Assessing Blood Pressure

Purposes:
 To obtain a baseline measurement of arterial blood pressure for subsequent
evaluation
 To determine the client’s hemodynamic status (e.g., cardiac output: stroke
volume of the heart and blood vessel resistance)

Equipment:
 Stethoscope or Doppler Ultrasound Stethoscope (DUS)
 Blood pressure cuff of the appropriate size
 Sphygmomanometer

 
No. Steps Rationale
  Preparation:  
 1 Ensure that the equipment is intact and Defective/malfunctioning
functioning properly. Check for leaks in the tubing equipment may render
between the cuff and the sphygmomanometer. erroneous result.  

2 Make sure that the client has not smoked or Smoking constricts blood
ingested caffeine within 30 minutes prior to vessels, and caffeine
measurement. increases the pulse rate.
Both of these cause a
temporary increase in blood
pressure.

  Steps:  
1 Prior to performing the procedure, introduce self To establish rapport and
and verify the client’s identity using agency gain cooperation.
protocol. Explain to the client what you are going
to do, why it is necessary, and how he or she can
participate. Discuss how the results will be used in
planning further care or treatments.
2 Perform hand hygiene and observe appropriate To prevent cross
infection prevention procedures. contaminations thereby
reducing
iatrogenic/nosocomial
infections.
3 Provide for client privacy.
4 Position the client appropriately.
 The adult client should be sitting unless Legs crossed at the knee
otherwise specified. Both feet should be flat results in elevated systolic
on the floor. and diastolic blood
pressures.
 The elbow should be slightly flexed with the The blood pressure
 palm of the hand facing up and the arm increases when the arm is
supported at heart level. Readings in any below the heart level and
other position should be specified. The decreases when the arm is
blood pressure is normally similar in sitting, above heart level.
standing, and lying positions, but it can vary
significantly by position in certain persons.

 Expose the upper arm

5 Wrap the deflated cuff evenly around the upper The bladder inside the cuff
arm. Locate the brachial artery. Apply the center of must be directly over the
the bladder directly over the artery. artery to be compressed if
the reading is to be
accurate.
 For an adult, place the lower border of the
cuff approximately 2.5 cm (1 in.) above the
antecubital space.
6 If this is the client’s initial examination, perform a The initial estimate tells the
preliminary palpatory determination of systolic nurse the maximal pressure
pressure. to which the
sphygmomanometer needs
to be elevated in subsequent
determinations. It also
prevents underestimation of
the systolic pressure or
overestimation of the
diastolic pressure should
auscultatory gap occur.

This gives an estimate of the

 Palpate the brachial artery with fingertips. systolic pressure.
 Close the valve on the bulb.
 Pump up the cuff until you no longer feel
the brachial pulse. At that pressure, the
blood cannot flow through the artery. Note
the pressure on the sphygmomanometer at A waiting period gives the
which pulse is no longer felt. blood trapped in the veins
 Release the pressure completely in the cuff,time to be released.
and wait 1 to 2 minutes before making Otherwise, false high
further measurements. systolic readings will occur.
7 Position the stethoscope appropriately.
 Cleanse the earpieces with antiseptic wipe.
 Insert the ear attachments of the
stethoscope in your ears so that they tilt Sounds are heard more
slightly forward. clearly when the ear
attachments follow the
 Ensure the stethoscope hangs freely from direction of the ear canal.
the ears to the diaphragm. If the stethoscope tubing
rubs against an object, the
 noise can block the sounds
of the blood within the
 Place the bell side of the amplifier of the artery.
stethoscope over the brachial pulse site. Because the blood pressure
is a low-frequency sound, it
is best heard with the bell-
shaped diaphragm.
 Place the stethoscope directly on the skin, This is to avoid noise made
not on clothing over the site. from rubbing the amplifier
against cloth.
 Hold the diaphragm with the thumb and
index finger.
8 Auscultate the client’s blood pressure.
 Pump up the cuff until the
sphygmomanometer reads 30 mmHg
above the point where the brachial pulse
disappeared.
 Release the valve on the cuff carefully so If the rate is faster or slower,
that the pressure decreases at the rate of 2 an error in measurement
to 3 mmHg per second. may occur.
 As the pressure falls, identify the There is no clinical
manometer reading at Korotkoff phases 1, significance to phases 2 and
4, and 5. 3.
 Deflate the cuff rapidly and completely. This permits blood trapped
 Wait 1 to 2 minutes before making further in the veins to be released.
determinations.
 Repeat the above steps to confirm the
accuracy of the reading – especially if it falls
outside the normal range (although this
may not be routine procedure for
hospitalized or well clients). If there is
greater than 5 mmHg difference between
the two readings, additional measurements
may be taken and the results averaged.
9 If this is the client’s initial examination, repeat the
procedure on the client’s other arm. There should
be a difference of no more than 10 mmHg
between the arms. The arm found to have the
higher pressure should be used for subsequent
examinations.

Variation: Obtaining a Blood Pressure by the

Palpation Method
If it is not possible to use a stethoscope to obtain
the blood pressure or if the Korotkoff sounds
cannot be heard, palpate the radial or brachial
pulse site as the cuff pressure is released. The
manometer reading at the point where the pulse
reappears is an estimate of systolic value.
 Variation: Taking a Thigh Blood Pressure
 Help the client to assume a prone position.
If the client cannot assume this position,
measure the blood pressure while the client
is in a supine position with the knee slightly
flexed. Slight flexing of the knee will
facilitate placing the stethoscope on the
popliteal space.
 Expose the thigh, taking care not to expose
the client unduly.
 Locate the popliteal artery.
 Wrap the cuff evenly around the midthigh The bladder must be directly
with the compression bladder over the over the posterior popliteal
posterior aspect of the thigh and the bottom artery if the reading is to be
edge above the knee. accurate.

 If this is the client’s initial examination,

perform a preliminary palpatory
determination of systolic pressure by
palpating the popliteal artery.
 In adults, the systolic pressure in the
popliteal artery is usually 20 to 30 mmHg
higher than that in the brachial artery; the
diastolic pressure is usually the same.

Variation: Using an Electronic Indirect Blood

Pressure Monitoring Device
 Place the blood pressure cuff on the
extremity according to the manufacturer’s
guidelines.
 Turn on the blood pressure switch.
 If appropriate, set the device for the desired
number of minutes between blood pressure
determinations.
 When the device has determined the blood
pressure reading, note the digital results.
10 Remove the cuff from the client’s arm.
11 Wipe the cuff with an approved disinfectant. Cuffs can become
significantly contaminated.
Many institutions use
 disposable blood pressure
cuffs. The client uses it for
the length of stay and then it
is discarded. This decreases
the risk of spreading
infection by sharing cuffs.
12 Document and report pertinent assessment data Undocumented
according to agency policy. Record two pressures findings/procedures are not
in the form “130/80” where “130” is the systolic considered done.
(phase 1) and “80” is the diastolic (phase 5)
pressure. Record three pressures in the form
“130/90/0,” where “130” is the systolic, “90” is the
first diastolic (phase 4), and sounds are audible
even after the cuff is completely deflated. Use the
abbreviations RA or RL for right arm or right leg
and LA or LL for left arm or left leg.