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Stella Palar

The Auscultator Method : Mercury, Aneroid and Hybrid


Location of measurement : Arm, Wrist, Finger, Thigh


- In the Clinic

- Self Measurement
The Auscultator Method
Korotkoff sounds

200 No sound

Clear sound Phase 1 Systolic BP
Muffling Phase 2
140 No sound gap

Phase 3
Clear sound Phase 3

Muffled sound Phase 4
Phase 4
80 Diastolic BP

40 No sound Phase 5

Recommended Equipment for
Measuring Blood Pressure

Use a mercury manometer or a

recently calibrated aneroid or a
validated automated device.

Aneroid devices should only be

used if there is an established
calibration check every 12
Recommended Equipment for
Measuring Blood Pressure at home

Automated oscillometric
Use a validated automated device
according to BHS, AAMI or IP
clinical protocols.

For home blood pressure

measurement devices, a logo on
the packaging ensures that this
type of device and model meets
the international standards for
accurate blood pressure
AAMI=Association for the Advancement of Medical Instrumentation;
BHS=British Hypertension Society; IP: International Protocol.
Location of Measurement

Arm - the standard location is the upper

Wrist a potential problem with wrist
monitors is the systematic error
introduced by the hydrostatic effect of
differences in the position of the wrist
relative to the heart
Finger Monitors have so far been
found to be inaccurate and are not
Blood Pressure Measurement in the Clinic:
Patient preparation and posture
Standardized Preparation:

1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the
preceding 30 minutes.
3. No use of substances containing
adrenergic stimulants such as
phenylephrine or pseudoephedrine (may
be present in nasal decongestants or
ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before
8. Patient should stay silent prior and during
the procedure.
Blood Pressure Measurement in the
Patient preparation and posture
Standardized technique:


The patient should be calmly

seated with his or her back well
supported and arm supported at
the level of the heart.

His or her feet should touch the

floor and legs should not be
Blood Pressure Assessment:
Patient position
Patient preparation
Cold exposure : 11/8 mmHg
Full bladder / bowel : 27 / 22 mmHg
Physical activity : 5-11 / 4-8 mmHg
Smoking : 10/8 mmHg
Stimulants : 8-10/7-8 mmHg (alcohol, smoking,
Talking : 17/13 mmHg
Use an appropriate size cuff
Arm circumference (cm) Size of Cuff (cm)

From 18 to 26 9 x 18 (child)

12 x 23 (standard adult
From 26 to 33

From 33 to 41 15 x 33 (large)

18 x 36 (extra large,
More than 41

For automated devices, follow the manufacturers directions.

For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.
Blood Pressure Measurement in the
Clinic: Body Position

The seated BP
measurement is the
standard position to
determine diagnostic
and therapeutic
treatment decisions

The standing blood

pressure is used to
test for postural
hypotension, if
present, which may
modify the treatment.
BP measurement in the Clinic:
Standing BP
Perform in patients :
- over age 65
- diabetes
- if symptoms of postural hypotension

Check after 1 to 5 minutes in the standing

position and under circumstances when the
patients complains of symptoms suggestive of
Blood Pressure Measurement in
the Clinic

Locate the brachial pulse

and centre the cuff bladder
over it
Position lower cuff border
2.5 cm above antecubital
Measurement of the pulse rate
The manometer scale should be at eye level, and
the column vertical. The patient should not be
able to see the column of the manometer
Position of the arm
If you immediately hear sound, pump up an
additional 20 mmHg and repeat

Deflate cuff slowly at a rate of 2-3 mmHg per


Listen for auditory vibrations from artery "bump,

bump, bump" (Korotkoff)

Systolic blood pressure is the pressure at which

you can first hear the pulse.

Diastolic blood pressure is the last pressure at

which you can still hear the pulse
In order to measure the BP

Avoid moving your hands

or the head of the
stethoscope while you are
taking readings as this may
produce noise that can
obscure the Sounds of
Technique of BP measurement
BP must take in both arms
and one lower extremity.
In order to measure the BP

The two arms readings

should be within 10-15
Differences greater then
10-15 mmHg imply
differential blood flow.
In order to measure the BP
If you wish to repeat the
BP measurement you
should allow the cuff to
completely deflate,
permit any venous
congestion in the arm to
resolve and then repeat
a minute or so later.
Home Measurement of BP
Home BP measurement should be encouraged to increase
patient involvement in care

For the diagnosis of hypertension

Suspected non adherence

Average BP equal to or over 135/85 mmHg

should be considered elevated
2009 Canadian Hypertension Education Program Recommendations
Measurement of BP for the
diagnosis of hypertension
Home BP values should be based on:

- duplicate measures,

- morning and evening,

- for an initial 7-days period.

Singular and first day home BP values should not be


For patients treated for hypertension: morning measurement

should be done before medication taking

2009 Canadian Hypertension Education Program Recommendations

Benefits of Home Blood Pressure
Rapid confirmation of the diagnosis of
Better prediction of cardiovascular
Diagnosis of white coat and masked
Reduced medication use in white coat
Improved adherence to drug therapy
Better blood pressure.

2009 Canadian Hypertension Education Program Recommendations

Recommended automated blood
pressure monitors for home blood
pressure measurement

Monitors A&D or LifeSource Models: 705, 767, 767PAC, 767Plus, 774, 774AC, 779, 787, 787AC
Monitors Omron Models: HEM-705 PC, HEM-711, HEM-741CINT
Monitors Microlife or Thermor (also sold under different brand names)
Models: BP 3BTO-A, BP 3AC1-1, BP 3AC1-1 PC, BP 3AC1-2, BP 3AG1, BP 3BTO-1,BP 3BTO-A (2), BP
3BTO-AP, RM 100, BP A100 Plus, BP A 100

2009 Canadian Hypertension Education Program Recommendations

Criteria of measurement in different methods
Systolic BP Diastolic BP
mmHg mmHg
Clinic BP 140 90

Home BP 135 85

Ambulatory BP
24 hour 130 80
Day 135 85
Night 120 70
Japan Society of Hypertension 2009
Ambulatory Blood Pressure Monitoring -
1. 24 hour B.P monitoring
2. Today - 24 hour B.P. control is essential
3. Identifies dippers and non-dippers
4. Excludes white coat hypertension

Stage 2 hypertensive dipper
Hypertensive Non-Dipper