3.

BLOOD PRESSURE AND ARTERIAL

PULSES
INTRODUCTION
Arterial Blood Pressure
Arterial blood pressure refers to the pressure in the large
systemic arteries. The pressure in the large arteries does
not remain constant but changes cyclically during each
cardiac cycle. Because of this constant fluctuation, arterial
blood pressure cannot be given as a single value. The
maximum pressure during ventricular systole is called
systolic blood pressure (SBP). The minimum pressure
during diastole is called diastolic blood pressure (DBP).
The blood pressure (BP) is written as

BP = SBP
DBP

Arterial blood pressure can be measured directly by

inserting a catheter with a pressure sensor into an artery.
This is the most accurate method for measuring blood
pressure. Blood pressure can be measured indirectly using
a sphygmomanometer, either mercury or aneroid, and
electronic devices. The mercury sphygmomanometer is the
most accurate for indirect measurement of blood pressure.

The sounds heard during BP measurement using

auscultation method are known as Korotkoff Sounds.
Table 3.1: Phases of Korotkoff sounds and related events

Phase Event
I appearance of sounds, snapping in
nature
II sounds have a murmur-like quality
III sounds become clear and sharp
IV muffling of sounds
V disappearance of sounds

It is not essential to identify the different phases during the

measurement of blood pressure. Only the pressures at
which Phase I sounds start and the pressure at which
sounds disappear need to be noted.

Figure 3.1: Proper placement of a cuff.

Arterial Pulses
Arterial pulses can be palpated at several sites in the body.
The most common site is at the radial artery. The other
sites are ulnar brachial, carotid, femoral, popliteal, posterior
tibial, and dorsalis pedis arteries. The pulses are palpated
with the fingertips or thumb tip (only for carotid artery) by
gently compressing the artery against some firm structures
such as bones.
Arterial pulse gives information regarding the activity of the
heart and the status of the peripheral circulation.

LEARNING OUTCOMES
At the end of this practical, student should be able to:
1. measure the arterial blood pressure using a
sphygmomanometer
2. examine arterial pulses and describe the findings
3. determine the cardiovascular responses during
changes of posture
4. explain the mechanisms and importance of the
cardiovascular responses during changes of posture

MATERIALS AND EQUIPMENT

1. Sphygmomanometer
2. Stethoscope
3. Couch
4. Stopwatch
 Figure 3.2: Sphygmomanometer and stethoscope.

METHODS
A. Measurement of arterial blood pressure using
a sphygmomanometer.
1. The subject may be seated, standing or lying down.
It is useful to indicate the position in which it was
recorded.
2. The subject should be relaxed for at least 15
minutes prior to measurement of blood pressure.
3. Ensure that the safety valve is on and the mercury
level is at zero.
4. Loosen the air valve cap and squeeze all the air out
from the cuff before applying on the arm of the
subject.
5. The bladder of the cuff should encircle about 75% of
the arm circumference. Appropriate cuff size should
be used accordingly for different arm
circumferences. Inappropriately smaller cuffs
overestimate the blood pressure while larger cuffs
underestimate the blood pressure.
6. Expose the upper arm adequately and apply the cuff
around it. Ensure that the middle of the bladder cuff
overlies the path of the brachial artery. (Some cuffs
have a mark to indicate the middle of the bladder
cuff).
(Note: The cuff should not be applied over clothing.
If the sleeve of the clothing is pushed up it should
not constrict the upper part of the arm.)
7. The lower border of the cuff should be at least
2.5cm above the cubital fossa to allow sufficient
space for palpation and auscultation of the brachial
artery.
8. The arm with the cuff and the sphygmomanometer
should be at the same level with the heart.
a. Estimation of SBP using palpation method
i. Apply the cuff.
ii. Palpate the radial pulse in the arm with the
cuff.
iii. While still palpating the radial pulse, tighten
the air valve cap and inflate the cuff bladder
by pressing the rubber bulb.
iv. Continue to inflate the bladder until the radial
pulse disappears. Keep the fingert ip s over
the artery and reduce the cuff pressure
gradually (5 mmHg at a time) by loosening
the air valve cap.
v. Note the pressure in the sphygmomanometer
when the radial pulse becomes palpable
again. This is the approximate SBP.
vi. Release the pressure in the cuff quickly by
loosening the air valve cap fully.
 b. Measurement of arterial BP using auscultation
method:
i. While the cuff is still applied but deflated,
palpate the brachial pulse on the medial side
of the anterior part of the elbow.
ii. Place the diaphragm of the stethoscope over
the brachial pulse. (There will be no sound
heard through the stethoscope).
iii. Inflate the cuff rapidly until the pressure is
about 30 mmHg above the estimated SBP
determined by the palpation method.
iv. Reduce the cuff pressure gradually (5 mmHg
at a time or 2mmHg per second) by
loosening the air valve cap until the first
sound is heard. This is the SBP.
v. Continue to reduce the pressure until the
sounds disappear. This is the DBP.
vi. When the pressure at which the sounds
disappear is noted, release the pressure in
the cuff quickly by loosening the air valve cap
fully.

B. Cardiovascular Responses during Postural

Changes

1. Subject lies down on the couch for 5 minutes.

Measure pulse rate and BP 3 times.
2. Ask the subject to stand up and measure pulse
rate and BP immediately and after 5 minutes.
3. Perform procedures 1 & 2 for three times.
4. Calculate the means for systolic, diastolic, mean
arterial blood pressure, pulse pressure and
pulse rate for all the readings.
Tabulate the mean systolic pressure and pulse rate.

Pulse
Posture SBP DBP PP MAP
rate
Lying (after 5
minutes)
1
2
3

Mean
Standing
(immediately)
1
2
3

Mean

Standing (after
5 minutes)
1
2
3

Mean
C. Radial Pulse
The radial pulse is palpated using tips of fingers
compressing against the head of radius, lateral to
the tendon of the flexor carpii radialis. The
subject’s forearm should be slightly pronated and
the wrist slightly flexed. In clinical practice, radial
arteries on both sites are palpated and compared.
There are four aspects of the arterial pulse that
should be determined while palpating:
1. Pulse rate: The number of palpable pulsations
or beats per minute.
Count the pulse for one minute. Counting the beats
for less than 30 seconds is not accurate and should
be avoided.
2. Rhythm: the regularity of the pulse.
Determine whether the rhythm is regular or irregular.
The pulse is regular if the beats occur at similar
intervals. The pulse is irregular if the beats occur at
different intervals. Normal pulse is regular but there
may be very minor irregularity in normal individuals,
which does not signify any abnormality.
3. Volume: the degree of expansion of the artery
Pulse volume is an indication of stroke volume in
normal arteries.
4. Character: the form of arterial pulse wave
Character of the pulse depends on the upstroke and
downstroke of the pulse. The rapidity with which the
pulse wave rises and falls should be appreciated.
Abnormalities in the rise and fall of the pulse wave
occur in disease. However, carotid or brachial
pulses are better sites to assess the character of the
pulse.
It is not essential to assess the same features with all
 the other arterial pulses palpated. It is only necessary to
determine whether each of the other pulses is present
or absent and the relative volumes of the pulses.

D. Palpation of other pulses:

Carotid pulse is palpated with the thumb over the
common carotid artery between the thyroid cartilage
and the medial border of the sternocleidomastoid
muscle. Do not palpate both carotid pulses
simultaneously.
Ulnar pulse is palpated against the head of the ulna,
lateral to the tendon of the flexor carpi ulnaris.
Brachial pulse is palpated against the humerus just
above the antecubital fossa, medial to the biceps
tendon. It is best felt with the elbow in a slightly flexed
position. There is some variation of the position
where the brachial pulse is best felt.
Dorsalis pedis pulse is palpated on the proximal
part of the dorsum of the foot just lateral to the tendon
of extensor hallucis longus. Slight dorsiflexion of the
ankle makes it easier to palpate the dorsalis pedis
pulse.
Posterior tibial pulse is best felt while the foot is
slightly inverted. It is palpated posteroinferior to the
medial malleolus between the malleolus and the
calcaneal tendon.
Popliteal pulse is palpated deep in the popliteal
fossa. The knee should be semiflexed to relax the
structures overlying the popliteal fossa. The subject
ideally may lie in the prone position. The pulse is best
felt in the inferior part of the fossa, against the upper
tibia. The palpating fingers must be pressed deep into
the popliteal fossa.
Femoral pulse is palpated below the inguinal
ligament.
QUESTIONS
1. Record your blood pressure. Record 3 of your friends’
blood pressure.

Your Blood Pressure

Friend 1 Blood Pressure

Friend 2 Blood Pressure

Friend 3 Blood Pressure

State 5 reasons why there may be variations in the

blood pressure.

2. State reasons for leaving sufficient space below the

lower part of the cuff.
3. a) Record your blood pressure at the following sites.

Blood Pressure

Right Arm

Left Arm

b) State whether the expected blood pressure at the

lower limb is higher / lower / similar to the right arm
pressure.

c) State a reason for your answer in (b).

4. State the changes in pulse rate and systolic blood

pressure that occur from lying to standing. Explain the
mechanisms responsible for the changes.
__
5. Why is it important to palpate the carotid pulse
alternately?

6. State the errors involved in the measurement of blood

pressure

Lecturer’s signature : ____________

Date : ____________