4.2.

Lab 2: BLOOD PRESSURE

- Indirect measurement
- Ventricular Systole & Diastole
- Korotkoff sounds
- Mean Arterial pressure
4.2.1. Hypothesis
Blood pressure (BP) is defined as the lateral pressure exerted by the column of blood on
the walls of the arteries, it usually means arterial pressure . A person's BP is usually
expressed in terms of the systolic blood pressure (SBP) and diastolic blood pressure
(DBP). Systolic pressure provides an estimate of the work of the heart and of the strain
against the arterial walls during ventricular contraction. Diastolic pressure provides an
indication of peripheral resistance or of the ease with which blood flows from the
arterioles into the capillaries. Elevated Blood pressure is a widespread and independent
risk factor for developing Coronary Heart Disease (CHD) and stroke. Therefore it is
crucial to accurately measure the blood pressure of an individual. The mercury
sphygmomanometer has been considered as the gold standard for measurement of blood
pressure .It works on the principle of auscultatory method which means diagnostic
monitoring of the korotkoff sounds.The sounds detected during blood pressure
measurements are referred to as Korotkoff sounds and were first identified by Russian
surgeon Nicolai SergeivichKorotkov in 1905. Sound is created by the turbulent flow of
blood through the compressed vessel. When cuff pressure exceeds systolic arterial
pressure, the artery collapses, blood flow through it ceases, and no sound is produced. As
cuff pressure is slowly reduced, blood flow through the artery begins when cuff pressure
falls just below systolic arterial pressure. At this point, a sharp tapping sound (the first
sound of Korotkoff) may be heard with the stethoscope or microphone over the artery.
The cuff pressure when this sound is first heard is taken as an approximation of systolic
pressure. As cuff pressure is further reduced, the sounds increase in intensity (and may
resemble swishing), then suddenly become muffled (the second sound of Korotkoff) at
the level of diastolic pressure, then disappear. Sounds disappear when the vessel is no
longer compressed by the pressure cuff and normal non-turbulent blood flow resumes. 

4.2.2. Materials

- BIOPAC Pressure Cuff (SS19L with gauge dial for MP3X or SS19LA with
onscreen gauge display for MP45)
- BIOPAC Stethoscope (SS30L)
- BIOPAC Electrode Lead Set (SS2L)
- Electrodes – disposable, 3 per Subject (EL503)
- Rubbing alcohol and swab (to clean stethoscope earpieces and stethoscope
diaphragm)
- Tape measure (for pulse speed calculation)Optional: washable felt pen (to mark
stethoscope placement on arm)
- Biopac Student Lab System: software BSL 3.7.7 or above data acquisition unit
MP36, MP35, MP30 (Windows only), or MP45
- Computer System

4.2.3. Method
4.2.3.1. Calibration
Step 1: Double check the electrodes and stethoscope, and make sure Subject is relaxed
and sitting down.
Step 2: Click Calibrate.
Step 3: Confirm cuff is deflated and click OK.
Step 4: Roll the cuff onto itself such that when completed, the Velcro will prevent it from
unrolling with inflated.
Step 5: When prompted, Director inflates cuff to 100 mmHg and Recorder clicks “OK”.
Step 6: At the next prompt, Director deflates cuff to 40 mmHg and Recorder clicks
“OK”.
Step 7: Director taps the stethoscope diaphragm twice.
Step 8: Check calibration data:
- If similar, proceed to Data Recording.
- If different, Redo Calibration.
4.2.3.2. Recording lesson data
Step 1: Prepare for the recording.
Step 2: Review the Blood Pressure measurement procedure provided in the Introduction
Step 3: Make sure all the air in the sphygmomanometer cuff is expelled and close the
pressure release valve.
Step 4: Place the cuff on Subject’s LEFT arm. (Fig. 4.2.3.1a)
- “Artery” label should be over the brachial artery (with the arrow on the label
facing down).
- Lower edge of cuff should be 1.5 to 2 inches above the antecubital fossa (inner
aspect of elbow).
- Wrap the cuff evenly and snugly on Subject’s arm.

Figure 4.2.3.1a: Placing the cuff

Step 5: Check that the tubing and cables are not tangled or pinched.
Step 6: Position Subject’s arm at heart level (Fig. 4.2.3.1b).
 Figure 4.2.3.1b: Position at heart level
Step 7: Palpate the brachial artery between the antecubital fossa and the lower edge of the
cuff to find where the pulse is best felt.
Step 8: Mark this spot with a washable felt pen.
Step 9: Make sure the “Artery” label of the cuff is aligned with the pulse point.
Step 10: Place the stethoscope in the correct position and apply firm but not excessive
contact pressure.
Left arm, Seated 1
Step 11: Recorder clicks Record when Director is ready.
Step 12: Director inflates cuff to 160 mmHg and says when ready.
Step 13: Recorder clicks OK.
Step 14: Director releases the pressure at a rate of 2 to 3 mmHg/second and calls out
when the Korotkoff sounds first appear (systolic). Recorder inserts an event marker.
▼ Systolic - (F4 key)
Step 15: Director continues to listen and call out when the pressure sounds completely
disappear (diastolic). Recorder inserts an event marker.
▼ Diastolic - (F5 key)
Delay for an additional 2 seconds
Step 16: Director deflates cuff as rapidly as possible and Recorder clicks Suspend
Step 17: Review the data on the screen (Fig. 4.2.3.1c).
 Figure 4.2.3.1c: After “Left arm, seated 1” segment
- If similar, go to Step 18.
- If different, Redo.
Left arm, Seated 2
Step 18: Director inflates cuff to 160 mmHg and says when ready.
Step 19: Recorder clicks Resume
Step 20: Director releases pressure at a rate of 2 to 3 mmHg/second and calls out when
systolic and then diastolic are detected. Recorder inserts event markers.
▼ Systolic - (F4 key)
▼ Diastolic - (F5 key)
Step 21: Recorder clicks Suspend and then Director deflates cuff as rapidly as possible.
Step 22: Review the data on the screen.
- If similar, go to Step 23.
- If different, Redo.
Right arm, Seated 1
Step 23: Switch cuff to Subject’s right arm.
Step 24: Director returns cuff pressure to 160 mmHg and says when ready.
- Subject remains relaxed and seated with arm at heart level.
Step 25: Recorder clicks Resume.
Step 26: Director releases cuff pressure at 2-3 mmHg/second and calls out when systolic
and then diastolic sounds are detected. Recorder inserts event markers.
▼ Systolic - (F4 key)
 ▼ Diastolic - (F5 key)
Step 27: Recorder clicks Suspend and then Director deflates cuff as rapidly as possible.
Step 28: Review the data on the screen.
- If similar, go to Step 29.
- If different, Redo.
Right arm, Seated 2
Step 29: Director returns cuff pressure to 160 mmHg and says when ready.
- Subject remains relaxed and seated
Step 30: Recorder clicks Resume.
Step 31: Director releases cuff pressure at 2-3 mmHg/second and calls out when systolic
and then diastolic sounds are detected. Recorder inserts event markers.
▼ Systolic - (F4 key)
▼ Diastolic - (F5 key)
Step 32: Recorder clicks Suspend and then Director deflates cuff as rapidly as possible.
Step 33: Review the data on the screen.
- If similar, go to Step 34.
- If different, Redo.
Right arm, Supine 1
Step 34: Subject lies down and relaxes.
Step 35: Director returns cuff pressure to 160 mmHg and says when ready.
Step 36: Recorder clicks Resume.
Step 37: Director releases cuff pressure at 2-3 mmHg/second and calls out when systolic
and then diastolic sounds are detected. Recorder inserts event markers.
▼ Systolic - (F4 key)
▼ Diastolic - (F5 key)
Step 38: Recorder clicks Suspend and then Director deflates cuff as rapidly as possible.
Step 39: Review the data on the screen.
- If similar, go to Step 40.
- If different, Redo.
Right arm, Supine 2
Step 40: Subject lies down and relaxes.
Step 41: Director returns cuff pressure to 160 mmHg and says when ready.
Step 42: Recorder clicks Resume.
Step 43: Director releases cuff pressure at 2-3 mmHg/second and calls out when systolic
and then diastolic sounds are detected. Recorder inserts event markers.
▼ Systolic - (F4 key)
▼ Diastolic - (F5 key)
Step 43: Recorder clicks Suspend and then Director deflates cuff as rapidly as possible.
Step 44: Review the data on the screen.
- If similar, go to Step 45.
- If different, Redo.
Right arm, after exercise
Step 45: Confirm Subject can safely exercise and determine if the cuff must be removed
for exercise.
Step 46: Subject exercises to elevate heart rate to a moderate level and then sit to recover.
Step 47: Check cuff placement
Step 48: Recorder clicks Resume
Step 49: Director inflates cuff pressure to 180 mmHg and says when ready.
Step 50: Director releases cuff pressure at 2-3 mmHg/second and calls out when systolic
and then diastolic sounds are detected. Recorder inserts event markers.
▼ Systolic - (F4 key)
▼ Diastolic - (F5 key)
Step 51: Recorder clicks Suspend and then Director deflates cuff as rapidly as possible.
Step 52: Review the data on the screen.
- If similar, go to Step 54.
- If different, Redo.
Step 53: Click Done.
Step 54: Click Yes.
4.3.4. Set up
Step 1: Select your lab group.
Step 2: Make sure the BIOPAC MP3X unit is turned OFF.
Step 3: Plug the equipment in as follows (Fig. 4.2.4.1a):
BP Cuff (SS19L/LA) — CH 1
Stethoscope (SS30L) — CH 3 *
Electrode lead set (SS2L) — CH 4 **
- If an MP45 is used for recording:
* Stethoscope is CH 2
** ECG is not recorded

Figure 4.2.4.1a: MP3X (top) and MP45 (bottom) equipment connections

Step 4: Turn the MP3X Data Acquisition Unit ON.
Step 5: Turn the computer ON.
Step 6: Place three electrodes on the Subject as shown. Fig 4.3.4.1b.
 Figure 4.2.4.1b: Standard Electrode placement
Step 7: Attach the electrode lead set (SS2L) to the electrodes as shown, paying close
attention to the lead colors (Fig. 4.2.4.1c).

Figure 4.2.4.1c: Standard electrode lead attachment

Step 8: Clean the stethoscope earpieces and diaphragm.
Step 9: Open the cuff valve and roll the cuff in on itself, then press to flatten and close the
valve.
Step 10: Start the Biopac Student Lab Program.
Step 11: Choose lesson L16 and click OK.
Step 12: Type in the Director’s name and click OK.
Step 13: Optional: Set Preferences.  
- Choose File > Preferences.  
- Select an option. 
- Select the desired setting and click OK. 
4.2.4. Experimental result
 4.2.4.1. Data and Calculations
Subject profile
Name: Nguyen Nhat Nam Height: 1m72
Age: 20 Gender: Male Weight: 78
A. Systolic Measurements
Complete Table 4.2.4.1a with the systolic measurements for all recorded data segments.
Note the pressure measurement at the marker insertion point (where Director detected
systolic) and where the first sound was detected with the stethoscope. Calculate the deltas
between the trials for each condition and between the Marker and Stethoscope pressure
measurements.
Systolic mmHg
Condition Trial At Marker Marker Avg. First Sound Sound Avg.
Insertion (calculate ) detected (calculate)
1 107,32 116,31
Left arm, seated 108,34 116,52
2 109,36 116,73
1 99,12 104,83
Right arm, seated 99,755 105,015
2 100,39 105,2
1 93,04 95,73
Right arm, lying down 93,355 97,335
2 93,67 98,94
Right arm, after exercise 1 137,4 137,4 140,65 140,65

Table 4.2.4.1a: Systolic Data

B. Diastolic Measurements
Complete Table 4.2.4.1b with the diastolic measurements from each of the recorded data
segments. Note the pressure measurement at the marker insertion point (when the
Director detected diastolic) and where the sound disappeared. Calculate the deltas
between the trials for condition and between the marker and the stethoscope
measurements for each segment.
 Diastolic mmHg
Condition Trial At Marker Marker Avg. First sound Sound Avg.
Insertion (calculate) detected (calculate)
1 67,43 73,68
Left arm, seated 68,275 73,485
2 69,12 73,29
1 64,82 69,69
Right arm, seated 64,49 69,36
2 64,16 69,03
1 58,74 62,03
Right arm, lying down 60,44 64,275
2 62,14 66,52
Right arm, after exercise 1 100,33 100,33 104,47 104,47

Table 4.2.4.1b: Diastolic Data

C. BPM Measurements
Complete Table 4.2.4.1c with the BPM measurements from three cycles of each of the
recorded data segments and calculate the mean BPM for each segment.

* Cycle measurements: If ECG was recorded, use , if ECG was not recorded,

use .
Cycle * Calculate the Mean
Condition Trial
1 2 3 of Cycles 1-3 of Trial 1-2 means
1 78,43 81,39 78,02 79,28
Left arm, seated 79,04
2 77,3 79,98 79,12 78,8
1 72,48 71,06 72,37 71,97
Right arm, seated 71,825
2 72,58 70,92 71,54 71,68
1 50,32 51,38 51,48 51,06
Right arm, lying down 51,275
2 49,47 52,58 52,42 51,49
Right arm, after exercise 1 96,23 97,88 96,2 96,77

Table 4.2.4.1c: BPM

D. Summary of Mean Blood Pressure Data
Complete Table 4.2.4.1d with the average from sound data from tables 4.2.4.1a and
4.2.4.1b and then calculate the pulse pressure and the mean Arterial Pressure (MAP).
SYSTOLE DIASTOLE BPM Calculations:
CONDITION Table 4.2.4.1a Table 4.2.4.1b Table 4.2.4.1c
Pulse pressure MAP
Sound Average Sound Average
Left arm, seated 116,52 73,485 79,04 43,035 87,83
Right arm, seated 105,015 69,36 71,825 35,655 81,245
Right arm, lying down 97,335 64,275 51,275 33,06 75,295
Right arm, after exercise 140,65 104,74 96,95 35,91 116,71

Table 4.2.4.1d
E. Timing of Korotkoff Sounds
 Timing of Sounds
Condition Trial
Mean (calc)
1 0,73
Left arm, seated 0,76
2 0,79
1 0,537
Right arm, seated 0,544
2 0,551
1 0,398
Right arm, lying down 0,4305
2 0,463
Right arm, after exercise 1 0,813 0,813

Table 4.2.4.1e
F. Calculation of Pulse Speed

Distance Distance between Subject’s sternum and right shoulder? cm

Distance between Subject’s right shoulder and antecubital cm
fossa?
Total distance? cm
Time Time between R-wave and first Korotkoff sound? secs
Speed Speed = distance/time = ___________cm / ________sec cm/sec

4.2.5. Questions
1. Note the difference in systolic pressure value between when the sound actually began,
was detected by the stethoscope transducer, and was recorded, and the time when the
observer first heard the sound and pressed the marker button. (Example: 141 mmHg –
135 mmHg = 6 mmHg). What factors could account for this difference? Would the
observed difference be the same if measured by another observer? Explain your answer.
There would be a difference, the recorded data would be less accurate than those detected
by Stethoscope transducer, because of the communication lag, there would be difference
between reaction time of hearing and recording the data, which is type of human error.
2. a) Does your systolic and/or diastolic arterial pressure change as your heart rate
increases?
Systolic and diastolic arterial pressure increases with increase in heart rate. Because
diastolic pressure is the pressure that take place on your artery walls between the heart
beats while systolic pressure refers to the pressure arises during heart beat. So, increase in
systolic pressure is greater than diastolic pressure.
b) How does this change affect your Pulse Pressure?
This change will result in two ways:
First way, with good cardiovascular health: Pulse pressure likewise increases as heart rate
increases after exercise. After exercise, supply routes are more versatile.
Second way, with hardened artries, they don't extend also with increased pressure; Pulse
pressure stays unaltered.
3. Give three sources of error in the indirect method of determining systemic arterial
blood pressure:
Wrong size cuff used: Large cuff will give false low blood pressure reading while Small
cuff will give false high blood pressure reading. Cuff size should be recommended that
the bladder length and width should be 80% and 40% respectively.
Not proper functioning of the electronic equipment: The correct working of the electronic
euipment can be checked by verifying the displayed pulse with an actual patient pulse.
Differences greater then 10% will affect the calculations seriously and results in incorrect
diastolic and systolic values on the display screen. Non Invasive Blood Pressure (NIBP)
machines is used as electronic machine that recognizes the changes in the air pressure in
the cuff caused due to the blood flowing through the BP cuff extremity. Sensors calculate
the patient’s pulse rate and Mean Arterial Pressure (MAP). Software use these two
variables for calculating the systolic and diastolic BP.
Incorect position of pateint body: Most accurate blood pressure is obtained by upright
seated position, in this the pressure remains at the patient side for longer. The problem in
measuring accurate pressure take place as pateint lying on their side or in other position.
For measuring correct blood pressure Bp cuff is put at mid heart level at the time of
pressure. Transducer should also place at mid heart level for accurate measuring of
pressure.
4. Use an equation that relates flow, pressure, and resistance to define mean arterial
pressure:
The equation for mean arterial pressure is:
MAP=(1/3) PP (pulse pressure) + Diastolic
Example: if someone's blood pressure is 125/65, then Pulse Pressure is 60. Now that you
have this info you can calculate MAP (mean arterial pressure)
MAP= (1/3) 60 + 65
 MAP= 85
CO is cardiac output (CO is defined as stroke volume, the amount of blood pumped out
in a single beat, times heart rate-- CO = SV x HR)
*MAP is mean arterial pressure
* SVR is systemic vascular resistance
* CVP is central venous pressure
Or, different equation, same answer: MAP = DP + (1/3)PP
Where DP is diastolic pressure and PP is pulse pressure. (Systolic minus Diastolic)
5. Blood flow (liters per min.) through the pulmonary circuit equals blood flow through
the systemic circuit, but pulmonary resistance to flow is 5 times less than the systemic
resistance to flow. Using the equation in Question 4, show that mean pulmonary pressure
is 5 times less than mean systemic pressure.
As we have known,
Pressure
Pressure = Flow x Resistance => Flow = (1)
Resistance
Given,
Systemic flow = Pulmonary flow (2)
Systemic Resistance = 5 x Pulmonary Resistance
So, we replace the equation (1) into (2):
Systemic Pressure Pulmonary Pressure
=
Systemic Resistance Pulmonary Resistance
Systemic Pressure Pulmonary Pressure
( ¿) =
5 x Pulmonary Resistance Pulmonary Resistance
 Systemic Pressure
( ¿) =Pulmonary Pressure
5
6. Define the first and second sounds of Korotkoff. Which sound is used to approximate
systolic pressure and which sound is used to approximate diastolic pressure?
The first sound occurs when the cuff pressure is same to the systolic arterial pressure.
When this sound occurs, the vibrations generated as blood is forced past the area of
occlusion. These vibrations are dependent on the systolic Korotokoff sound. The diastolic
sound is different in pitch of vibration. When the occlusion pressure cuff reduces below
the diastolic pressure and there is no more occlusion of the artery. The second sound
represents the diastolic pressure. The first sound is used approximate systolic pressure.
The first sound of Korotkoff occurs when the cuff pressure equals the systolic pressure.
The second sound is used approximate diastolic pressure. The second Korotkoff sound
occurs when the cuff pressure equals the diastolic pressure.
7. Why is mean arterial pressure not equal to (systolic pressure – diastolic pressure)/2?
The heart spends more time in diastole than in systole, therefore the MAP has to take into
account the extra amount of time spent in diastole. The lengths of systole and diastole are
different. The amount of time spent in diastole is longer than the amount of time spent in
systole. The length of time the heart is in diastole is approximately twice as long as it is
in systole. As one's heart-rate increases and the length of diastole shortens, the mean
arterial pressure is much closer to just the average of systolic blood pressure and diastolic
pressure.
8. Define pulse pressure. Explain, in terms of changes in systolic and diastolic pressures,
why pulse pressure increases during exercise.
Pulse pressure is a measurement obtained by calculating the difference the systolic and
diastolic pressure. During exercise flow needs to increase in order to supply the body
with more oxygen. In this process the systolic pressure increases while the diastolic
pressure stays the same or increases by a small amount at best. Using the equation stated
earlier to find pulse pressure, knowing that systolic pressure increases and diastolic does
not change during exercise it can be found that pulse pressure increases during exercise.
9. Give one reason why blood pressure in the left arm may be different than blood
pressure in the right arm of a Subject at rest
A blood pressure difference of less than 5 mmHg between the left and right arm is
considered normal. This minor difference is usually due to the asymmetry in how the
blood vessels come off the aorta, the main vessel leaving the heart.the left arm is closest
to the aorta.
10. Name an artery other than the brachial that could be used for an indirect
measurement of blood pressure and explain your choice.
Brachial artery is used most often for checking the blood pressure.Another artery used for
indirect measurement of blood pressure is femoral artery .
Explanation: Femoral artery pressure gives standard for calibrating auscultatory technics.
As this pressure is widely used cardiac catheterization.
One advantage of of femoral artery is that the vessel is larger and gives stronger
impulsation than radial artery.
Note that, while measuring the blood pressure from femoral artery a cuff which 25%
wider should be used.