Definition
It includes measuring blood pressure using a sphygmomanometer
Purposes
- To determine patient’s blood pressure as a baseline for comparing future measurements.
- To aid in diagnosis.
- To aid in the assessment of cardiovascular system preoperatively and postoperatively, during and after invasive procedure
- To monitor changes in the condition of patient
- To assess response to medical therapy.
- To determine patient’s hemodynamic status.
Articles
1. A sphygmomanometer comprises:
- Compression bag/inflatable rubber bladder enclosed in a cloth cuff (appropriate size)
- An inflating bulb (to raise the pressure)
- A manometer (mercury) to read the pressure
- A screw type release valve for inflation and deflation (to control the pressure).
2. Stethoscope
3. Patient chart for recording
4. Black/blue pen for charting
Procedure
| Nursing Action | Rationale | |
| 1 | Before procedure Check physician’s order, nursing care plan, and progress notes | Obtains any specific instruction/information. |
| 2 | Explain the procedure and reassure the patient. Ensure that patient has not smoked, consumed caffeine, or involved in strenuous physical and mental activity 30 min prior to procedure | Obtains patient’s consent and cooperation and also relieves anxiety. Smoking and ingestion of caffeine can increase blood pressure. |
| 3 | Collect and check equipment. | Ascertains evidence of malfunction. |
| 4 | During procedure Wash and dry hands. | Prevents cross infection. |
| 5 | Assist the patient to either sitting or supine position and ensure that legs are not crossed. | Obtains an accurate reading |
| 6 | Position the sphygmomanometer at approximately heart level of the patient ensuring that mercury level is at zero. | Helps in obtaining accurate reading |
| 7 | Select a cuff of appropriate size. | Ensures that compression bladder wider is at least 20% wider than the circumference of the midpoint of the extremity used. If the bladder is too wide the reading may be erroneously low. If it is too small, the reading may be erroneously high. |
| 8 | Expose the arm to make sure that there is no constrictive clothing above the placement of cuff. | Ensures accurate reading. |
| 9 | Apply the cuff approximately 2.5 cm above the point where brachial artery can be palpated. The cuff should be applied smoothly and firmly with the middle of the rubber bladder directly over the artery | Ensures accurate reading. Wrapping the cuff too tightly will impede circulation whereas wrapping the cuff very loosely will lead to false elevation of pressure. |
| 10 | Secure the cuff by tucking the end underneath or by fixing the Velcro fastener. | Prevents unwrapping of the cuff |
| 11 | Place the entire arm at the patient’s heart level. | Obtains accurate reading. For every centimeter that the cuff is above below heat level, blood pressure varies by 0.8mm of mercury |
| 12 | Keep the arm well rested and supported. | Ensure comfort of the patient thereby enable an accurate reading. Movement of arm can cause noise when auscultating. |
| 13 | Place yourself in a comfortable position | |
| 14 | Connect the cuff tubing to the manometer tubing and close the valve of the inflation bulb. | |
| 15 | Palpate the radial pulse and inflate the cuff until pulse is obliterated. | Estimates systolic pressure to determine how high to pumps mercury to avoid errors related to auscultatory gap. |
| 16 | Inflate the compression bag further 20-30 mm of mercury and then slowly deflate the cuff. Note the point at which pulse reappears and then release the valve | Ensures that mercury column is high enough to minimize error related to auscultatory gap. The point at which pulse reappears is the systolic pressure. |
| 17 | Palpate brachial artery and place diaphragm of the stethoscope lightly over the brachial artery. Ensure that ear pieces of the stethoscope are placed correctly (slightly tilted forward and ensure that tubing hangs freely). Raise mercury level 20-30 mm Hg above the point of systolic pressure obtained by means of palpatory method. | Ensures accurate reading. If diaphragm is placed too firmly the artery gets compressed. Sounds are heard well with correct placement of Stethoscope. Rubbing of stethoscope against an object can obliterate Korotkoff sounds |
| 18 | Release the valve of the inflation bulb, so that mercury column falls at the rate of 2-4 mm Hg per second. | Prevents venous congestion and falsely elevated pressure reading due to slower rate of deflation and prevents erroneous reading d to faster rate of deflation. |
| 19 | When the first sound is heard, mercury level is noted, this denotes systolic pressure | First sound is heard when the blood begins to flow through brachial artery. |
| 20 | Continue to deflate the cuff, note the point on manometer at which sound muffles. This is diastolic pressure. | |
| 21 | Deflate the cuff completely. Disconnect the tubing and remove the cuff from patient’s arm. | Occlusion of artery during the pressure reading causes venous congestion in the forearm. |
| 22 | Repeat the procedure after one minute if there is any doubt about the reading. | Waiting time of one minute allows venous blood to drain completely. |
| 23 | After procedure Ensure that patient is comfortable. | |
| 24 | Remove equipment and clean earpiece with a spirit swab | Prevents cross infection. |
| 25 | Wash and dry hands. | Prevents chances of cross infection. |
| 26 | Document the reading in appropriate observation chart or flowchart. | |
| 27 | Report any abnormal findings. |
Special Precautions
1. Do not the blood pressure on a patient’s arm if:
- The arm has an intravenous infusion
- The arm is injured/infected.
- The arm has a shunt/fistula for renal dialysis
- On the same side, if the patient had a radical mastectomy
- If the arm is paralyzed
2. Always chosen is needed for blood before checking upright measurement.
3. if comparison is needed for blood pressure in lying/standing position,
a minimum of 3 minutes.
4. Use appropriate size cuff.
Paediatric Variations
- For children on appropriate cuff size is one having a bladder width approximately 40% of the arm circumference midway between the olecranon and acromion processes.
- Systolic pressure in lower extremities (thigh/calf) is greater than the pressure in the upper extremities.
Normal Bp Range-Age wise
| Age | Minimum | Normal blood pressure (mm of Hg) |
| 1-12 months | 75/50 | 90/60 |
| 1-5 years | 80/55 | 95/65 |
| 6-13 years | 90/60 | 105/70 |
| 14-19 years | 105/73 | 117/77 |
| 25-34 year | 109/76 | 122/81 |
| 35-44 years | 112/79 | 125/83 |
| 45-54 years | 115/80 | 129/85 |
| 55-64 years | 118/82 | 134/87 |
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
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