NURSING Blood Pressure Reading, Indirect: Taking Adult Patient

PRACTICE &
SKILL What is Taking an Indirect Blood Pressure Reading in an
Adult?
Blood pressure (BP) measurements reflect the pressure exerted by circulating blood upon
the walls of blood vessels. BP results from two forces: the pressure created by the heart
as it contracts to pump blood into the arteries and through the circulatory system and the
force of the arteries as the vessel walls resist the pumping pressure of the heart. Indirect
BP readings can be taken using either a manual sphygmomanometer (Figure 1) (e.g.,
manual mercury or aneroid [non-fluid based]) or an automated BP device (Figure 2) .
This Nursing Practice & Skill focuses on the skills needed to accurately perform indirect
BP measurement in an adult using both the automated method and manual methods

Figure 1: Manual sphygmomanometer.

Copyright 2014, EBSCO Information Services.
Authors
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA

Reviewers
Lee Allen, RN, MS
Glendale Adventist Medical Center,
Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA

Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA

Figure 2: An automated BP device. Copyright 2014, EBSCO Information Services.

November 6, 2015

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2015, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 What: BP is measured in millimeters of mercury (mmHg) in the United States, and by the International System of Units
(SI) in most countries outside the U.S. BP readings are comprised of two numbers, the systolic BP (SBP; i.e., the force of
the heart contracting during systole) and the diastolic BP (DPB; i.e., the pressure of the heart as it relaxes between beats
[diastole]), which is a function of blood volume and the size, elasticity, and resistance of the bodys blood vessels against
the hearts contractions
How: The inflatable cuff of the sphygmomanometer is placed around a limb to occlude an artery (typically the brachial
artery of the upper arm) and is inflated to a pressure that prevents the flow of blood through the brachial artery Figure 3
. As the cuff is slowly deflated, a stethoscope placed over the brachial artery is used to auscultate the rhythmic tapping of
Korotkoff sounds (i.e., the tapping sounds made by the blood flowing through the arteries during compression of the cuff
of the sphygmomanometer). Both manual methods of taking indirect BP measurement require the clinician to know how
to determine the appropriate size BP cuff to use and how to properly place the cuff on the patients brachial artery unless a
different position is preferred. The manual method requires knowledge of the appropriate pressure to inflate the cuff before
releasing the pressure to auscultate for Korotkoffsounds (For more information see, What You Need to Know Before Taking
an Indirect Blood Pressure Reading in an Adult, below)

Figure 3: Position the cuff over the upper arm and the stethoscope just above
the antecubital fossa. Copyright 2014, EBSCO Information Services.

Where: BP is measured in all areas where patient care is rendered

Who: Depending on facility protocol, licensed and unlicensed clinicians with specialized training are permitted to perform
manual indirect BP measurement. Although automated indirect BP measurement requires minimal training, it is important
for the clinician to recognize the automated indirect measurement is not always accurate and the initial measurement should
be compared to manual indirect measurement. A significant drawback to the use of automated BP machines is that readings
can be inaccurate for patients with an irregular heart rhythm (Howlin et al., 2010)

What is the Desired Outcome of Taking an Indirect Blood Pressure Reading in an

Adult?
BP measurement is performed to
establish a baseline BP for use as reference when interpreting future BP measurements
Assess for hypertension, defined as SBP 140 mmHg, and/or diastolic BP 90 mmHg and monitor the effect of
antihypertensive medication
Assess for hypotension, which could be the result of various conditions (e.g., dehydration, hemorrhage, infection,
neurogenic injury, and the effects of medications)
assist in determining the appropriate level of physical activity. Measuring BP during exercise is useful in evaluating the
stress placed on the heart during exertion and can be a valuable gauge in establishing an effective exercise program

Why is Taking an Indirect Blood Pressure Reading in an Adult Important?

BP is one of the four cardinal vital signs of health (i.e., the measures of physiological status that assess the bodys basic
functions [e.g., BP, body temperature, heart rate, respiratory rate]). Monitoring BP is an effective way of evaluating the stress
on the cardiovascular system; which has a global impact on the body
 Untreated hypotension can cause dizziness, fainting, organ damage, and eventually death
Signs and symptoms of a hypertensive crisis that can be life-threatening can include
severe chest pain
severe headache, especially if accompanied by confusion and blurred vision
nausea and vomiting
severe anxiety
shortness of breath
seizures
unresponsiveness
Compared to direct BP measurement, which requires a transducer-based arterial catheter and monitoring equipment), indirect
BP measurement is portable, less complicated and costly, and requires relatively limited instruction

Facts and Figures

In September 2015, the National Heart, Lung, and Blood Institute (NHLBI) announced significant conclusions from
a landmark study (Systolic Blood Pressure Intervention Trial; SPRINT) that suggested intensive BP management
significantly reduced rates of cardiovascular disease and lowered the risk of death among patients 50 years old with
hypertension who are at increased risk for heart disease or those with kidney disease. The NHLBI suggested the SBP target
of < 120 mmHg replace the existing target of < 140 mmHg (NHLBI et al., 2015)
In December 2013, the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 8) published updated recommendations on the treatment of hypertension, which include the
following key changes (James et al., 2013):
Less aggressive BP targets
Less aggressive thresholds for treatment-initiation for older adults and for individuals < 60 years of age with diabetes and
kidney disease
Elimination of the recommendation to use thiazide-type diuretics only as the initial therapy in most patients. Instead, for
non-Blackhypertensive patients, the recommendation is to begin treatment with one of the following: thiazide-type diuretic,
calcium channel blocker, angiotensin converting enzyme inhibitor, or angiotensin receptor blocker. For Black patients, the
recommendation is to initiate treatment with either a thiazide-type diuretic or calcium channel blocker
In the United States, BP definitions for individuals over age 18 are as follows (Chobanian et al., 2003; Note: These values
are standard parameters for BP assessment and are measured in mmHg. The first number represents SBP. The second
number, preceded by a forward slash, represents DBP):
Hypotension: 90/60 or less
Normal: More than 90/60 and less than 120/80
Prehypertension: More than 120/80 and less than 140/90
Stage 1 hypertension: More than 140/90 and less than 160/100
The Centers for Disease and Control and Prevention (CDC) includes a classification for uncontrolled BP: an average SBP
140 mmHg or an average DBP 90 mmHg (CDC, 2012)
Stage 2 hypertension: 160/100 and less than 180/102
Hypertensive crisis, also called hypertensive emergency, formerly called malignant hypertension: SBP 180 or DBP > 120
mmHg
An estimated 20% of adults worldwide have hypertension. In many countries, half of adults over 60 years of age are
hypertensive(Madhur et al., 2014)
Ambulatory BP monitoring (ABPM; i.e., measurement of BP at regular intervals over a 24-hour period by a small device
worn by the patient)is less likely to produce falsely elevated results due to white coat syndrome (i.e., hypertension caused
by anxiety while in the physicians office)and is more effective for assessing for hypertensive episodes because, rather
than using a single BP recording, BP measurements are averaged over a 24-hour period. In addition, ABPM can uncover
masked hypertension (i.e., normal BP readings in the clinicians office and elevated out-of-office BP). ABPM is superior
to home BP monitoring, because the latter involves periodic patient self-monitoring only and usually does not include
nocturnal measurements (Perry, 2013)
Although not as effective as ABPM, home BP monitoring does have advantages. Investigators in a cluster randomized
controlled study of 450 patients with uncontrolled BP reported that, at 6 months, BP control was achieved in 57% of
participants who underwent home BP monitoring in combination with pharmacist case management, compared to only
30% of participants who received the usual care. At 18 months, BP control was achieved in 71% and 57% of participants,
 respectively. Improvements in BP control achieved through home BP monitoring and pharmacist case management
persisted during 6 months of postintervention follow-up (Margolis et al., 2013)
Authors who conducted a recent systematic review reported that patient self-monitoring of BP is associated with a
2.5mmHg reduction in SBP and a 1.8mmHg reduction in DBP (Glynn et al., 2010)
Programs designed to educate patients with hypertension to self-monitor BP can improve BP control by teaching patients
how to use home BP monitors properly, how to correctly position the BP cuff over the brachial artery, and the importance of
not relying on a single reading but using an average of at least two BP measurements taken at least one minute apart (Fung et
al., 2014)
Researchers who conducted a recent study including 49 patients in the post-anesthesia care unit reported that clinicians often
used the forearm to measure BP for patients with large upper-arm circumference, a practice that resulted in inaccurate BP
readings. Note: The American Heart Association guidelines recommend the use of an appropriately-sized cuff positioned on
the upper arm to use the brachial artery (Watson et al., 2011)
A systematic review and meta-analysis noted that a difference of > 10 mmHg in DBP between both arms of a patient was
associated with pre-existingcardiovascular disease and all-cause mortality (Clark et al., 2012)

What You Need to Know Before Taking an Indirect Blood Pressure Reading in an
Adult
Prior to measuring indirect BP, clinicians should be knowledgeable about the following:
Knowledge of cardiovascular physiology as it relates to BP and knowledge of the events/substances that can cause
constriction or dilatation of blood vessels and affect the heart rate (e.g., medications, certain foods [e.g., tea, coffee,
caffeinated soft drinks], physical activity, changes in posture, hot or cold weather, emotional stress)
Recognition that BP can be affected by age, weight, pregnancy, pain, dietary salt intake, overall level of fitness, genetic
predisposition, disease processes (e.g., kidney disease, thyroid disease), use of alcohol or drugs, and cigarette smoking. BP
varies slightly throughout the day
Knowledge of the events of BP measurement, which include auscultating for the first and last Korotkoff sounds during cuff
inflation over an artery and observing the simultaneous pressure reading on the sphygmomanometer. When documenting
BP, the SBP value is recorded first and the two values are separated by a forward slash (e.g., 120/80 mmHg)
The first of the Korotkoff sounds denotes the SBP measurement, and signals that the pressure in the cuff is low enough to
allow blood to flow through the artery at the most forceful part of ventricular ejection
The last Korotkoff sound indicates the diastolic measurement, which is heard when the pressure in the cuff is low enough
for the blood to flow freely through the artery. It is typical to observe small bumps of the needle on the pressure gauge
after the Korotkoff sounds cease. Do not mistake the small needle bumps on the sphygmomanometer as DBP
remember, it is the Korotkoff sounds that indicate SBP and DBP, not the needle bumps on the sphygmomanometer
Patient considerations for measuring BP
Patient position: BP measurement should be taken in a seated or supine position. Feet should be flat on the floorcrossed
legs can impede blood flow. The patient should remain quiet
Patient activity level: Wait at least 20 minutes and verify that the patient is relaxed before measuring BP in patients who
have been engaged in activities that can temporarily increase BP (e.g., smoking, drinking coffee, walking briskly)
Equipment considerations for measuring BP
Cuff size selection: The cuff should be sized to accommodate the patients extremity. The cuff should be wide enough
to encircle 80% of the upper arm and long enough to be fastened securely (Figure 4) even if the cuff doesnt pop off
during inflation, an inappropriately sized cuff will produce inaccurate readings. Consider using a thigh cuff for an
obese patient or a pediatric cuff for patients with low body fat. Recommended cuff size per age group/size is as follows
(Figure 5) :
- Small adult (arm circumference < 23 cm/9 in) 12 cm/4.7 in x 18 cm/7 in
- Most adults (arm circumference < 33 cm/13 in) 12 cm/4.7 in x 26 cm/10.2 in
- Large-size adult (arm circumference < 50 cm/19.6 in) 12 cm/4.7 in in x 40 cm/15.7 in
 Figure 4: The blood pressure cuff width should cover approximately
80% of the upper arm. Copyright 2014, EBSCO Information Services.

Figure 5: Blood pressure cuffs are available in various sizes. Using an appropriately sized
cuff is essential for an accurate reading. Copyright 2014, EBSCO Information Services.

Stethoscopebell or diaphragm? When auscultating Korotkoff sounds, the bell of the stethoscope allows for better
auscultation of the lower-pitched Korotkoff sounds heard with arterial flow. Some clinical resources recommend
use of the bell for auscultation of low-pitched arterial sounds, while others make no specific recommendation. For
example, the American Heart Association recommended use of the bell for auscultating Korotkoff sounds in their
2004 guidelines (Pickering et al., 2005), while the American Association of Critical-Care Nurses (AACN) offered no
specific recommendation for bell or diaphragm in their 2010 Practice Alert for noninvasive BP measurement (American
Association of Critical-Care Nurses, 2010)
- The stethoscope should be placed firmly against the skin to make a complete seal between the edge of the bell (or
diaphragm) and the skin. Avoid pressing too firmly to avoid obliterating the lower-pitchedKorotkoff sounds
BP measurement technique considerations
Cuff positioning:Position the cuff around the upper arm so
- the lower border of the cuff is 23 cm/~1 inch above the antecubital fossa to best auscultate the brachial artery
- the artery mark on the cuff is aligned with the brachial artery
Arm support: Support the patients forearm at the level of the phlebostatic axis (i.e., the location of the right atrium,
which is the fourth intercostal space at the mid-anterior-posterior diameter of the chest [midaxillary line]) (Figure 6) . If
the arm is not supported properly, the muscle contraction can result in inaccurately high DBP measurement
- The BP reading can be inaccurately low if the arm is elevated above the heart level of the phlebostatic axis due to the
effect of gravity and inaccurately high if the arm is below the heart level
 Estimate SBP prior to actual measurement to avoid damaging blood vessels, which can occur if the cuff is inflated
more than 30 mmHg above the actual SBP. Prior to measuring BP, inflate the cuff so that it barely occludes the artery.
Palpate the radial or brachial pulse to determine the estimated systolic blood pressure(ESBP). When performing BP
measurement, inflate the cuff no more than 30 mmHg higher than the estimated value

Figure 6: Location of the phlebostatic axis. Copyright 2014, EBSCO Information Services.

Contraindications for measuring BP include use of a limb

being used for I.V. fluid infusion
with an arteriovenous (AV) shunt or fistula
on the same side of the body as mastectomy or axillary surgery
with evidence of disease or trauma
Be aware of the technique for measuring orthostatic BP measurements (i.e., BP measurements taken after lying supine for
five minutes and at one and three minute intervals after standing to detect postural changes) (CDC, n.d.). Often orthostatic
BP is measured several times to establish an average baseline (for more information, see Nursing Practice & Skill Vital
Signs, Postural: Measuring )
Preliminary steps that should be performed before taking an indirect BP reading include the following:
Review the facility/unit-specific protocol for the designated times for indirect measurement of BP
Review the treating clinicians order for measurement of BP if different from the scheduled times or methods (e.g.,
orthostatic measurements). Recognize that typically no order exists for BP measurement because as a standard of care, BP
measurement is taken on a scheduled basis or when the patients condition has changed
Review patients medical history/medical record for previous readings and to become knowledgeable about the baseline
reading and to determine if he/she has an irregular heart rhythm, which requires use of the manual technique
Review the manufacturers instructions for all equipment to be used and verify
the equipment is in good working order
Review the patients medical history/medical record for current medications, and any allergies (e.g., to latex, medications,
or other substances); use alternative materials, as appropriate
Gather the following equipment and supplies necessary for measuring BP indirectly:
Nonsterile gloves and additional personal protective equipment (PPE; e.g., gown, mask, eye protection) can be necessary
depending on the patients condition and if exposure to body fluids is anticipated
Facility-approved antiseptic wipes to disinfect equipment, including stethoscope and BP cuff, before and after patient
contact. Many facilities provide each patient with a disposable BP cuff that can be thrown away after the patient is
discharged
For manual BP measurement: sphygmomanometer with appropriately-sizedcuff, and stethoscope
For automated BP measurement: automated BP machine with appropriately-sized cuff
Written information to reinforce verbal instruction, if available

How to Take an Indirect Blood Pressure Reading in an Adult

Perform hand hygiene; don PPE
Identify the patient using at least two unique identifiers, according to facility protocol
 Establish privacy by closing the door to the patients room, and/or drawing the curtain surrounding the patients bed
Introduce yourself to the patient and family member(s) and explain your clinical role
Assess the patient and family for knowledge deficits and anxiety regarding BP measurement
Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language
barriers, or deafness); make arrangements to meet these needs if they are present
- Use a professional certified medical interpreter when a communication barrier exists
Explain the procedure for BP measurement and its purpose; answer any questions and provide emotional support as needed
Advise the patient that he/she might feel minor discomfort during cuff inflation. If using an automated cuff, explain that it
can inflate more tightly than manual ones. Reassure the patient that any discomfort caused by cuff inflation will be brief
Adhere to facility infection control standards and employ correct aseptic technique throughout the procedure
Assist the patient into a seated or supine position with the involved arm supported and positioned at the phlebostatic axis
Assess the selected arm to confirm there are no contraindications for BP measurement
Verify that the equipment, including stethoscope, has been disinfected between patients
(Note: The following directions assume use of the brachial arteryadjust the instructions below if a different artery is
selected.) Confirm the selected cuff is the appropriate size for the patient by wrapping the cuff snugly around the patients
upper arm, approximately 23 cm/~1 inch above the antecubital fossa. The artery marking on the cuff should be aligned with
the patients brachial artery
Perform a manual BP measurement as follows :

Estimate the systolic pressure by palpating the brachial or radial pulse while inflating the cuff to the pressure where the
pulse is obliterated, noting this measurement as the ESBP
Deflate the cuff and wait 3060 seconds for any venous congestion caused by the cuff to dissipate before measuring BP
Inflate the cuff to approximately 30 mmHg higher than the ESBP. The cuff should be inflated quickly to avoid
measurement distortion
Place the bell or diaphragm of the stethoscope over the brachial artery
Slowly release the cuff pressure while auscultating for Korotkoff sounds and observing the gauge on the
sphygmomanometer. At the first Korotkoff sound, note the pressure reading on the gauge (the needle on the gauge should
bump upward slightly, then continue to fall)this pressure measurement represents the SBP
Continue to listen for when the Korotkoff sounds cease and note the pressure gauge measurement. Record this reading as
the DBP
Recall that the SBP and DBP are identified by sounds, not by the intermittent needle bumps observed on the pressure
gauge
Perform automated BP measurement as follows a manual BP readings should be performed if the patient has an
irregular heart rhythm :
Power on the machine and wait for the indication the machine is ready to measure BP
Press the appropriate panel/button to begin cuff inflation and wait for the cuff to be inflated, then fully deflated
Note: Most automated BP measurement devices are programed to inflate the cuff to standard parameters. If your
patients SBP is higher than the established parameters, the machine will first attempt to measure BP using the standard
parameters, then reset itself to adjust upward until an accurate BP can be measured
Evaluate if the reading appears within the expected values based on previous baseline measurements and patients
condition. If the reading appears to be inaccurate, remeasure the BPbest practice is to use the manual method when
rechecking BP
Record the SBP/DBP numerical measurement shown on the display monitor
Advise the patient of the BP reading
Clean and disinfect equipment, including stethoscope, per facility protocol
Discard PPE and perform hand hygiene
Update the patients plan of care, if appropriate, and document indirect BP measurement in the patients medical record,
including the following information:
Date and time of BP measurement
BP measurement and type of device used
Site used to obtain BP
Patients position during the procedure
 Any unexpected patient events or outcomes, the nursing interventions performed, patients response to interventions, and
whether the treating clinician was notified
Patient/family member education, including topics presented, response to education provided/discussed, plan for follow-up
education, and details regarding any barriers to communication and/or techniques that promoted successful communication

Other Tests, Treatments, or Procedures That Can Be Necessary Before or After Taking
the Blood Pressure Reading in an Adult
Alert the treating clinician of unexpected readings
Diagnostic testing (e.g., EKG, echocardiogram, renal ultrasound, CT scan) can be ordered to evaluate for disorders causing
abnormal BP, as well as end-organ damage
If the abnormal BP is determined to be related to an existing treatment regimen, the treating clinician will adjust the plan
(e.g., lower or increase dosage or decrease in prescribed medication)
Counseling with nutrition services can be ordered if hypertension is related to unhealthy weight

What to Expect After Taking a Blood Pressure Reading in an Adult

The patients BP will be measured accurately without complications and with minimal discomfort

Red Flags
A hypertensive crisis or hypertensive emergency can require immediate treatment with intravenous antihypertensive
medications (e.g., nicardipine, nitroprusside, fenoldopam, nitroglycerin, enalaprilat, hydralazine, labetalol, esmolol, and
phentolamine)
Hypertensive crises require immediate treatment to avoid neurologic end-organ damage (e.g., hypertensive encephalopathy,
cerebral vascular accident/cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage), cardiovascular
end-organ damage (e.g., myocardial ischemia/infarction, acute pulmonary edema, aortic dissection, left ventricular
dysfunction), or damage to other organ systems (e.g., eclampsia during pregnancy, retinopathy, acute renal failure/
insufficiency)
Hypertensive crises are distinguished from hypertensive urgencies, in which target organ damage is not probable, but there
exists elevated risk for stroke, heart attack, and other life-threatening events
Life-threatening hypotension can indicate shock or cardiovascular collapse

What Do I Need to Tell the Patient/Patients Family?

Communicate the indication for BP measurement and the results of the measurement to the patient
If hypertension is diagnosed, the patient should be educated about making improvements in diet and lifestyle, such as
smoking cessation and weight loss
If home monitoring of BP is part of the treatment plan, the patient, family, and any caregivers, should be instructed how to
perform BP measurement and the importance of communicating with the treating clinician anyunexpected values, especially
SBP > 180mmHg or DBP > 120 mmHg
Provide contact information (name of contact, telephone number or pager with 24-hour access) in the event emergency care
is needed
Signs and symptoms of a hypertensive crisis (review the signs, symptoms, and complications of hypo- and hypertension
listed in Why is Taking an Indirect Blood Pressure Readings in Adults Important?)

References
1. American Association of Critical Care Nurses. (2010). AACN practice alert: Noninvasive blood pressure monitoring. Retrieved October 7, 1970, from
http://www.aacn.org/WD/practice/docs/practicealerts/NIBP%20monitoring%2004-2010%20final.pdf
2. Bishop, T. (2009). Measuring blood pressure. Practice Nurse, 38(9), 11, 13-16.
3. Blood pressure assessment. (2012). Lippincott's nursing procedures and skills. Retrieved October 7, 2015, from http://procedures.lww.com/lnp/view.do?pId=791972&s=p
4. Centers for Disease Control and Prevention. (n.d.). Measuring Orthostatic Blood Pressure. Retrieved October 7, 2015, from
http://www.cdc.gov/steadi/pdf/measuring_orthostatic_blood_pressure-a.pdf
5. Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., ... Roccella, E. J. (2003). Seventh report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42(6), 1206-1252. doi:10.1161/01.HYP.0000107251.49515.c2.
6. Clark, C. E., Taylor, R. S., Shore, A. C., Ukoumunne, O. C., & Campbell, J. L. (2012). Association of a difference in systolic blood between arms with vascular disease and
mortality: a systematic review and meta-analysis. The Lancet, 379(9819), 905-914. doi:10.1016/S0140-6736(11)61710-8
 7. Fung, C. S. -C., Wong, W. C. -W., Lee, A., & Lam, C. L. -K. (n.d.). Home blood pressure monitoring- A trial on the effect of a structured education program. Australian Family
Physician, 42(4), 233-237.
8. Glynn, L. G., Murphy, A. W., Smith, S. M., Schroeder, K., & Fahey, T. (2010). Self-monitoring and other non-pharmacological interventions to improve the management of
hypertension in primary care: A systematic review. British Journal of General Practice, 60(581), 924-929.
9. Hopkins, C. (2015, August 18). Hypertensive emergencies. Medscape. Retrieved October 7, 2015, from http://emedicine.medscape.com/article/1952052-overview#showal
10. James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J. T., ... Ortiz, E. (2013). Evidence-based guideline for the management of
high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. Advance online publication. doi:10.1001/
jama.2013.284427
11. Landmark NIH Study Shows Intensive Blood Pressure Management May Save Lives. (2015, September 11). Retrieved October 7, 2015, from
http://www.nhlbi.nih.gov/news/press-releases/2015/landmark-nih-study-shows-intensive-blood-pressure-management-may-save-lives
12. Madhur, M. S., Riaz, K. R., Dreisbach, A. W., & Harrison, D. G. (2014, September 30). Hypertension. Medscape. Retrieved October 7, 2015, from
http://emedicine.medscape.com/article/241381-overview#a0156
13. Margolis, K. L., Asche, S. E., Bergdall, A. R., Dehmer, S. P., Groen, S. E., Kadrmas, H. M., ... Trower, N. K. (2013). Effect of home blood pressure telemonitoring and
pharmacist management on blood pressure control: A cluster randomized clinical trial. JAMA, 310(1), 46-56. doi:10.1001/jama.2013.6549
14. Pickering, T. G., Hall, J. E., Appel, L. A., Falkner, B. E., Graves, J., Nill, M. N., ... Roccella, E. J. (2005). AHA scientific statement: Recommendations for blood pressure
measurement in humans and experimental animals. Part 1: Blood pressure measurement in humans: A statement for professionals from the Subcommittee of Professional and
Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation, 45, 142-161. doi:10.1161/01.HYP.0000150859.47929.8e
15. Valderrama, A. L., Gillespie, C., King, S. C., George, M. G., Hong, Y., & Gregg, E. (2012). Vital signs: Awareness and treatment of uncontrolled hypertension among adults
United States, 2003-2010. Centers for Disease Control and Prevention. Retrieved October 7, 2015, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6135a3.htm
16. Watson, S., Aguas, M., Bienapfl, T., Colegrove, P., Foisy, N., Jondahl, B., & Anastas, Z. (2011). Postanesthesia patients with large upper arm circumference: Is use of an
"extra-long" adult cuff or forearm cuff placement accurate? Journal of Perianesthesia Nursing, 26(3), 135-142. doi:10.1016/j.jopan.2011.02.001