Assessing Blood Pressure

1. Check physician’s order or nursing care plan for frequency of blood pressure measurement. More frequent measurement may be appropriate based on nursing judgment.

 2. Identify the patient.

 3. Explain the procedure to the patient.

4. Perform hand hygiene and put on gloves if appropriate or indicated.

5. Close curtains around bed and close door to room if possible.

6. Select the appropriate arm for application of cuff.

7. Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and the palm of the hand upward.

8. Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff will be placed.

9. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1″ to 2″) above the inner aspect of the elbow. Line up the artery marking on the cuff with the patient’s brachial artery. The tubing should extend from the edge of the cuff nearer the patient’s elbow.

10. Wrap the cuff around the arm smoothly and snugly, and fasten it. Do not allow any clothing to interfere with the proper placement of the cuff.

11. Check that the needle on the aneroid gauge is within the zero mark. If using a mercury manometer, check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level.

Estimating Systolic Pressure

12. Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips.

13. Tighten the screw valve on the air pump.

14. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears.

15. Deflate the cuff and wait 15 seconds.

Obtaining Blood Pressure Measurement

16. Assume a position that is no more than 3 feet away from the gauge.

17. Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal and not against the ear itself.

18. Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery. Do not allow the stethoscope to touch clothing or the cuff.

19. Pump the pressure 30 mm Hg above the point at which the systolic pressure was palpated and estimated. Open the valve on the manometer and allow air to escape slowly (allowing the gauge to drop 2 to 3 mm per heartbeat).

20. Note the point on the gauge at which the first faint, but clear, sound appears that slowly increases in intensity. Note this number as the systolic pressure.

21. Read the pressure to the closest even number.

22. Do not reinflate the cuff once the air is being released to recheck the systolic pressure reading.

23. Note the pressure at which the sound first becomes muffled. Also observe the point at which the sound completely disappears. These may occur separately or at the same point.

24. Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait 30 to 60 seconds between readings to allow normal circulation to return in the limb. Deflate the cuff completely between attempts to check the blood pressure.

25. Remove the cuff, and clean and store the equipment.

26. Complete documentation.