PROTOCOLS FOR PRACTICE:

APPLYING RESEARCH AT THE BEDSIDE

This column is designed to provide the latest research findings in patient care in a format that is easy to understand and integrate
into clinical practice. The information is drawn from individual protocols in the various Protocols for Practice series available
from AACN, which cover research-based practice protocols in detail.

waveforms are recorded from sites

Arterial Pressure
Monitoring
Flerida Imperial-Perez, RN,
MN, and Marion McRae,
RN, MSc
Q: When monitoring arterial
pressure using an intra-arterial
pressure device, what do nurses
need to know to ensure accuracy
of readings?
ANATOMICAL SITES
Intra-arterial pressure monitor-
ing is designed to measure sys-
temic pressure as close to the heart
as possible. The best way to mea-
sure true systemic pressure is
through the use of a central aortic
pressure catheter, which can only
be accomplished during cardiac
surgery or with an intra-aortic bal-
loon catheter. As arterial pressure
monitoring sites go from central to
peripheral, changes in waveform
configurations and readings occur
(Figure 1). When arterial pulse
distal to the central aorta (for
example, the dorsalis pedis), the
systolic portion (anacrotic limb)
becomes peaked and narrowed
with increased amplitude. As a
result, the systolic blood pressure
in distal sites will be significantly
higher than that recorded from a
more central site. The diastolic
portion of the waveform may dis-
play a secondary (reflectance)
wave, as the monitoring site
becomes more distal to the central
aorta. The dicrotic notch becomes
less defined as the monitoring site

With the advent of disposable

pressure transducer technology,
Aortic root
accuracy affecting intra-arterial
pressure readings is now limited to
patients’ clinical conditions and Subclavian
clinicians’ knowledge and skills in
the use of the intra-arterial pres- Axillary
sure monitoring device. Some of
the most common elements affect-
ing accuracy of intra-arterial pres- Brachial
sure readings include anatomical
sites, peripheral vascular diseases,
and use of vasoactive medications. Radial
The knowledge, experience, and
skills of clinicians in leveling and Femoral
zeroing pressure transducers; vari-
ations in patient position relative
to the transducers; and waveform Figure 1 Progressive changes in the arterial pulse waveform from the
ascending aorta to the femoral artery
configurations also need to be con-
sidered in ongoing intra-arterial Reprinted from Sladen A. Invasive Monitoring and Its Complications in the Intensive Care
Unit. St Louis, Mo: CV Mosby Co; 1990:51. Used with permission
pressure measurement.

70 CRITICAL CARE NURSE Vol 22, No. 1, FEBRUARY 2002

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is moved toward the periphery.
These changes could also be inten-
sified with significant doses of
vasodilators or vasopressors. With
vasodilators, the waveform takes
on a more central appearance (for
example, the femoral arterial wave-
form). With vasoconstrictors, the
systolic pressure component
becomes exaggerated due to
enhanced resistance in the periph-
eral arteries. In infants, however,
the change in waveform from cen-
tral aortic to peripheral sites may
not be as pronounced due to age
and shorter limbs.
PRECISION AND
ACCURACY OF
ARTERIAL PRESSURE
SYSTEM
Advanced technology in dis-
posable transducer systems en-
sures accurate calibration and low
drift from zero. Transducer failures
are rare. There are, however, steps
nurses can take to ensure precision
and accuracy of the intra-arterial
pressure monitoring system:
1. Level the transducer system
to an anatomically consistent site
to eliminate effects of hydrostatic
and atmospheric pressure. The
phlebostatic axis is used as the
reference point for leveling and
zeroing (Figure 2). The goal is to
measure central aortic pressures,
even if the catheter is located in a
distal artery. This leveling ap-
proach depends on patient posi-
tion (ie, head of bed elevation or
lateral positioning); erroneous
pressure readings may be ob-
tained if the transducer is not
releveled with position changes.
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Monitor
Transducer
Figure 2 Arterial catheter setup in adult. The reference stopcock of the
transducer must be leveled to the phlebostatic axis. Moving from supine to a
sitting position changes the reference level and could lead to erroneous
pressure measurements.
2. Check the dynamic response
of the pressure monitoring system
(transducer and plumbing). There
are 2 dynamic response character-
istics that can affect accuracy in
instrument reproduction of the
patient’s blood pressure: natural
frequency and damping coeffi-
cient. Natural frequency refers
to the number of oscillations per
second (measured in hertz or
cycles/s) produced by the moni-
toring system after it is exposed to
a pressure signal. Systems with
high natural frequencies (>10 Hz)
are considered to have an excel-
lent dynamic response. The use of
long and compliant (non-rigid)
tubing, air in tubing, and extra
stopcocks in the system can
decrease the resonant frequency
and cause overestimation of sys-
tolic blood pressure by as much as
30%. To further ensure accuracy,
zero the transducer before inser-
tion, after disconnection from the
cable, and when the accuracy of
the pressures is in question.
CRITICAL CARE NURSE Vol 22, No. 1, FEBRUARY 2002 71
Phlebostatic axis
3. Be aware of certain clinical
conditions that can cause fluctu-
ations in pressure readings asso-
ciated with respiration. These
conditions include asthma, cardiac
tamponade, and pulsus paradoxus.
Therefore, to avoid influence of
respiration on pressure measure-
ment, all pressure readings should
be taken at end-expiration using
a strip chart recording or a freeze-
frame function along with a mov-
able cursor (available on many
monitors to allow greater accuracy
of measurement when artifact is
of concern).
Control and monitoring of
intra-arterial pressure device is
predominantly within nursing’s
domain. To ensure optimum phar-
macological and mechanical inter-
vention on changes in systemic
pressure, it is crucial that nurses be
aware of all factors affecting accu-
racy of monitoring.✙
Bibliography
1. McRae M, Imperial-Perez F. Arterial pres-
sure monitoring. In: Chulay M, Gawlinski
A, eds. Hemodynamic Monitoring Series
AACN Protocols for Practice; 1998.
 2. Urzua J, Sessler DI, Meneses G, Sacco M, Canessa R. Thermo-
regulatory vasoconstriction increases the difference between femoral
and radial arterial pressures. J Clin Monit. 1994;10(4):229-236.
3. Khder Y, Bray-Desboscs L, Aliot E, Zannad F. Effects of blood pres-
sure control on radial artery diameter and compliance in hyperten-
sive patients. Am J Hyperten. 1997;10(3):269-274.

Flerida Imperial-Perez is a clinical nurse specialist

in the Cardiothoracic ICU at UCLA Medical Center. She
is also assistant clinical professor at UCLA School of
Nursing in Los Angeles, Calif.

Marion McRae is a clinical nurse III in the

Cardiothoracic ICU at UCLA Medical Center.

This article is based on the protocol “Arterial Pressure

Monitoring” by Flerida Imperial-Perez and Marion
McRae. It was taken from the Hemodynamic Monitoring
series of AACN’s Protocols for Practice. Protocols can be
obtained from AACN, 101 Columbia, Aliso Viejo, CA
92656-1491, (800) 899-AACN, (949) 362-2000. $11.01,
AACN members; $12.95, nonmembers

Note
This article was first published in CRITICAL CARE NURSE
April 1999.

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Arterial Pressure Monitoring
Flerida Imperial-Perez and Marion McRae
Crit Care Nurse 2002;22 70-72
Copyright © 2002 by the American Association of Critical-Care Nurses
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