Taking Blood Pressure correctly-

it's no
OFF-THE-CUFF
matter

You may take blood pressure readings every day- but just how accurate are your
findings? Make sure you meet American Heart Association standards for this key
assessment procedure by reviewing the guidelines here.

Breathless, Patty Smith arrives for her clinic visit a few minutes late. As you prepare
to take her blood pressure, you learn that she's 39, single, and the mother of three
preteen children.

Her blood pressure by arm cuff is 140/94 mm Hg- not surprising, you think,
considering her obesity and her stressful life. You report your findings to the doctor,
who schedules her for a follow-up visit and possible therapy for high blood pressure.

But is this really such an open-and-shut case? Or could the reading be falsely high
because you used a normal-size adult cuff instead of one designed for larger
persons? Perhaps Patty's blood pressure was temporarily high because she was
harried and never stopped chattering about her trouble finding a sitter and a parking
space.

Though the procedure seems simple, taking a blood pressure reading with a cuff is
fraught with potential errors that can stand between you and a valid assessment of
your patient's condition. These errors could leave a hypertensive patient untreated
while a patient with normal blood pressure ends up on an expensive drug regimen
he doesn't need. Either way, the patient loses.

What's more, keep in mind that a single measurement may not represent your
patient's true blood pressure. The American Heart Association recommends this
procedure: Take your patient's blood pressure twice while he's standing, then record
the average of the two; next, take it twice while he's sitting and record the average
of those two. Document which pressure was taken with the patient standing and
which with him sitting. Use the sitting measurement as your final reading- the
standing measurement is a reference point only.
Initially, take the blood pressure in each arm and document any difference in the
reading. After that, use the arm that gave the higher reading.

Of course, measuring and assessing blood pressure is easy-provided you know the
three possible sources of error: the equipment, the patient and the operator (you).
Let's look at each one.

The equipment...

Errors can arise from uncalibrated or damaged equipment or from using the wrong
equipment. Mercury manometers, for example, can yield inaccurate readings if the
air vent at the top of the column is clogged or the mercury has oxidized. You may not
spot these problems by looking at the manometer, but suspect them if the mercury
column responds sluggishly. To prevent these problems, find out whether your
institution has a written policy for regular assessment and maintenance of mercury
manometers - and make sure to follow it.

With aneroid manometers, check before each use that the needle is on zero at
baseline. If it isn't, recalibrate it to a mercury manometer using a Y connector
attached to the tubing on both manometers. Compare pressures at several points
along the scale. As with mercury mamometers, be sure this equipment is monitored
and maintained regularly.

Incorrect cuff size is a major source of equipment-related errors. A cuff that's too
small will produce a falsely high reading; one that's too large, a falsely low reading.

Using the wrong-size cuff is a common problem with obese patients. Taken with a
regular cuff, their systolic and diastolic pressures will be falsely elevated. A similar
potential for error exists for patients with extremely thin arms- for them, a regular-
size cuff may be too big, leading to falsely low blood pressure readings.

To check for proper cuff size, the American Heart Association recommends
comparing the cuff with your patient's arm. The length of the bladder should be at
least 80% of the arm's circumference.

The stethoscope you use for auscultation should have a shallow bell with a large
diameter. This lets you auscultate (from auscultation: listening to the sounds within the body)
low-frequency sounds.
Most nurses use the diaphragm of the stethoscope, but you should use the bell to
auscultate indirect arterial blood pressures. Don't put too much pressure on the bell;
you may occlude arterial flow and dampen out the low frequencies.

...the patient...

As you know, using too small a cuff to measure an obese person's blood pressure can
cause a falsely elevated reading. You can also get a falsely high reading with a patient
who has a peripheral edema-even if you use the right equipment. Like obesity,
peripheral edema can diminish sound transmission, so avoid using edematous limbs
to take blood pressure when possible.

Talking can also produce a falsely high measurement, as can pain, anxiety, or
discomfort. Conversely, peripheral vasoconstriction, brought on by cold
temperatures or vasopressors, decreases blood flow and can cause a falsely low
reading.

Failing to support the patient's arm, which causes isometric muscle contraction, can
also lead to false measurements. So be sure the patient's arm is supported and
positioned at the level of his heart. Otherwise, hydrostatic and gravitational forces
within the blood vessel will produce a false reading: If his arm is above heart level,
you'll get a low reading; if it's below heart level, you'll get a high one.

In short, the more rested and relaxed your patient is while you're taking a reading,
the more reliable your measurement will be.

...and you

The last major source of blood pressure error is the person taking the measurement.
And in most instances, the problem is incorrect technique. (See 12 Steps to Taking
Accurate Measurements.)

To ensure an accurate reading, position a mercury manometer with the meniscus at

eye level and an aneroid manometer in your direct line of sight. To hear soft sounds
that you might otherwise miss, deflate the cuff slowly.

Taking a patient's blood pressure correctly requires keeping your eye not just on the
manometer but on the rest of the equipment, the patient, and yourself as well. If you
do, your efforts will translate into more effective practice for you and better care for
your patient.
WHAT YOU'RE MEASURING ISN'T WHAT YOU'RE HEARING

When you take a patient's blood pressure, you're measuring the pressure in the cuff-
only indirectly are you measuring the pressure in the blood vessel. Here's why.
The mercury or aneroid manometer is attached to the cuff's bladder. When the
pressure in that bladder exceeds their pressure in your patient's brachial artery, the
artery is compressed and distal blood flow diminishes, then stops.

As you release the air in the cuff, the bladder deflates and cuff pressure falls. Then
pressure in the cuff reaches the pressure generated by the heart during contraction,
blood begins to flow through the artery again.

This flow produces Korotkoff's sounds: sharp topping or knocking sounds at each
contraction. The cause of these sounds is still debated, but they may be caused by
blood jetting through the partly occluded vessel. The jetting causes turbulence in the
open vessel beyond the cuff.

According to the American Heart Association, Korotkoff's sounds occur in five

phases.

Phase 1: faint, clear, tapping sounds. This is the systolic pressure.

Phase 2: murmurs or swishing sounds

Phase 3: crisper, more intense sounds

Phase 4: distinct, abrupt muffle of sound. In children, this is the diastolic pressure; in
adults, it reveals hyperkintetic state (increased movement in blood vessels from
disease or strenuous exercise) if it remains throughout deflation.

Phase 5: no longer any sound. This is diastolic pressure in adults.

Korotkoff's sounds have a frequency that's too low for the unaided human ear.
Though you might estimate systolic pressure by palpating the return of the pulse in
the brachial artery, you can't detect diastolic pressure without a stethoscope's
amplification.

CHECK FOR PROBLEMS BEFORE THEY START

Stethoscope

• Check the tubing for holes.

• Clean any wax from the ear tips. Point earpieces forward.
• Use the bell portion of the stethoscope to listen for Korotkoff's sounds. Be
sure to place it lightly over the artery, with skin contact all around.

Cuff

• Make sure the cuff size suits your patient.

• Check to see that the screw valve on the ball works properly.
• Pump up the bladder and watch for any air leaks. If the mercury column or
aneroid needle doesn't rise steadily as you pump the ball, suspect a leak.

Aneroid Manometer

• Check that the needle is at the zero mark at the start and the end of the
measurement.
• Place the manometer in your direct line of sight.

Patient

• Determine whether your patient has smoked or drunk alcoholic beverages

within the last 15 minutes. Both can alter the reading.
• Determine whether the patient has done any vigorous activity (walking,
running, chores, etc.)
• If possible, have him sit or lie down for 5 minutes.
• Remove all clothing from his arm. Avoid using an arm that has an I.V. line,
shunts, edema, injury, or paralysis. Don't place the cuff over clothing or let a
rolled-up sleeve constrict the arm.
• Ask your patient not to talk during the measurement.
• Flex the arm and support it on a smooth surface at heart level.
 • Place the center of the inflatable bladder over the brachial artery.

By Frances Dee Anderson, RN, CCRN, PhD

Lieutenant Colonel, Army Nurse Corps
Director, Critical Care
Dwight David Eisenhower Army Medical Center
Augusta, Georgia

Joseph P. Maloney, RN, PhD

Associate Professor
Medical College of Georgia
Augusta, Georgia