ACCURACY IN

BLOOD PRESSURE
MEASUREMENT
Importance of site and accuracy

ACCURATE BLOOD PRESSURE (BP)

MEASUREMENT IS ESSENTIAL TO
PROVIDE APPROPRIATE HEALTHCARE

Classification of BP for adults aged 18 and older. Figures

based on the average of seated BP readings properly
measured during 2 or more office visits.

FOR MOST ACCURATE BLOOD

PRESSURE RESULTS

Patient should avoid caffeine, tobacco, or alcohol for 30 minutes

prior to measuring.
Patient should rest for 3 to 5 minutes before screening. They
should also refrain from talking.
Patient may lie supine or sit erect in a comfortable position, with
legs uncrossed and back supported.
Place patients arm at heart level, on a stable surface, allowing
the arm to remain still.
Wrap the properly sized cuff snugly around a bare arm, leaving
enough room for a fingertip under the cuff.
Be certain that the bottom edge of the cuff is 1 inch (2.5 cm)
above the antecubital fossa.
Position the cuff on the arm properly by placing the arrow or
tubing on the inside of the elbow.
Measure blood pressure in both arms during the initial assessment.
Take multiple readings at least one minute apart and record all
the results.
Measure at the same time daily unless otherwise specified.
Use the correct sized cuff for your arm.

WHY IS THE RIGHT SIZED CUFF

IMPORTANT?
The

right cuff size is very important.

Blood

pressure readings may be wrong if

your cuff is the wrong size.

If

the cuff is too wide, it will underestimate

the BP

While

a cuff that is too narrow tends to

overestimate the BP.

To

ensure proper size, the National Institute

of Health and American Heart Association
each offer different methods.

NATIONAL INSTITUTE OF
HEALTH PROPOSES THAT
Cuff

width should be 40% of the

circumference of the limb being used.

The

bladder within the cuff should

encircle 80% of the upper arm.

AMERICAN HEART
ASSOCIATIONS (AHAS)
GUIDELINES ON BP CUFF SIZE

Cuff
NEWBORN
INFANT
CHILD
SMALL ADULT
ADULT REGULAR
ADULT LARGE
THIGH

Arm Circumference
<2.5 (< 6 cm)
2.5-6 (615 cm)
68.5 (16-21 cm)
8-10 (22-26 cm)
1113 (27-34 cm)
1417 (35-44 cm)
1821 (45-52 cm)

AHA generally recommends larger cuffs be used for

borderline measurements (AHA. 1993).

The brachial (upper arm) site is the gold

standard for non-invasive BP monitoring.
However, in some situations, this site is
inaccessible due to injury, surgery, dialysis
shunts, intravenous devices, and
lymphedema.

When

the upper arm is unavailable to be

used, the forearm site is sometimes the
alternative. The increased incidence of
obesity also contributes to a heightened use
of forearm BP monitoring.

Upper Arm Placement

and Measurement
Place BP cuff 1 inch (2.5 cm) above the
antecubital fossa. Position the cuff on the
arm properly by placing the arrow on the
inside of the elbow to line up with the
brachial artery.

FOREARM PLACEMENT AND

MEASUREMENT
Place BP cuff 2-3 cm above radial artery, with the
arrow positioned over the radial artery. Support
forearm at heart level and auscultate at the radial
artery.

AMERICAN HEART ASSOCIATION GUIDELINES

RECOMMEND THE FOREARM METHOD
FOR SELECTED BARIATRIC PATIENTS
ONLY WHEN 1 OF THE FOLLOWING 2 CRITERIA IS MET:

Upper arm circumference is >20 (50 cm)

Size & shape of upper arm suggest

available cuffs will fit extremely poorly

When appropriate (per AHA guidelines), forearm BPs

should be assessed using an ADULT REGULAR cuff at the
radial artery (a regular size cuff is appropriate since
morbid obesity generally spares the wrist).

SOME RESEARCH STUDIES SHOWED THAT

FOREARM MEASURES ALL OVERESTIMATED THE UPPER
ARM MEASURES WITH GREATEST VARIABILITY IN
SYSTOLIC BLOOD PRESSURES.

THE FOREARM MEASURE OVERESTIMATED SYSTOLIC

(MEAN DIFFERENCE 2.2 MMHG) DIASTOLIC (MEAN
DIFFERENCE 3.4 MMHG), AND MEAN ARTERIAL
PRESSURES (MEAN DIFFERENCE 4.1 MMHG).

EVIDENCE BASED PRACTICE SHOWS

However, population wide, small inaccuracies in blood
pressure measurement can have considerable
consequences.
Underestimating true blood pressure by 5 mmHg would
mislabel more than 20 million Americans with
prehypertension when true hypertension is present. It has
been predicted that the consequences of an untreated 5
mmHg of excessive systolic blood pressure would be a 25%
increase over current levels of fatal strokes and fatal
myocardial infarctions for these individuals.
Conversely, overestimating true blood pressure by 5 mmHg
would lead to inappropriate treatment with antihypertension
medications in almost 30 million Americans, with attendant
exposure to adverse drug effects, the psychological effects
of misdiagnosis, and unnecessary cost.

Many questions remain concerning the accuracy

of forearm BP measurements. In fact, many
researchers recommend utilizing other alternative
BP measures, such as the popliteal (thigh) site,
ahead of the forearm.

Research has consistently found

that upper arm and forearm BP
readings are NOT
interchangeable.

Forearm BP's differ from upper arm BP's.

Recent evidence suggests forearm BPs overestimate systolic,
diastolic & mean values anywhere from 10 to 33 mmHg.
Trends in BP readings & patient status will need to be carefully
evaluated prior to treatment.
As a result, it is critical that when the forearm method is
indicated, all caregivers consistently use the forearm for BP
readings.
More so, the difference in BP measurement sites can be used
as a basis for a change in current practice to include
recording the BP measurement along with the site, as is current
practice with temperature measurement.

Accuracy in Blood Pressure measurement is relied upon

for both quality patient care and safe medication
administration. Many medications have an impact on not
only blood pressure but other vital signs and these
measurements are used in determining if the medication
should be given and to assess the effect of the
medication. Accuracy also plays a part in improving staff
communication in that the forearm and the brachial site
are not interchangeable. Remember the Brachial Site is
the Gold Standard.

Quality and Safety Education for Nurses competencies of

Evidence Based Practice play a part of accuracy in
blood pressure measurement as the different sites have
been researched and tested thoroughly such as in
Clinical Comparison of Automatic, Noninvasive
Measurements of Blood Pressure in the Forearm and
Upper Arm

NATIONAL PATIENT SAFETY

GOALS & QUALITY AND SAFETY
EDUCATION FOR NURSES

In what situations should the forearm site be

used?

QUIZ TIME

How do you properly measure a cuff for fit?

QUIZ TIME

How far from the Antecubital Fossa should the

cuff be placed?

QUIZ TIME

What happens if the cuff is too small or too

large?

QUIZ TIME

What is the Gold Standard location?

QUIZ TIME

References

American Heart Association. (2011, January). Understanding blood pressure readings. Retrieved from the American Heart Association Web site:
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure Readings_UCM_301764_Article.jsp>.
American Heart Association (2004). Recommendations for blood pressure measurement in humans and experimental animals. Hypertension, 45, 142. doi:
10.1161/01.HYP.0000150859.47929.8e
Fortune, M., Jeselnik, K., Johnson, S., Zhao, J., Wiley, L., Smith, A., & ... Crigger, N. (2009). A comparison of forearm and upper arm blood pressure measurements in a
sample of healthy young adults. Journal of Undergraduate Nursing Scholarship, 11(1), Retrieved from EBSCOhost.
Potter, P. A., & Perry, A. G. (2007). Basic Nursing: Essentials for Practice (6 ed.). St. Louis, MO: Mosby Elsevier.
Prisant, L. M., Friedman, B., Alpert, B., Grim, C. E., Hayes, M., & Grim, C. M. (2006). Miscuffing: a problem with new guidelines. Hypertension, 48 (4). doi:
10.1161/01.HYP.0000229663.60259.c0
Schell, K., Bradley, E., Bucher, L., Seckel, M., Lyons, D., Wakai, S., et al. (2005). Clinical comparison of automatic, noninvasive measurements of blood pressure in the
forearm and upper arm. American Journal of Critical Care, 14(3), 232-241. Retrieved from EBSCOhost.
United Hospital Research Council. (2008, January). Evidence-based practice (EBP) protocol: selecting an appropriately-sized cuff to ensure accurate bp readings.
Retrieved from: http://www.allina.com/ahs/united.nsf/page/BPCuff.pdf/$FILE/BPCuff.pdf
Wilson, S.F. & Giddens, J.F. (2009). Health assessment for nursing practice (4th ed.). St. Louis: Elsevier.