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ACCURACY IN BLOOD

PRESSURE
MEASUREMENT
Importance of site and accuracy

ACCURATE BLOOD PRESSURE (BP)


MEASUREMENT IS ESSENTIAL TO
PROVIDE APPROPRIATE
HEALTHCARE

Classification of BP for adults aged 18 and older.


Figures based on the average of seated BP readings
properly measured during 2 or more office visits.

FOR MOST ACCURATE BLOOD


PRESSURE RESULTS

Patient should avoid caffeine, tobacco, or alcohol for 30


minutes prior to measuring.
Patient should rest for 3 to 5 minutes before screening. They
should also refrain from talking.
Patient may lie supine or sit erect in a comfortable position,
with legs uncrossed and back supported.
Place patients arm at heart level, on a stable surface, allowing
the arm to remain still.
Wrap the properly sized cuff snugly around a bare arm, leaving
enough room for a fingertip under the cuff.
Be certain that the bottom edge of the cuff is 1 inch (2.5 cm)
above the antecubital fossa.
Position the cuff on the arm properly by placing the arrow or
tubing on the inside of the elbow.
Measure blood pressure in both arms during the initial
assessment.
Take multiple readings at least one minute apart and record all
the results.
Measure at the same time daily unless otherwise specified.
Use the correct sized cuff for your arm.

WHY IS THE RIGHT SIZED


CUFF IMPORTANT?

The right cuff size is very important.

Blood pressure readings may be wrong if


your cuff is the wrong size.

If the cuff is too wide, it will


underestimate the BP

While a cuff that is too narrow tends to


overestimate the BP.

To ensure proper size, the National


Institute of Health and American Heart
Association each offer different methods.

NATIONAL INSTITUTE OF
HEALTH PROPOSES
THAT

Cuff width should be 40% of the


circumference of the limb being used.

The bladder within the cuff should


encircle 80% of the upper arm.

AMERICAN HEART
ASSOCIATIONS (AHAS)
GUIDELINES ON BP CUFF SIZE

Cuff
NEWBORN
INFANT
CHILD
SMALL ADULT
ADULT REGULAR
ADULT LARGE
THIGH

Arm Circumference
<2.5 (< 6 cm)
2.5-6 (615 cm)
68.5 (16-21 cm)
8-10 (22-26 cm)
1113 (27-34 cm)
1417 (35-44 cm)
1821 (45-52 cm)

AHA generally recommends larger cuffs be used for


borderline measurements (AHA. 1993).

The brachial (upper arm) site is the


gold standard for non-invasive BP
monitoring. However, in some situations,
this site is inaccessible due to injury,
surgery, dialysis shunts, intravenous
devices, and lymphedema.

When the upper arm is unavailable to be


used, the forearm site is sometimes the
alternative. The increased incidence of
obesity also contributes to a heightened
use of forearm BP monitoring.

Upper Arm Placement


and Measurement
Place BP cuff 1 inch (2.5 cm) above the
antecubital fossa. Position the cuff on the
arm properly by placing the arrow on the
inside of the elbow to line up with the
brachial artery.

FOREARM PLACEMENT AND


MEASUREMENT
Place BP cuff 2-3 cm above radial artery, with the
arrow positioned over the radial artery. Support
forearm at heart level and auscultate at the
radial artery.

AMERICAN HEART ASSOCIATION GUIDELINES


RECOMMEND THE FOREARM METHOD
FOR SELECTED BARIATRIC PATIENTS
ONLY WHEN 1 OF THE FOLLOWING 2 CRITERIA IS
MET:

Upper arm circumference is >20 (50


cm)

Size & shape of upper arm suggest


available cuffs will fit extremely poorly

When appropriate (per AHA guidelines),


forearm BPs should be assessed using an
ADULT REGULAR cuff at the radial artery (a
regular size cuff is appropriate since
morbid obesity generally spares the wrist).

EVIDENCE BASED PRACTICE


SHOWS
However, population wide, small inaccuracies in blood
pressure measurement can have considerable consequences.
Underestimating true blood pressure by 5 mmHg would
mislabel more than 20 million Americans with
prehypertension when true hypertension is present. It has
been predicted that the consequences of an untreated 5
mmHg of excessive systolic blood pressure would be a 25%
increase over current levels of fatal strokes and fatal
myocardial infarctions for these individuals.
Conversely, overestimating true blood pressure by 5 mmHg
would lead to inappropriate treatment with antihypertension
medications in almost 30 million Americans, with attendant
exposure to adverse drug effects, the psychological effects of
misdiagnosis, and unnecessary cost.

Many questions remain concerning the


accuracy of forearm BP measurements. In
fact, many researchers recommend utilizing
other alternative BP measures, such as the
popliteal (thigh) site, ahead of the forearm.

Research has consistently found


that upper arm and forearm BP
readings are NOT
interchangeable.

CONCLUSIONS

Forearm BP's differ from upper arm BPs.


Recent evidence suggests forearm BPs overestimate
systolic, diastolic & mean values anywhere from 10
to 33 mmHg.
Trends in BP readings & patient status will need to
be carefully evaluated prior to treatment.
As a result, it is critical that when the forearm
method is indicated, all caregivers
consistently use the forearm for BP readings.
More so, the difference in BP measurement sites can
be used as a basis for a change in current practice
to include recording the BP measurement along with
the site, as is current practice with temperature
measurement.

NATIONAL PATIENT SAFETY


GOALS & QUALITY AND
SAFETY EDUCATION FOR
NURSES

Accuracy in Blood Pressure measurement is relied upon


for both quality patient care and safe medication
administration. Many medications have an impact on
not only blood pressure but other vital signs and these
measurements are used in determining if the
medication should be given and to assess the effect of
the medication. Accuracy also plays a part in improving
staff communication in that the forearm and the
brachial site are not interchangeable. Remember the
Brachial Site is the Gold Standard.

Quality and Safety Education for Nurses competencies


of Evidence Based Practice play a part of accuracy in
blood pressure measurement as the different sites have
been researched and tested thoroughly such as in
Clinical Comparison of Automatic, Noninvasive
Measurements of Blood Pressure in the Forearm and
Upper Arm

QUIZ TIME

In what situations should


the forearm site be used?

QUIZ TIME

How do you properly


measure a cuff for fit?

QUIZ TIME

How far from the


Antecubital Fossa should
the cuff be placed?

QUIZ TIME

What happens if the cuff


is too small or too large?

QUIZ TIME

What is the Gold Standard


location?

DID YOU
SPOT ALL
10
ERRORS?

1. Pts arm is unsupported above heart level


2. Pts back is unsupported
3. Pt is talking
4. Pt is engaged in active listening
5. Wrong cuff size in use (too big)
6. BP is too low on upper arm, appears to be
over elbow, likely that arterial marker is
malpositioned as well
7. Cuff is over clothing
8. Observer is not eye level with the monitor.
Where is the monitor?
9. Pts legs are crossed
10.End of stethoscope is in coat pocket

References