ASSESSING BLOOD PRESSURE (ARM)

PURPOSES:
• To obtain a baseline measure of arterial blood pressure for subsequent evaluation
• To determine the client’s homodynamic status (eg, stroke volume of the heart and
blood vessel resistance)
• To identify and monitor changes in blood pressure resulting from a disease
process and medical therapy (eg, presence of history of cardiovascular disease,
renal disease, circulatory shock, or acute pain, rapid infusion of fluids on blood
products)
ASSESSMENT FOCUS:
Signs and symptoms of hypertension (eg, headaches, ringing in the ears flushing of face,
nosebleeds, fatigue); sings and symptoms of hypotension (eg, tachycardia, dizziness,
mental confusion, restlessness, cool and clammy skin, pale or cyanotic skin); factors
affecting blood pressure (eg, activity, emotional stress pain, and time the client last
smoke or ingested caffeine).

EQUIPMENT
• Stethoscope or DUS
• Blood pressure cuff of the appropriate size (newborn, infant, child, small adult,
large adult, thigh.)
• Sphygmomanometer
INTERVENTION:

STEP RATIONALE

1. Prepare and position the client

appropriately.
• Make sure the client has not smoke
or ingested caffeine within 30
minutes prior to measurement.
• Make sure that the bladder of the
cuff encircles at least two-thirds of
the arm and the width of the cuff is
appropriate.
• Position the client in a sitting The blood pressure is normally similar in
position unless otherwise specified. witting, standing, and lying positions, but it
The arm should be slightly flexed can vary significant by position in certain
with the palm of the hand facing up persons and may need to be measured in all
and the forearm supported at heart three positions. The blood pressure
level. Reading in any position increases when the arm is below heart level
should be specified. and decreases when the arm is above heart
• Expose the upper arm. level.

2. Wrap the deflated cuff evenly

 around the upper arm.
• Apply the center of the bladder The bladder inside the cuff must be directly
directly over the medial aspect of over the artery to be compressed if the
the arm. reading is to be accurate.

3. This is the client’s initial

examination; perform a
preliminary palpatory
determination of systolic pressure.
• The initial estimated tell the nurse
the maximal pressure to which the
manometer needs to be elevated in
subsequent determinations. It also
prevents underestimation of the
systolic pressure should an
auscultatory gap occur.
• Palpate the brachial artery with the
fingertips. The brachial artery is
normally found medially in the
antecubital space.
• Close the valve on the pump by
turning the knob clockwise.
• Pump up the cuff until you no
longer feel the brachial pulse.
• Note the pressure on the
sphygmomanometer at which the
pulse is no longer felt.
Release the pressure the blood cannot flow
• Release the pressure completely in
the cuff, and wait 1 to 2 minutes through the artery.
before making further This gives an estimate of the maximum
measurements. pressure required to measure the systolic
pressure.
A waiting period gives the blood trapped in
the veins time to be released.

4. Position the stethoscope

appropriately.
Sounds are heard more clearly when the ear
• Insert the ear attachments of the
attachments follow the direction of the ear
stethoscope in your ears so that they
canal.
tilt slightly forward.
• Ensure the stethoscope hangs freely
from the ears to the diaphragm.
Rubbing the stethoscope against an object
• Place the diaphragm of the can obliterate the sounds of the blood
stethoscope over the brachial pulse. within an artery.
Use the bell-shaped diaphragm. Because the blood pressure is a low-
Hold the diaphragm with the thumb
 and index finger. frequency sound, it is best heard with the
bell-shaped diaphragm.
5. Auscultate the client’s blood
pressure.
• Pump up the cuff until the If the rate is faster or slower, an error on
sphygmomanometer registers about measurement may occur.
30 mm Hg above the point where
the brachial pulse disappeared.
• Release the valve on the cuff
carefully so that the pressure
decreases at the rate of 2 to 3 mm
Hg per second.
• As the pressure falls, identify the This permits blood trapped in the veins to
manometer reading at each of the be released.
five phases.
• Deflate the cuff rapidly and
completely.
• Wait 1 to 2 minutes before making
further determinations.
• Repeat the above steps once or
twice as necessary to confirm the
accuracy of the reading.
6. Remove the cuff from the client’s
arm.
7. If this is the client’s initial
examination
• There should be a difference of no
more than 5 to 10 mm Hg between
the arms.
• The arm found to have the highest
pressure should be used for
subsequent examinations.

8. Document and report pertinent

data.
• Document the blood pressure
according to agency policy. Record
two pressures in the form “130/80”
where “13” is the systolic (phase 1)
and (phase 5) pressure. Record
three pressures in the form “130/11
– 0/90,” where “130” is the systolic
“110” is the first diastolic (phase 4),
and “90” is the second diastolic
(phase 5) pressure. Use the
abbreviations RA for right arm LA
 for left arm. Record a difference of
greater than 10 mm Hg in the arms.
• Report any significance change is
then client’s blood pressure to the
nurse in charge.
• Also report these findings:
a. Systolic blood pressure (of an adult)
above 140 mm Hg
b. Diastolic blood pressure (of an
adult) above 90 mm Hg
c. Systolic blood pressure (of an adult)
below 100 mm Hg

Variation: Taking a Thigh Blood Pressure

• Help the client to assume a prone
position. If the client cannot assume Slight flexing of the knee will facilitate
this position with the knee slightly placing the stethoscope on the popliteal
flexed. phase.
• Expose the thigh, taking care not to
expose the client unduly.
• Wrap the cuff evenly around the
midnight with the compression
bladder over the posterior aspect of
then thigh and the bottom edge
above the knee.
• If this is the client’s initial
examination, perform a preliminary The bladder must be directly over the
palpatory determination of systolic posterior popliteal artery if the reading is to
pressure by palpating the popliteal be accurate.
artery. The systolic pressure in the
popliteal arteri is usually 20 t0 30
mm Hg higher than that in the
brachial artery because of use of a
larger bladder; the diastolic is
usually the same.
• Auscultate the pressure as above.

Evaluation Focus

The blood pressure in relation to baseline

data, normal range for age, and health
status, relationship to pulse and respiration.