BLOOD PRESSURE

STEPS RATIONALE
1. Perform hand hygiene and Reduces transmission of microorganisms.
clean stethoscope earpieces and
diaphragm with alcohol swab.
2. Position patient.
a. Arm: Position patient sitting or If arm is extended and not supported,
lying; position his or her forearm patient performs isometric exercise that
at heart level (see illustration) increases diastolic pressure. Placing arm
Turn palm up. If sitting, instruct above level of heart causes false-low
patient to keep feet flat on floor reading 2 mm Hg for each inch above heart
without crossing legs. level. Leg crossing falsely increases systolic
b. Thigh: Position patient lying BP. Even in the supine position a diastolic
with thigh flat (provide support as pressure increases Bp up to 3-4 mm Hg for
needed). Have knee slightly each 5-cm (1.97-in) change in heart level.
flexed.
3. Expose extremity (arm or leg) Ensures proper cuff application. Tight
fully by removing constricting clothing causes congestion of blood and can
clothing. Cuff may be placed over falsely elevate BP readings.
shirt sleeve as long as
stethoscope rests on skin of
antecubital space (Box 30-14).
4. Palpate brachial artery (arm) or Inflating bladder directly over artery ensures
popliteal artery (leg). With cuff that proper pressure is applied during
fully deflated, apply bladder of cuff inflation. Loose-fitting cuff causes fake-high
above artery by centering arrows readings.
marked on cuff over artery. If
there are no center arrows on
cuff, estimate center of bladder
and place it over artery. Position
cuff 2.5 cm (1 inch) above site of
pulsation (antecubital or popliteal
space). Wrap cuff evenly and
snugly around extremity (see
illustrations).
5. Position manometer gauge Looking up or down at scale results in
vertically at eye level and no inaccurate readings.
farther than 1 m (approximately 1
yard) away.
6. Measure BP
a. Two-step method
(1) Relocate brachial or popliteal Estimating systolic pressure prevents fake-
pulse. Palpate artery distal to cuff low readings. Determine maximal inflation
with fingertips of nondominant point for accurate reading by palpation. If
hand while inflating cuff rapidly to unable to palpate artery because of
pressure 30 mm Hg above point weakened pulse, use an ultrasonic
at which pulse disappears. Slowly stethoscope (see Chapter 31). Completely
deflate cuff and note point when deflating cuff prevents venous congestion
pulse reappears. Deflate cuff fully and false-high readings.
and wait 30 seconds.
(2) Place stethoscope earpieces Each earpiece follows angle of ear canal to
in ears and be sure that sounds facilitate hearing.
are clear, not muffled.
(3) Relocate brachial or popliteal Proper stethoscope placement ensures best
artery and place bell or diaphragm sound reception. Stethoscope improperly
chest piece of stethoscope over it. positioned causes muffled sounds that often
Do not allow chest piece to touch result in false-low systolic and false-high
cuff or clothing (see illustration). diastolic redings.
(4) Close valve of pressure bulb Tightening valve prevents air leak during
clockwise until tight. inflation.
(5) Quickly inflate cuff to 30 mm Rapid inflation ensures accurate
Hg above palpated systolic measurement of systolic pressure.
pressure (patient's estimated
systolic pressure) (see
illustration).
(6) Slowly release pressure bulb Too-rapid or too-slow decline in pressure
valve and allow needle of causes inaccurate readings (Zheng et. al,
manometer gauge to fall at rate of 2011). Noise interferes with precise
2-3 mm Hg/sec. Make sure that assessment of sounds.
there are no extraneous sounds.
(7) Note point on manometer First sound reflects systolic BP.
when you hear first clear sound.
Sound slowly increases in
intensity.
(8) Continue to deflate cuff, noting Fourth sound involves distinct muffling of
point at which muffled or sounds and is an indicator diastolic pressure
dampened sound appears in children (Kaplan et at, 2014).
(9) Continue to deflate cuff Beginning of fifth sound is indicator of
gradually, noting point at which diastolic pressure in adults (Kaplan et ati
sound disap-pears in adults. 2014). Continuous cuff inflation causes
Listen for 10-20 mm Hg after last arterial occlusion, resulting in numbness:
sound and allow remaining air to and tingling of patient's arm.
escape quickly.
b. One-step method
(1) Place stethoscope earpieces Each earpiece follows angle of ear canal to
in ears and be sure that sounds facilitate hearing.
are clear, not muffled.
(2) Relocate brachial or popliteal Proper stethoscope placement ensures
artery and place bell or diaphragm optimal sound reception. Stethoscope
chest piece of stethoscope over it. improperly positioned causes muffled
Do not allow chest piece to touch sounds that result in false-low systolic and
cuff or clothing. false-high diastolic readings.
(3) Close valve of pressure bulb Tightening of valve prevents air leak during
clockwise until tight. inflation.

(4) Quickly inflate cuff to 30 mm Inflation above systolic level ensures

Hg above patient's usual systolic accurate measurement of systolic BP.
pressure.
(5) Slowly release pressure bulb Too-rapid or too-slow decline in pressure
valve and allow needle of causes inaccurate readings (Zheng et at
manometer gauge to fall at rate of 2011)
2 to 3 mm Hg/sec.
(6) Note point on manometer First sound reflects systolic pressure.
when you hear first clear sound.
Sound slowly increases in
intensity
(7) Continue to deflate cuff, noting In children fourth sound involves distinct
point at which muffled or muffling of sounds and indicates diastolic
dampened sound appears. presSure (Hockenberry and Wilson, 2015).
(8) While gradually deflating cuff, Beginning of last or fifth sound indicates
note point at which sound diastolic pressure in adults. Continuous cuff
disappears in adults. Listen for 10 inflation causes arterial occlusion, resulting
to 20 mm Hg after last sound and
allow remain-ing air to escape
quickly.
7. American Heart Association
recommends average of two sets
of BP measurement, 2 minutes
apart. Use second set of BP
measurements as baseline. If
readings are different by more
than 5 mm Hg, additional readings 2014)
are necessary.
8. Remove cuff from extremity
unless you need to repeat
measurement. If this is first
assessment of patient, repeat BP
assessment on other extremity.
9. Help patient return to
comfortable position and cover
upper arm if previously clothed.
10. Discuss findings with patient
as needed.
11. Perform hand hygiene. Wipe
cuff with facility-approved cleaning Reduces transmission of microorganisms.
agent if used between patients.
in numbness and tingling of patient's arm.
Two sets of BP measurements help to
prevent false-positives based on patient's
sympathetic response (alert reaction).
Averaging minimizes effect of anxiety, which
often causes first reading to be higher than
subsequent measurements (Kaplan et al.
Comparison of BP in both extremities
detects circulation problems. (Normal
difference of 5-10 mm Hg exists between
extremities.) Use arm with higher pressure
for repeated measurements (Frese et al.,
2011).
Restores comfort and promotes sense of
well-being.
Promotes participation in care and
understanding of health status.