Vital Signs – Blood Pressure

Equipment:

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• Aneroid sphygmomanometer
• Cloth or disposable vinyl pressure cuff or appropriate size for patient’s extremity
• Stethoscope
• Alcohol swab
• Pen and vital sign flow sheet in chart or electronic health record (EHR)

Steps:

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1. WIIAPA:
   1. Wash hands
   2. Introduce self
   3. Identify patient (use 2 identifiers)
   4. Allergies – don’t forget food allergies
   5. Plan of care
   6. Assess patient

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2. Determine previous baselines BP and site from patient’s record.
3. Have patient assume sitting or lying position. Be sure that room is warm, quiet and relaxing. Provide privacy.
4. Assess BP by auscultation:
   • Upper extremity: with patient sitting or lying, position his or her forearm at heart level with palm turned up. If sitting, instruct patient to keep feet flat on floor without legs crossed. If supine, patient should not have legs crossed.
   • Lower extremity: with patient prone, position patient so knee is slightly flexed.
5. Expose extremity (arm or leg) fully by removing constricting clothing. Cuff may be placed over a sleeve as long as stethoscope rests on skin.
6. Palpate brachial artery (arm) or popliteal artery (leg). With cuff fully deflated, apply bladder of cuff above artery by centering arrows marked on cuff over artery. Position cuff 2.5 cm (1 inch) above site of pulsation. With cuff fully deflated, wrap it evenly and snugly around upper arm or leg.
7. Position manometer gauge vertically at eye level.
8. Measure BP using two-step method:
   • Relocate brachial or popliteal pulse. Palpate artery distal to cuff with fingertips of nondominant hand while inflating cuff rapidly to pressure 30 mm Hg above point at which pulse disappears. Slowly deflate cuff and note point when pulse reappears. Deflate cuff fully and wait 30 seconds.
   • Place stethoscope earpieces in ears and be sure that sounds are clear, not muffled.
   • Relocate artery and place bell or diaphragm chest piece of stethoscope over it.
   • Close valve of pressure bulb clockwise until tight. Quickly inflate cuff to 30 mm Hg above patient’s estimated systolic pressure.
   • Slowly release pressure bulb valve and allow manometer needle to fall at rate of 2 to 3 mm Hg/second.
   • Note point on manometer when you hear first clear sound. Sound will slowly increase in intensity.
   • Continue to deflate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mm Hg. Listen for 20 to 30 mm Hg after last sound and allow remaining air to escape quickly.
9. Measure BP using one-step method:
   • Place stethoscope earpieces in ears and be sure that sounds are clear, not muffled.
   • Relocate brachial or popliteal artery and place bell or diaphragm chest piece of stethoscope over it.
   • Close valve of pressure bulb clockwise until tight. Quickly inflate cuff to 30 mm Hg above patient’s usual systolic pressure.
   • Slowly release pressure bulb valve and allow manometer needle to fall at rate of 2 to 3 mm Hg/second. Note point on manometer when you hear first clear sound. Sound will slowly increase in intensity.
   • Continue to deflate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mm Hg. Listen for 10 to 20 mm Hg after last sound and allow remaining air to escape quickly.
   • Remove cuff from patient’s arm or leg unless you need to repeat measurement.
   • If this is the first assessment of the patient, repeat the procedure on the other arm or leg.
10. Assess systolic BP by palpation:
    • Upper extremity: with patient sitting or lying, position his or her forearm at heart level with palm turned up. If sitting, instruct patient to keep feet flat on floor without legs crossed. If supine, patient should not have legs crossed.
    • Lower extremity: with patient prone, position patient so knee is slightly flexed.
    • Expose extremity (arm or leg) fully by removing constricting clothing. Cuff may be placed over a sleeve as long as the stethoscope rests on the skin.
    • Palpate brachial artery (arm) or popliteal artery (leg). With cuff fully deflated, apply bladder of cuff above artery by centering arrows marked on cuff over artery. If the cuff does not have any center arrows, estimate the center of the bladder and place this center over the artery. Position cuff 2.5 cm (1 inch) above the site of pulsation. With cuff fully deflated, wrap it evenly and snugly around the upper arm or leg.
    • Position manometer gauge vertically at eye level. You should be no farther than 1 meter (approximately 1 yard) away.
    • Locate and then continually palpate brachial, radial, or popliteal artery with fingertips of one hand. Inflate cuff to pressure 30 mm Hg above the point at which you can no longer palpate pulse.
    • Slowly release the valve and deflate the cuff, allowing the manometer needle to fall at a rate of 2 mm Hg/second. Note the point on the manometer when the pulse is again palpable.
    • Deflate the cuff rapidly and completely. Remove the cuff from the patient’s extremity unless you need to repeat the measurement.
11. Help patient return to a comfortable position and cover the upper arm or leg if previously clothed.
12. Discuss findings with the patient.
13. Clean earpieces and diaphragm of the stethoscope with an alcohol swab as needed. Wipe the cuff with an agency-approved disinfectant if used between patients.
14. Perform hand hygiene.
15. Document.