Diploma of Health Science (Nursing/ Midwifery/ Paramedic)

Skill Topic: Blood Pressure Measurement

Requisites:

 Mercury Sphygmomanometer
 Stethoscope
 BP chart

Approach to the patient

1 Greet patient and introduce self appropriately

2 Explains the procedure to the client and ask for consent
Preparing procedure
3 Prepare and bring the requisites to patient’s bedside.
4 wash and dry hands
Performing the procedure
5 Lying or sitting position with the forearm supported and the palm facing upward.
6 Place the mercury Sphygmomanometer is in vertical position and the mercury must be at zero level.
7 Deflate the cuff completely.
8 Locate the brachial and radial arteries/pulses by pressing gently with the index and third finger.
9 Roll up the sleeve to expose the arm.
Rationale: To ensure proper cuff application.
10 Wrap the cuff around the arm over the brachial artery and fasten it (approximately two fingers (2.5 -3cm)
from the inner aspect of the elbow). Note: Wrinkles in the cuff should be smoothed out.
11 Tighten the screw bulb valve.
Rationale: to prevent air leak during inflation.
12 Palpate radial artery with fingertips with one hand while inflating the cuff and note until the pulsation
ceases.
Rationale: to estimate the systolic pressure
13 Deflate the cuff pressure slowly and note when the pulses feel / reappear.
Rationale: to estimate the diastolic pressure.
14 Deflate the cuff fully and wait for 30 seconds
15 Place the earpieces of stethoscope in the ears and check the sounds are clear and not muffled.
16 Relocate the brachial artery and place the diaphragm of the stethoscope over it.

Page 1 of 2
Revised by: Norashikin Haji Md Sofian (10.8.2017)
Acknowledgement: Zainatul Ashiqin Hj Salleh
15 Re-inflate the cuff pressure up to the estimated systolic pressure felt earlier and continue to inflate the cuff
to a pressure approximately above 30 mm Hg point.
16 Deflate the cuff pressure slowly by releasing the pressure bulb valve. Allow the mercury to fall at rate of 2-3
mm Hg /sec.
17 Listen and note on the manometer when the first pulse sound heard clearly (systolic pressure).
18 Continue to deflate the cuff gradually and note the point when the sound disappears (diastolic pressure).
18 Listen for 20 -30 mm Hg after the last sound and then allow the air from the cuff to escape quickly.
19 Remove the cuff from the client and tidy up the blood pressure set.
20 Record the finding correctly on the chart provided.

Blood pressure Optimal Normal High Normal Hypertension

Systolic Less than 120 Less than 130 130-139 140 or higher
Diastolic Less than 80 Less than 85 85-89 90 or higher

21 Thank the client at the end of taking blood pressure measurement in appropriate manner.

Page 2 of 2
Revised by: Norashikin Haji Md Sofian (10.8.2017)
Acknowledgement: Zainatul Ashiqin Hj Salleh