patient rest 5-10 minutes. Note any abnormal or difficult breathing and abort the
procedure if severe, address patient safety issues and notify the physician.
3. After the patient has rested, obtain blood pressure and pulse and record.
4. Assist the patient to a sitting position with feet to the side of the bed/table and dangling or
with feet on the floor.
5. Wait 2-3 minutes with the patient in the sitting position and then obtain blood pressure and
pulse from the same extremity, then record.
6. Assist the patient to a standing position. Wait 2-3 minutes and obtain blood pressure and
pulse from the same extremity.
7. Remove blood pressure cuff and assist the patient back to a sitting or lying position. Record
standing measurements.
8. Document blood pressure reading and pulse at each position, extremity used, and any signs,
symptoms or patient complaints.

Documentation
· In the patient's chart, record blood pressure as systolic over diastolic pressures, such as 120/78 mm Hg.

· Chart an auscultatory gap if present.

· Document the extremity used and the patient's position.

· Include patient teaching about lifestyle modifications, drug therapy, and follow-up care.

· Record the name of any doctor notified about blood pressure results and any orders given.

TROUBLESHOOTING

CORRECTING PROBLEMS OF BLOOD PRESSURE MEASUREMENT

REACTION AND CAUSES NURSING ACTIONS

False-high reading
Cuff too small
Cuff wrapped too loosely, reducing
its effective width
Slow cuff deflation, causing venous
congestion in the arm or leg
Tilted mercury column
Poorly timed measurement — after
patient has eaten, ambulated,
appeared anxious, or flexed arm
muscles
False-low reading
Incorrect position of arm or leg
Mercury column below eye level
Failure to notice auscultatory gap
(sound fades out for 10 to 15 mm
Hg, then returns)
Inaudible low-volume sounds
Make sure the cuff bladder length is 80% of the arm circumference and the width is
at least 40% of arm circumference (a length-to-width ratio of 2:1).
Tighten the cuff.
Never deflate the cuff more slowly than 2 mm Hg/heartbeat.
Read pressures with the mercury column vertical.
Postpone blood pressure measurement or help the patient relax before taking
pressures.
Make sure the arm or leg is level with the patient's heart.
Read the mercury column at eye level.
Estimate systolic pressure by palpation before actually measuring it. Then check this
pressure against the measured pressure.
Before reinflating the cuff, instruct the patient to raise the arm or leg to decrease
venous pressure and amplify low-volume sounds. After inflating the cuff, tell the
patient to lower the arm or leg. Then deflate the cuff and listen. If you still fail to
detect low-volume sounds, chart the palpated systolic pressure.

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Related Procedures
• Blood pressure measurement, ambulatory care
• Blood pressure measurement, neonate
• Blood pressure measurement, pediatric
• Edema assessment, home care

References
Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2006.

Eser, I. The effect of different body positions on blood pressure. Journal of Clinical Nursing 16(1):137-140, January 2007.

O'Rourke, M.F., and Seward, J.B. Central arterial pressure and arterial pressure pulse: new views entering the second century after
Korotkov. Mayo Clinical Proceedings 81(8):1057-68, August 2006.

Ostchega, Y., Prineas, R.J., Dillon, C., McDowell, M., and Carroll, M. Estimating equations and tables for adult mid-arm circumference
based on measured height and weight: data from the third National Health and Nutrition Examination Survey (NHANES III) and NHANES
1999-2000. Blood Pressure Monitoring 9 (3):123-131, June 2004.

Pickering, T.G., Hall, J.E., Appel, L.J., Falkner, B.E., Graves, J., Hill, M.N., Jones, D.W., et al. Recommendations for blood pressure
measurement in humans and experimental animals: part 1: blood pressure measurements in humans: a statement for professionals from
the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research.
Hypertension 45(1):142-161

Rushing, J. Assessing for Orthostatic Hypotension. Nursing 2006 35(1):30

Schell, K.A. Evidence-based practice: noninvasive blood pressure measurement in children. Pediatric Nursing 32(3):263-67, May-June
2006.

The Seventh Report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure. NIH Publication
No. 03-5233. Bethesda, Md.: National Institutes of Health; National Heart, Lung, and Blood Institute; National High Blood Pressure
Education Program. December 2003. Accessed August 2007 via the Web at www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

Revised: 9/2009, 4/2014

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