ASSESSING BLOOD PRESSURE

DEFINITION:
Arterial blood pressure is a measure of pressure exerted by the blood as it flows through arteries. Because
the blood moves in waves, there are two blood pressure measurements, systolic and diastolic pressure.

PURPOSES:
 To obtain a baseline measurement of arterial blood pressure for subsequent evaluation
 To determine the client’s hemodynamic status
 To identify and monitor changes in blood pressure resulting from a disease process or medical
therapy

PRINCIPLES:
 A noisy environment can interfere with correct reading on sphygmomanometer
 A twisted cuff may produce unequal pressure and can cause inaccurate reading
 Accurate reading is possible only when the stethoscope is directly over the artery
 Airtight system of cuff and tubing facilitates accurate reading
 Sufficient pressure in the cuff obliterates the flow of blood through the brachial artery
 Wash hands before and after the procedure

EQUIPMENT:
 Stethoscope
 Blood pressure cuff of the appropriate size
 Sphygmomanometer

STEPS:
1. Introduce self, identify the client (ask the
complete name, check the wristband, and bed
tag) and explain the procedure.
RATIONALE:
Checking physician’s order can help the nurse to
know what specific part of the body to be treated.
Introducing oneself helps build trust and rapport
with the patient. And explaining the procedure
helps the patient understand, prepare for the
procedure, and reduces anxiety.

2. Wash hands aseptically. To prevent the spread of microorganism

3. Provide for client privacy. For the patient to be comfortable and ease anxiety.

4. Position the client appropriately.
 The adult client should be sitting unless
otherwise specified. Both feet should be flat
on the floor.
 The elbow should be slightly flexed with the
palm of the hand facing upward and the
forearm supported at heart level. (Note:
preferably left arm unless contraindicated)
 Expose the upper arm.
 Legs crossed at the knee results in elevated
systolic and diastolic blood pressures (Pinar,
Ataalkin, & Watson, 2010).
 The blood pressure increases when the arm is
below heart level and decreases when the arm is
above heart level.

5. Wrap the deflated cuff evenly around the upper
arm.
 Locate the brachial artery.
 Apply the center of the bladder directly over
the artery.
 The bladder inside the cuff must be directly
over the artery to be compressed if the reading
is to be accurate.

6. If this is the client's initial examination, perform  The initial estimate tells the nurse the maximal
a preliminary determination of systolic pressure. pressure to which the sphygmomanometer
  Palpate the brachial artery with the
fingertips.
 Close the valve on the bulb.
 Pump up the cuff until you no longer feel
the brachial pulse. Note the pressure on the
sphygmomanometer at which pulse is no
longer felt.
 Release the pressure completely in the cuff,
and for wait 1 to 2 minutes before making
further measurements.
7. Position the stethoscope appropriately.
 Cleanse the earpieces with antiseptic wipes
(prep pads).
 Insert the ear attachments of the stethoscope 
in your ears so that they tilt slightly forward.
 Ensure that the stethoscope hangs freely
from the ears to the diaphragm.
 Place the diaphragm side of the stethoscope 
over the brachial pulse site. (Note: for
Pediatric client, use bell side of the
stethoscope)
 Place the stethoscope on the skin, not on
clothing over the site.
 Hold the bell of the stethoscope on the side
of the rim 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
that the pressure decreases at the rate of 2 to
3 mmHg per second.
 As the pressure falls, identify the
manometer reading at Korotkoff phases 1, 4,
and 5.
 Deflate the cuff rapidly and completely.
 Wait 1 to 2 minutes before making further
determination.
 Repeat the above steps to confirm the
accuracy of the reading
9. If this is the client's initial examination repeat
the procedure on the client's other arm.
10. Make the client feel comfortable
11. Clean the earpieces of the stethoscope.
12. Do the aftercare of the equipment and wash
your hands.
needs to be elevated in subsequent
determinations. It also prevents underestimation
of the systolic pressure or overestimation of the
diastolic pressure should an auscultatory gap
occur.
 This gives an estimate of the systolic pressure.
 A waiting period gives the blood trapped in the
veins time to be released. Otherwise, false high
systolic readings will occur.
 Sounds are heard more clearly when the ear
attachments follow the direction of the ear
canal.
If the stethoscope tubing rubs against an object,
the noise can block the sounds of the blood
within the artery.
Because the blood pressure is a low-frequency
sound, it is best heard with the bell-shaped
diaphragm.
 This is to avoid noise made from rubbing the
amplifier against cloth.
 If the rate is faster or slower, an error in
measurement may occur.
There is no clinical significance to phases 2 and
3.
 This permits blood trapped in the veins to be
released.
To ensure accurate results
To have fast recovery of the patient
This decreases the risk of spreading infection
To maintain durable to prevent spread of
microorganism.
13. Document the BP reading on the client's record. For documentation and baseline data for health
plan.

REFERENCE:
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017a). Fundamentals of Nursing. Elsevier
Gezondheidszorg.
Berman, A. T., Snyder, S., & Msn Rn, F. G. E. (2020). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice (11th ed.). Pearson.