18
SKILL 4 Blood Pressure
EQUIPMENT
Stethoscope and manual blood pressure cuff or
Electronic blood pressure machine
CUFF SIZE
The American Heart Association recommends:
1. Width: 40–50% of limb circumference.
2. Length: Bladder of cuff needs to completely or nearly
completely encircle the arm without overlapping.
SAFETY
1. Do not take a blood pressure (BP) on an injured or
painful extremity or one where there is an intravenous
line (IV). Cuff inflation can temporarily interrupt blood
flow and compromise circulation in an extremity already
impaired or a vein receiving IV fluids.
GENERAL GUIDELINES FOR VITAL SIGNS
1. Check record for baseline and factors (age, illness, med-
ications, etc.) influencing vital signs. Provides parame-
ters and helps in device and site selection.
2. Gather equipment, including paper and pen, for record-
ing vital signs. Promotes organization and efficiency.
3. Wash hands. Reduces transmission of microorganisms.
4. Prepare child and family in a quiet and nonthreatening
manner. Enhances cooperation and participation;
reduces anxiety and fear, which can affect readings.
NOTE: Infants and young children may be quiet and
more cooperative if vitals signs are obtained while
child is sitting on caregiver’s lap.
BLOOD PRESSURE,
AUSCULTATION OR PALPATION
PROCEDURE
1. Steps 1–4 of General Guidelines.
2. Cleanse ear pieces and bell/diaphragm of stethoscope
with an alcohol wipe. Reduces transmission of microor-
ganisms from practitioner to practitioner and from
client to client.
3. Position child.
a. Arm: Sitting or recumbent position with forearm
supinated and slightly flexed and supported at heart
level. If arm is below level of heart, BP reading is
higher than normal; if it is above the level of the
heart, BP reading is lower than normal.
Copyright © 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. All rights reserved.
b. Leg: Prone or if unable to lie prone, supine with knee
slightly flexed to permit placing stethoscope over
popliteal area.
4. Remove clothing as necessary to expose extremity.
5. Place correct size cuff around the extremity with the
center of the bladder cuff over the artery. Too narrow a
cuff will give false high reading; too wide a cuff will give
a false low reading.
a. Arm: Cuff should be placed around upper arm with
the lower edge about 3 cm above the antecubital
fossa.
b. Leg: Cuff should be placed around the mid thigh
with the lower edge about 2 cm above the popliteal
space.
6. Locate the artery by palpation. Allows for proper place-
ment of stethoscope to hear BP.
7. Palpate a pulse distal to the cuff, e.g., brachial or radial.
Close air valve and rapidly inflate cuff to 30 mm Hg
above where pulse no longer felt or above expected sys-
tolic blood pressure. Ensures cuff is inflated to a pres-
sure exceeding the child’s systolic BP.
8. Place stethoscope gently over artery. Too firm a pressure
will occlude blood vessel.
NOTE: While the diaphragm of the stethoscope is fre-
quently used, the American Heart Association recom-
mends using the bell of the stethoscope.
NOTE: To obtain a blood pressure reading by palpa-
tion, keep fingers on a distal pulse.
9. Open the valve and slowly release the air, permitting the
pressure to drop 2–3 mm Hg per heart beat while aus-
cultating for BP sounds or palpating for a pulse. Slower
or faster deflation yields false readings.
NOTE: Do not reinflate cuff without letting cuff totally
deflate. Reinflating cuff results in erroneously high
readings.
10. Obtain a blood pressure reading.
a. Auscultation.
1. Systolic pressure: The pressure at which you first
hear sounds.
2. Diastolic pressure: The American Heart
Association recommends the onset of muffling as
the diastolic pressure in children up to 13 years of
age; the pressure when sounds become inaudible is
the diastolic pressure in children > 13 years of age.
continued
 19

SKILL 4 Blood Pressure continued

b. Palpation: Continue to slowly release pressure until a 4. Wrap the extremity distal to the cuff with an elastic ban-
pulse is felt. This is the systolic pressure. The dias- dage. Begin with the finger or toes and progress to the
tolic pressure is recorded as P, e.g., 100/P. The sys- edge of the cuff. Forces blood out of extremity.
tolic pressure obtained by palpation is 5–10 mm Hg 5. Inflate the cuff to 150–200 mm Hg.
lower than that obtained by auscultation.
6. Remove elastic bandage. The hand or foot should
NOTE: If using a mercury manometer read at eye level. appear pale in color and exsanguinated.
Ensures accuracy. 7. Lower the pressure in the cuff by 5 mm Hg and leave
there for 3–4 seconds. Repeat process until flushing
11. Do not leave the cuff inflated for a prolonged period.
observed in the pale extremity, i.e., a sudden pink color
Inflated cuff is uncomfortable.
appears below the edge of the cuff and spreads distally.
12. Deflate the cuff rapidly and completely and remove
8. Reading is taken at point flushing appears. This is the
from the arm. Prevents discomfort (from numbness or
mean arterial pressure. To be accurate, an assistant is
tingling) and arterial occlusion.
needed to observe for flushing while you monitor the
13. Wait 2 minutes before taking another blood pressure. pressure gauge.
Releases blood trapped in vessels.
9. Repeat the procedure at least twice to confirm the read-
ing. Ensures more accurate reading.
BLOOD PRESSURE, ELECTRONIC
DOCUMENTATION
PROCEDURE
1. Blood pressure reading.
1. Steps 1–4 of General Guidelines.
2. Method used.
2. Set up machine according to instructions:
3. Site.
a. Plug in monitor/machine.
b. Connect dual air hose to back of monitor. 4. Size of cuff.
c. Connect correct size cuff by screwing the pressure 5. Who notified if findings of concern.
cuff’s tubing into the other end of the air hose.
3. Place cuff. (See step 5 of Blood Pressure, Auscultation
or Palpation.)
4. Turn machine on and follow manufacturer’s instructions.
5. Obtain reading.
6. Remove cuff.

BLOOD PRESSURE, FLUSH

Flush is used to obtain a BP reading on a newborn or small
infant when BP difficult or impossible to obtain by other
means.

PROCEDURE
1. Place infant in a recumbent position.
2. Apply cuff snugly and smoothly to distal arm, with outer
edge at the wrist or to the distal leg with the outer edge
at the ankle.
3. Elevate extremity above heart level. Facilitates flow of
blood out of extremity.

Copyright © 2007 by Thomson Delmar Learning, a division of Thomson Learning, Inc. All rights reserved.