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Clinical Practice Keywords Blood pressure/

Hypertension/Hypotension/
Review Assessment/Monitoring
Assessment skills
In this article...
● P
 rinciples of blood pressure measurement
● Different types of blood pressure measurement device
● The importance of training and maintenance of blood pressure measurement devices

Blood pressure 1: key principles

and types of measuring equipment
Key points
Author Phil Jevon is academy tutor, Manor Hospital, Walsall, and honorary clinical
Non-invasive lecturer, School of Medicine, University of Birmingham.
measurement of
blood pressure is a Abstract Blood pressure measurement is a common diagnostic and monitoring
common diagnostic procedure, and accuracy is essential if patients are to receive the appropriate
and monitoring treatment and care in a timely manner. This article, part 1 in a two-part series,
technique discusses principles of blood pressure monitoring and the devices used. Part 2 will
describe the procedures for monitoring blood pressure.
A range of manual
and automated Citation Jevon P (2020) Blood pressure 1: key principles and types of measuring
devices are available equipment. Nursing Times [online]; 116: 7, 36-38.
to measure blood

T
pressure
he accurate measurement of occlude the artery under the cuff, then
Blood pressure blood pressure (BP) is an impor- released in a controlled manner.
devices should be tant diagnostic and monitoring BP is a variable haemodynamic phenom-
properly maintained tool in a wide range of clinical enon, and can be influenced by a range of
and calibrated to conditions. Good practice is essential factors; these are outlined in Box 2. In some
ensure accuracy when measuring BP to ensure abnormali- situations, for example when managing a
ties are identified and patients receive the patient with hypertension, it is advised to
correct treatment and care in a timely undertake three consecutive BP readings to
manner. This article reviews the principles improve accuracy. Posters and videos out-
guiding the non-invasive measurement of lining how to measure BP can be down-
BP. Part 2 of the series will explain the dif- loaded from: Bit.ly/BIHSBPMeasurement.
ferent procedures for measuring BP.
Arm selection and patient position
General principles of measurement BP should initially be measured in both
Terms used in the measurement of BP are arms, after which the arm with the higher
outlined in Box 1. reading(s) should be used for subsequent
It can be measured: measurements (O’Brien, 2015). Although a
l M anually, using the auscultatory method difference in BP measurements between
– this involves listening to arterial the arms can be expected in 20% of
sounds (named ‘Korotkoff sounds’, after patients, if this difference is >20mmHg for
Nicolai Korotkoff, a Russian surgeon systolic or >10mmHg for diastolic meas-
who first described the auscultation urement, BP should be measured on both
method of measuring BP in 1905); arms for the next reading. If these differ-
l A utomatically, using the oscillometric ences are seen in three consecutive read-
method – this detects variations in ings (with a one-minute gap between
pressure oscillations due to arterial wall each), further investigation may be indi-
movement. cated (O’Brien, 2015).
Both methods use a measuring device The patient’s arm should be supported
attached to an inflatable cuff that is placed while BP is measured; if it is unsupported
around the patient’s upper arm, inflated to muscle contraction in the arm can lead to

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 Copyright EMAP Publishing 2020
This article is not for distribution
except for journal club use

Clinical Practice
Review

Box 1. Definitions of terms requires use of a stethoscope;

l Electronic sphygmomanometer – this
Blood pressure – the pressure of blood against the walls of the main arteries battery-powered device replaces the
Systolic blood pressure – peak blood pressure in the artery following ventricular mercury manometer with a pressure
systole (contraction) sensor and electronic display. The display
Diastolic blood pressure – level to which the arterial blood pressure falls during may be numerical, or a circular or linear
ventricular diastole (relaxation) bar graph. No stethoscope is needed.
Hypertension – high blood pressure: consistently >140/90mmHg Where local protocols dictate that mer-
Hypotension – low blood pressure: typically a systolic reading of <90mmHg cury devices still need to be used, Control of
Sources: National Institute for Health and Care Excellence (2019); McFerran and Martin (2017)
Substances Hazardous to Health (COSHH)
and health and safety procedures and regu-
lations should be followed (MHRA, 2019).
an erroneous increase in the BP reading by are prone to observer bias (Medicines and Health professionals should be trained in:
as much as 10% (O’Brien, 2015). Healthcare products Regulatory Agency, l S  afe handling during normal use;
The arm should be positioned at heart 2019). Mercury sphygmomanometers are l S  torage of the device;
level: if it is lower than the heart, this can considered the ‘gold standard’ in BP meas- l W  hat to do in the event of a mercury
lead to overestimation, while being above urement but, as mercury is a toxic sub- spillage (mercury spillage kits should
the level of the heart can lead to an under- stance, there are maintenance and disposal be available);
estimation. This error may be as great as problems and environmental concerns. As l W  hat procedures to follow in the event
10mmHg (O’Brien, 2015). If seated, the a result, these devices are being phased out: of mercury disposal or when the device
patient should not cross their legs as this their use has already been banned in some is discarded (MHRA, 2019).
can lead to an increase in BP. European countries, while in the UK a ban Although aneroid sphygmomanometers
on their sale will be introduced from are mercury free and easy to use, wear and
Cuff size 31 December 2020 (MHRA, 2019). It would, tear or mechanical shock to the mechanism
It is vital that the appropriate cuff size is therefore, be prudent for healthcare pro- can lead to incorrect readings; this means
used when measuring BP. Miscuffing – par- viders still using mercury sphygmoma- regular calibration checks are required.
ticularly using a cuff that is too small – can nometers to start planning to phase these Electronic sphygmomanometers are prone
lead to inaccurate readings (O’Brien, 2015): out and to ensure health professionals are to observer bias and require clinical skill to
if a cuff is too small, the BP will be overesti- competent at using alternative devices. use accurately (MHRA, 2019). Devices need
mated and, if it is too big, the BP will be Devices that are generally used for regular maintenance in line with the manu-
underestimated. In general, there are three manual BP measurement include: facturer’s instructions and local policy.
cuff sizes: l A  neroid sphygmomanometer – this
l C  hildren or small adults; replaces the mercury manometer with Automated measurement
l S  tandard adults; an aneroid (liquid-free) gauge that Automated electronic BP devices
l O  bese adults. registers pressure using a bellows and Most automated BP measurement devices
The inflatable bladder should encircle lever system (O’Brien, 2015), and in current clinical practice use the oscillo-
between 80% and 100% of the arm. metric method. Each arterial pulse wave
results in a small rise and fall in the volume
Box 2. Factors that can cause
Manual auscultatory measurement a variation in blood pressure of the limb which, in turn, causes an
Manual BP measurement devices require increase then a decrease in the pressure
the user to inflate the upper-arm cuff to l Emotional state within the encircling cuff (Lewis, 2019).
occlude the brachial artery, then listen to l Temperature The oscillometric method relies on detec-
the Korotkoff sounds through a stetho- l Respiration tion of variations in pressure oscillations
scope while the cuff is slowly deflated. l Bladder distension due to arterial wall movement beneath an
When the cuff is slowly deflated, five dif- l Pain occluding cuff to calculate the systolic and
ferent sound phases can be heard: l Exercise diastolic BP readings (Lewis, 2019).
l P hase I – a thud; l Age It is important to note that some auto-
l P hase II – a blowing or swishing noise; l Food consumption mated oscillometric BP measurement
l A uscultatory gap – in some patients, l Race/ethnicity devices are unreliable in patients with car-
the sounds disappear for a short period; l Tobacco use diac arrhythmia, such as atrial fibrillation
l P hase III – a softer thud than in phase I; l Diurnal variation (blood pressure is at (AF) (National Institute for Health and
l P hase IV – a disappearing blowing noise; its lowest during sleep) Care Excellence, 2019); this is because the
l P hase V – silence: all sounds disappear l Alcohol use pulse pressures can vary significantly with
(O’Brien, 2015). l ‘White coat’ hypertension (raised each pulse. Where possible, manual BP
Practically, the systolic reading is when blood pressure when measured in measurement should be used when a
the Korotkoff sounds are first heard and the clinical settings) patient has AF (Clark et al, 2019).
diastolic reading is when they disappear. l Sudden change in posture Extreme bradycardias can also cause
The patient’s systolic (phase I) and dias- l Underlying medical conditions, such inaccurate BP readings (O’Brien, 2015);
tolic (phase V) BP are recorded from the as renal failure, diabetes, anaphylaxis, again, where possible, manual BP measure-
readings on the sphygmomanometer. hypovolaemia ment is preferable, with slow cuff deflation.
Although portable and generally reliable, Source: O’Brien (2015)
A number of automated BP measure-
manual BP devices require clinical skill and ment devices are available including:

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 Copyright EMAP Publishing 2020
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l  pot-check non-invasive BP monitor

S medications including diuretics and anti- cuffs, hoses and tubing connectors may
– this is probably the device most often hypertensive therapy (Windsor et al, 2016). reduce the accuracy of the readings. If re-
used in secondary care settings on Postural hypotension can present with a usable cuffs are used, they should be
general wards. Both mains and battery clinical picture of dizziness, syncope and cleaned between patients in accordance
powered, they are designed for routine falls on changing position. Although it with the manufacturer’s instructions,
clinical assessment. Many have the may seem to be a relatively harmless phe- ensuring that cleaning fluid does not enter
option to measure other vital signs, such nomenon, the patient’s safety and quality the cuff bladder or hoses.
as oxygen saturation levels, while some of life can be seriously affected. Faulty devices can lead to inaccurate
have an automatic-cycling facility to BP measurements, with significant effects
record a patient’s BP at set time intervals; Falls risk assessment on patient care. Healthcare providers have
l Multiparameter patient monitors Measurement of lying and standing BP is a responsibility to ensure adequate main-
– generally used only in critical care part of a multifactorial patient risk assess- tenance arrangements are in place
areas, these devices enable a range of ment (Royal College of Physicians, 2017). A (MHRA, 2019).
vital signs (typically including arterial diagnosis of postural hypotension is indi- Aneroid devices are particularly prone
BP, pulse, electrical activity of the heart, cated when there is a: to inaccuracies (Coleman et al, 2005); the
respiratory rate, oxygen saturation l D rop in systolic BP of ≥20mmHg (with MHRA (2019) recommends these are
levels and end tidal carbon dioxide) to or without symptoms); checked and calibrated at least twice a year.
be monitored; l D rop in BP to <90mmHg on standing, Hand-held devices used in the community
l Automated (spot-check) device – an even if the drop is <20mmHg (with or are particularly prone to shocks and drops,
electronic monitor with a pressure without symptoms); but devices that incorporate anti-shock
sensor, a digital display and an l D rop in diastolic BP of 10mmHg with mechanisms may be more resilient to this
upper-arm cuff. Battery powered and symptoms (but, clinically, much less type of wear and tear.
very portable, this is often used in significant than a drop in systolic BP). It is considered good practice to occa-
primary care settings; NICE (2013) stated that the following sionally check the device against another
l Wrist device – an electronic monitor groups of inpatients should be considered validated device (BIHS, 2017).
with a pressure sensor (an electrically as at risk of falling in hospital and receive
driven pump) attached to a wrist cuff. an individualised, multifactorial assess- Conclusion
Function is similar to that of the ment, including lying and standing BP: Accurate measurement of BP is an impor-
automated (spot-check) device. Not l A ll patients aged ≥65 years; tant diagnostic and monitoring tool in a
commonly used in healthcare settings; l P atients aged 50-64 years who are wide range of clinical conditions. Nurses
l Finger device – this includes an judged by a clinician to be at higher risk must be able to carry out the procedure
electronic monitor and a finger cuff, or of a fall due to an underlying condition. accurately and reliably, and should be
the device itself may be attached to the aware of the common pitfalls that can lead
finger. Not commonly used in Errors in measurement to inaccuracies. Part 2 of this series will
healthcare settings; There are numerous causes of errors in BP explain the procedure for measuring BP. NT
l L
 ists of reliable/unreliable automated measurements, including:
BP devices are available from the British l P atient not being rested and relaxed References
British and Irish Hypertension Society (2017)
and Irish Hypertension Society (BIHS) when BP is measured; Blood Pressure Measurement: Using Automated
(Bit.ly/BIHSMonitors). l D efective equipment – for example, Blood Pressure Monitors. Leicester: BIHS.
leaky tubing or a faulty valve; Clark CE et al (2019) Measurement of blood
pressure in people with atrial fibrillation. Journal of
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In healthy patients, there is usually little l U se of incorrectly sized cuff; Coleman AJ et al (2005) Accuracy of the pressure
difference between lying and standing BP l C uff not being on a level with the heart;
scale of sphygmomanometers in clinical use within
primary care. Blood Pressure Monitoring; 10: 4, 181-188.
readings. However, a significant fall in BP l P oor technique; Lewis P (2019) Oscillometric measurement of
(≥20mmHg) can occur with a change of l ‘Digit preference’ – rounding a reading blood pressure: a simplified explanation. A
technical note on behalf of the British and Irish
position, particularly in patients aged up to the nearest 5mmHg or 10mmHg; Hypertension Society. Journal of Human
≥65 years and those with diabetes or symp- l O bserver bias – for example, expecting Hypertension; 33: 5, 349-351.
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Nursing (7th edn). Oxford: Oxford University Press.
The routine measurement of both lying l I rregular pulse (as can occur with, for
Medicines and Healthcare products Regulatory
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is, therefore, advisable (National Institute tremors, a weak pulse or profound Devices. London: MHRA.
National Institute for Health and Care Excellence
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Postural hypotension, sometimes termed Prevention. London: NICE.
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suddenly assumes a standing position, regularly checked and calibrated in accord- Royal College of Physicians (2017) Measurement
typically inducing dizziness and syncope. ance with the manufacturer’s instructions of Lying and Standing Blood Pressure as Part of a
The condition is more common in older (MHRA, 2019). Cuffs and their hoses should Multifactorial Falls Risk Assessment. RCP.
Windsor J et al (2016) Orthostatic hypotension 1:
people and its prevalence increases with be regularly inspected and replaced as nec- effect of orthostatic hypotension on falls risk.
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