Chapter1 Health Assessment 11
1.4: Monitoring Blood Pressure
DEFINITION
Measuring blood pressure using a sphygmomanometer.
PURPOSES
1. To determine patient's blood pressure as a baseline for comparing future measurements.
2. To aid in diagnosis.
3. To aid in the assessmernt of cardiovascular system preoperatively and postoperatively, during and after invasive
procedures.
4. To monitor change in condition of the patient.
5. To assess response to medical therapy.
6. To determine patient's hemodynamic status.
ARTICLES
1. Asphygmomanometer comprising of:
a. Compression bag/inflatable rubber bladder enclosed in a cloth cuff (appropriate size).
b. An inflating bulb (by which pressure is raised).
C A manometer (mercury) from which pressure is read.
d. Ascrew type release valve for inflation and deflation (pressure control).
2. Stethoscope.
3. Patient chart for recording.
4. Black/blue pen for charting
PROCEDURE
Nursing action Rationale
1. 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 Obtains patient's consent and cooperation and also reiieves
patient has not smoked, ingested cafteine or involved in anxiety. Smoking and ingestion of caffeine can increase blood
strenuous physical and mental activity within 30 minutes prior pressure.
to procedure.
3. Wash and dry hands Prevents cross-infection
4. Assist the patient to either sitting or lying down position and Obtains an accurate reading
ensure that legs are not crossed
5. Collect and check equipment Ascertains evidence of nialfunction
6. Position the sphygmomanometer at approximately heart level of Helps in obtaining accurate reading.
the patient ensuring that mercury level is at zero (Figure 1.4(a)
Figure 1.4(a): Positioning sphygmomanometer at heart level
Contd..
12 Clinical Nursing Procedures: The Art of Nursing Practice
Contd...
Nursing action Rationale
7. Selecta cuff of appropriate size [Figure 1.4(b)] Ensures that compression bladder width is at least 20%
wider than the circumference of the mid-point of the
exterimity used. If the bladder is too wide the reading may
be erroneously low. If it is too small, the reading may be
erroneously high.
Figure 1.4(b): Selecting blood pressure cuff of
appropriate size
8. Expose the arm to make sure that there is no constrictive Ensures accurate reading.
clothing above the placement of cuff.
9. Apply the cuff approximately 2.5 cm above the point where Ensures accurate reading
brachial artery can be palpated. The cuff should be appiied Wrapping the cuff too tightly willimpede circulation.
Wrapping the cuff very loosely will lead to false elevation of
smoothly and firmly with the middle of the rubber bladder
directly over the artery (Figure 1.4(C)]. pressure.
Figure 1.4(c): Application of blood pressure cuf over arm
10. Secure the cuff by tucking the end under or by fixing the Prevents unwrapping of the cuff.
velcro fastener
11. Place the entire arm at the patient's heart level. Obtains accurate reading. For every cm that the cuff is above/
below heart level. Blood pressure varies by 0.8 mm of mercury.
12. Keep the arm well rested and supported Ensures comfort of the patient thereby enabling 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 Estimates systolic pressure in order to determine how high
obliterated. to pump the mercury in order to avoid error related to
auscultatory gap.
16. Inflate the compression bag a further 20-30 mm of mercury Ensures that mercury column is high enough to minimize
and then deflate cuff slowly. Note the point at which pulse error related to auscultatory gap. The point at which pulse
reappears. Release the valve. reappears is the systolic pressure.
Contd.
Chapter1 Health Assessment 13
Contd..
Nursing action Rationale
17. Paipate brachial artery and place diaphragm ofthe Ensures accurate reading. If diaphragm is placed too firmly the
stethoscope lightly over the brachial artery. Ensure that ear artery gets compressed. Sounds are heard better with correct
pieces of the stethoscope are placed correctly (slightly tilted placement of stethoscope. Rubbing of stethoscope against an
forward and ensure that tubing hangs freely). Raise mercury object can obiliterate Korot-Kov's sounds.
level 20-30 mm of mercury above the point of systolic pressure
obtained by means of palpatory method [Figure 1.4(d)].
Figure 1.4(d): Auscultatory method of checking blood
pressure
18. Release the valve of the inflation bulb, so that mercury column Prevents venous congestion and falsely elevated pressure
falls at the rate of 2-4 mm of mercury/sec. reading due to slower rate of deflation and prevents
erroneous reading due to faster rate of deflation.
19. When first sound is heard, the mercury level is noted, this First sound is heard when the blood begins to flow through
denotes systolic pressure. brachial artery.
20 Continue to deflate the cuff, note the point on manometer at
which sound muffles. This is diastolic pressure.
21. Deflate cuff completely. Disconnect the tubing and remove Occlusion of artery during the pressure reading causes venous
the cuff from the patient's arm. congestion in the forearm.
22. Repeat the procedure after one minute if there is any doubt Waiting time of one minute allows venous blood to d1ain
about the reading. completely.
23. Ensure that patient is comfortable.
24. Remove equipment and clean ear piece with a spirit swab.
25. Wash and dry hands Prevents chances of cross-infection.
26. Document the reading in appropriate observation chart or
flow chart.
27. Report any abnormal findings.
SPECIAL PRECAUTIONS
1. Do not take blood pressure on a patient's arm if:
a. The arm has an intravenous infusion on it.
b. The arm is injured/diseased.
c. The arm has a shunt/fistula for renal dialysis.
d. On the same side if the patient had a radical mastectomy.
e. If the arm is paralyzed.
2. Always check supine measurement before checking upright measurement.
3. for
Ifcomparison is needed for blood pressure in lying/standing position, the patient must be in lying/standing position
a minimum of 3 minutes.
4. Appropriate sized cuff should be used.
14 Clinical Nursing Procedures: The Art of Nursing Practice
PEDIATRICVARIATIONS
QIn children, an appropriate cuffsizeis one having a bladder width that is approximateBy 40% of the arm circumference
midway between the olecranon and acromion processes
J Systolic pressure in lower extremities (thigh/calf) is greater than the pressure in the upper extremities.
NORMAL BP RANGE-AGEWISE
Age Blood pressure (mm of Hg)
Newborn 46, 92
38 72
3 years 72 o 110
AC 74
84 122
10 years to
40 74
94, 120
16 years 48 46
