Assessing Blood Pressure

Purposes:
1. To obtain a baseline measurement of blood pressure for subsequent evaluation
2. To determine the client’s hemodynamic stable(e.g., cardiac output; stroke volume of the heart and blood
vessel resistance
3. To identify and monitor changes in blood pressure resulting from a disease process or medical therapy (e.g.,
presence of history of CVD, renal disease, circulatory shock or acute pain, rapid infusion of fluids or blood
products)
Assess:
1. S/Sx of hypertension (headache, ringing in the ears, flushing of face, nosebleed, fatigue)
2. S/Sx of hypotension (tachycardia, dizziness, mental confusion, restlessness, cool and clammy skin, pale or
cyanotic skin)
3. Factors affecting blood pressure (activity, emotional stress, pain, and time the client last smoked or ingested
caffeine)
4. Some blood pressure cuff contains latex, assess the client for latex allergy and obtain a latex free cuff if
indicated
Equipment:
1. Blood pressure cuff of the appropriate size.
a. Blood pressure cuffs come in various must be the correct sizes because the bladder must be correct
width and length for the client’s arm
b. Bladder to narrow, Bp reading will be elevated
c. Bladder to wide, Bp reading will be erroneously low
d. Bladder width should be 40% of the circumference
i. Lay the cuff lengthwise at the midpoint of the upper arm, with the other hand, wrap the
width of the cuff around the arm, and ensure that the width is 40% of the arm circumference
e. Bladder length should be sufficiently long to cover at least 2/3 of the limbs circumference. For obese
clients, a standard sized bladder in an extra-long cuff may be the most appropriate (McFarlane,2012)
2. Sphygmomanometer
Classification of Blood Pressure
Table 29-4 page 527
FNP by Kozier
Category Systolic BP (mm/hg) Diastolic BP (mm/hg)
Normal <120 and <80
Prehypertension 120-130 or 80-89
Hypertension stage 1 140-159 or 90-99
Hypertension stage 2 >160 or >100

Steps Rationale
Perform hand hygiene and observe appropriate Reduces transfer of microorganisms
infection prevention procedures.
Assembles/ gather equipment needed
 Check for leaks in the tubing between the cuff
and the sphygmomanometer
Introduce self and verify the client’s identity using Ensures correct patient
agency protocol.
Make sure that the client has not smoked or ingested Smoking constricts blood vessels, and caffeine
caffeine within 30 minutes prior to measurement. increases the pulse rate. Both of these causes
temporary increase in blood pressure
Ask the client to rest for 5 minutes before
measurement. Activity affects BP readings.

Explain the procedure

 What you are going to do To allay fear
 Why is it necessary To gain cooperation
 How he/she can participate
 How the result will be used in planning further
 care or treatments
Determine which extremity is most appropriate The client has an intravenous infusion or blood
transfusion in that limb
The client has an Arteriovenous fistula (renal
dialysis) on that limb
The blood pressure cannot be measured on either
arm because of burns or other trauma
A cast or bulky bandage is on any part of the limb
The client has a surgical removal of breast or axillary
(or inguinal) lymph nodes on that side
Select appropriate cuff size
Provide client privacy
Position the Client appropriately Legs crossed at the knee results in elevated systolic
 The adult client should be sitting unless and diastolic blood pressure (Pinar 2010)
otherwise specified
 Both feet should be flat on the floor
 The elbow should be slightly flexed with the The blood pressure increases when the arm is below
palm of the hand facing up and the arm the heart level and decreases when the arm is
supported at the heart level. Readings in any above heart level.
other position should be specified. The blood
pressure is normally similar in sitting, standing,
and lying position, but it can vary significantly
by position in certain persons.
Moves clothing away from the outer aspect of the
arm.
Make sure the bladder cuff is fully deflated and the
pump valve move freely
Wrap the deflated cuff evenly around the upper arm. The bladder inside the cuff must be directly over the
Locate the brachial artery. Apply the center of the artery to be compressed if the reading is to be
bladder directly over the artery. accurate.
 For an adult, place the lower border of the
cuff approximately 2.5 cm (inch) above the
antecubital space
If this is the client’s initial examination, perform a The initial estimate tells the nurse the maximal
preliminary palpatory determination of systolic pressure to which the sphygmomanometer needs to
pressure. be elevated in subsequent determinations. It also
 Palpate the brachial artery with the finger prevents underestimation of the systolic pressure or
pads overestimation of the diastolic pressure should an
 Close the valve on the bulb auscultatory gap occur.
 Pump up the cuff until you no longer feel the
brachial pulse. At that, the pressure the blood This gives an estimate of the systolic pressure
cannot flow through the artery.(remember the
reading)
NOTE the pressure on the A waiting period gives the blood trapped in the
sphygmomanometer at which pulse is no veins time To be released. Otherwise, false high
longer felt. systolic readings will occur
 Release the pressure completely in the cuff
and wait 1-2 minutes before making further
measurements
Position the stethoscope appropriately using non
dominant hand Sounds are heard more clearly when the ear
 Cleanse the earpiece with antiseptic wipes attachments follow the direction of the ear canal
 Insert the ear attachments in your ears, so
that they tilt slightly forward If the stethoscope tubing rubs against an object, the
 Ensure that the stethoscope hangs freely from noise can block the sounds of the blood within the artery
the ears to the diaphragm Because the blood pressure is a low frequency
 Place the the bell side of the amplifier of the sound, it is best heard with the bell shaped
stethoscope over. diaphragm
 Place the stethoscope directly on the skin, not
on clothing over the site This is to avoid noise made from rubbing the
 Hold the diaphragm with the thumb and index amplifier against cloth.
finger
Auscultate the client’s blood pressure
  Pump up the cuff until the
sphygmomanometer reads 30mm/hg where
the brachial pulse disappeared
 Release the valve on the cuff carefully so that If the rate is faster or slower, an error in
the pressure decreases at the rate of 2 to 3 measurement may occur
mm/hg per second
 As the pressure falls, identify the manometer There is no clinical significance to phases 2 and 3
reading at korotkoff phases 1,4 and 5
 Phase 1, the pressure level at which
the first faint clear tapping or This permits the blood trapped in the veins to be
thumping sounds are heard released
 The 1st tapping sound heard during
deflation of the cuff is the systolic
blood pressure
 Phase 4 and 5, The pressure at which
the last sound is heard is the diastolic
pressure. Followed by a period of
silence
 Deflate the cuff rapidly and completely
 Wait 1 to 2 minutes before making further
determinations
 Repeat the above steps to confirm the
accuracy of the reading- especially if it fails
outside the normal range
If this is client’s initial examination, repeat the
procedure on the client’s other arm, unless
contraindicated. There should be a difference of no
more than 10mm/hg between the arms. The arm
found to have the higher pressure should be used for
subsequent examinations
Variation: Obtaining Blood pressure by the palpation
method:
 If it is not possible to use stethoscope to
obtain blood pressure, or if korotkoff sound
cannot be heard, palpate the radial or brachial
pulse site as the cuff pressured is released.
The manometer reading at the point where
the pulse reappears is an estimate of systolic
value
Variation: Taking a thigh Blood pressure
 Help the client to assume a prone position. If
the client cannot assume this position,
measure BP while the patient is in supine
position with the knee slightly flexed. Slight
flexing of the knee will facilitate placing the
stethoscope on the popliteal space.
 Expose the thigh, taking care not to expose
the client unduly
 Locate the popliteal artery
 Wrap the cuff evenly around the midthigh The bladder inside the cuff must be directly over the
with the compression bladder over the artery to be compressed if the reading is to be
posterior aspect of the thigh and the bottom accurate.
edge above the knee
 If this is the client’s initial examination,
perform a preliminary palpatory
determination of systolic pressure, by
palpating the popliteal artery
 In adults, the systolic pressure in the popliteal
artery is usually 20 to 30 mm/hg higher than
the brachial artery; the diastolic pressure is
usually the same

Informs the client of the reading Promotes participation in care and understanding of
 health status
Remove the cuff from the client’s arm
Make the patient comfortable
Wipe the cuff with approved disinfectant Cuffs can become significantly contaminated. Many
institutions use disposable cuff, the client uses it for
the length of stay and then it is discarded
This decreases the risk of spreading infection by
sharing cuffs.
Document and report pertinent assessment data
according to agency policy
 RA/LA
 RL/LL
Washes hands
Reports untoward findings For necessary intervention

Assessment Orthostatic Hypotension

1. Place the client in a specific position for 10 minutes
2. Record the client Blood pressure
3. Assist the client to sit or stand. Support the client in case of faintness.
4. Immediately check the blood pressure in the same sites as previously
5. Repeat the pulse and blood pressure after 3 minutes
6. Record the results. A drop in the blood pressure of 20 mmhg systolic or 10 mmhg diastolic, indicates
orthostatic hypotension