Vital Signs: Assessing Blood Pressure

PROCEDURE RATIONALE
1. Check Physician’s order Establish parameters for client’s normal
measurements and helps determine site to use
for measurement.
2. Identify the patient
3. Introduce yourself and explain the procedure to the patient This will decrease anxiety and promote
cooperation
4. Perform hand hygiene and put on gloves if appropriate or Reduces the transmission of microorganisms
indicated
5. Close curtains around bed and close door to room if Promoting client’s privacy and to reduce
possible embarrassment
6. Select the appropriate arm for application of cuff
7. Have the patient assume a comfortable lying or sitting To obtain accurate reading. Measurements
position with the forearm supported at the level of the made with arm dangling by the hip can be 11-
heart and the palm of the hand upward. 12 mmHg higher than those made with arm
supported. Measurement made with arm raised
can be falsely high.
8. Expose the brachial artery by removing garments, or move To obtain accurate reading.
a sleeve, if it is not too tight, above the area where the cuff
will be placed
ESTIMATING SYSTOLIC PRESSURE
9 Palpate the location of the brachial artery. Center the To obtain correct reading.
bladder of the cuff over the brachial artery, about midway
on the arm, so that the lower edge of the cuff is about 2.5
to 5 cm (1” to 2”) above the inner aspect of the elbow. Line
up the artery marking on the cuff with the patient’s brachial
artery. The tubing should extend from the edge of the cuff
nearer the patient’s elbow.
10 Wrap the cuff around the arm smoothly and snugly, and
fasten it. Do not allow any clothing to interfere with the the
proper placement of the cuff
11 Check that the needle on the aneroid gauge is within zero
mark.
12 Palpate the pulse at the brachial or radial artery by
pressing gently with the fingertips
13 Tighten the screw valve on the air pump
14 Inflate the cuff while continuing to palpate the artery. Note To avoid error caused by ausculatatory gap.
the point on the gauge where the pulse disappears About 5% of population have auscultatory gap
and it is most common in those with
hypertension
15 Deflate the cuff and wait until 15 seconds
OBTAINING BLOOD PRESSURE MEASUREMENT
16 Assume a position that is no more than 3 feet away from
the gauge
17 Place the stethoscope earpieces in your ears. Direct the To obtain accurate reading
earpieces forward into the canal and not against the ear
itself
18 Place the bell or diaphragm of the stethoscope firmly but Excessive pressure can distort sounds or make
with as little pressure as possible over the brachial artery. them persist for longer than normal
DO not allow the stethoscope to tough clothing or the cuff
19 Pump the pressure 30mm Hg above the point at which the Pressure exerted prevents blood from flowing
systolic pressure was palpated and estimated. Open the through the artery.
valve on the manometer and allow air to escape slowly Slower rates can cause venous congestion and
(allowing the gauge to drop 2 to 3 mm per heartbeat.) arm pain. Faster rates of deflation give
inaccurate reading.
20 Note the point on the gauge at which the first faint but
clear, sound appears that slowly increases in intensity.
Note the number as the systolic pressure
21 Read the pressure to the closest even number
22 Note the pressure at which the sound first becomes
muffled. Also observe the point at which the sound
completely disappears.
23 Allow the remaining air to escape quickly. Repeat any
suspicious reading, but wait 30-60 seconds between
readings to allow normal circulation to return in the limb.
Deflate the cuff completely between attempts to check the
blood pressure.
24 Remove the cuff, and clean and store the equipment
25 Remove gloves if worn, perform hand hygiene
An average of two or more readings is often
taken to represent patients BP. Taking more
than one blood pressure reduces the
influences of anxiety.
To reduce the risk of cross infection
To reduce the risk of cross infection