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As you release the air in the cuff, the bladder deflates and cuff pressure falls. Then pressure in the cuff reaches the pressure generated by the heart during contraction, blood begins to flow through the artery again. This flow produces Korotkoff's sounds: sharp topping or knocking

sounds at each contraction. The cause of these sounds is still debated, but they may be caused by blood jetting through the partly occluded vessel. The jetting causes turbulence in the open vessel beyond the cuff. According to the American Heart Association, Korotkoff's sounds occur in five phases. Phase 1: faint, clear, tapping sounds. This is the systolic pressure. Phase 2: murmurs or swishing sounds Phase 3: crisper, more intense sounds Phase 4: distinct, abrupt muffle of sound. In children, this is the diastolic pressure; in adults, it reveals hyperkintetic state (increased movement in blood vessels from disease or strenuous exercise) if it remains throughout deflation. Phase 5: no longer any sound. This is diastolic pressure in adults. Korotkoff's sounds have a frequency that's too low for the unaided human ear. Though you might estimate systolic pressure by palpating the return of the pulse in the brachial artery, you can't detect diastolic pressure without a stethoscope's amplification. CHECK FOR PROBLEMS BEFORE THEY START

Stethoscope Check the tubing for holes. Clean any wax from the ear tips. Point earpieces forward. Use the bell portion of the stethoscope to listen for Korotkoff's sounds. Be sure to place it lightly over the artery, with skin contact all around. Cuff Make sure the cuff size suits your patient. Check to see that the screw valve on the ball works properly. Pump up the bladder and watch for any air leaks. If the mercury column or aneroid needle doesn't rise steadily as you pump the ball, suspect a leak. Aneroid Manometer Check that the needle is at the zero mark at the start and the end of the measurement. Place the manometer in your direct line of sight. Patient Determine whether your patient has smoked or drunk alcoholic beverages within the last 15 minutes. Both can alter the reading. If possible, have him sit or lie down for 5 minutes. Remove all clothing from his arm. Avoid using an arm that has an I.V. line, shunts, edema, injury, or paralysis. Don't place the cuff over clothing or let a rolled-up sleeve constrict the arm. Ask your patient not to talk during the measurement. Flex the arm and support it on a smooth surface at heart level. Place the center of the inflatable bladder over the brachial artery.