PROCEDURE GOALS AND OBJECTIVES
Goal: To accurately measure the systemic arterial blood pressure
in any patient in any setting.
Objectives: The student will be able to …
• Describe the indications, contraindications, and rationale for
performing arterial blood pressure measurement.
• Describe the essential anatomy and physiology associated with
the performance of blood pressure measurement.
• Identify the necessary materials and their proper use for
performing blood pressure measurement.
• Perform the proper steps and techniques for obtaining blood
pressure measurement.
• Describe the indications for performing orthostatic blood
pressure assessment.
• Perform the proper steps and techniques for obtaining
orthostatic blood pressure measurement.
Goal: To accurately measure the systemic arterial blood pressure
in any patient in any setting.
Objectives: The student will be able to …
• Describe the indications, contraindications, and rationale for
performing arterial blood pressure measurement.
• Describe the essential anatomy and physiology associated with
the performance of blood pressure measurement.
• Identify the necessary materials and their proper use for
performing blood pressure measurement.
• Perform the proper steps and techniques for obtaining blood
pressure measurement.
• Describe the indications for performing orthostatic blood
pressure assessment.
• Perform the proper steps and techniques for obtaining
orthostatic blood pressure measurement.
BACKGROUND AND HISTORY
Various theories about circulation and blood pressure (BP) emerged about
400 BC. Hippocrates knew about arteries and veins, but he believed veins
carried air. Six hundred years later, Galen demonstrated that both arteries
and veins carried blood; however, he also thought that the heart was a
warming machine for two separate types of blood. He was convinced that
veins and arteries were not connected and that blood flowed both backward
and forward from the heart. Subsequently Galen’s teachings remained
unchallenged for over 1000 years (Stevens, 1978).
It was William Harvey, in 1616, who disagreed with Galen by demonstrating
one-way circulation of blood and theorized the existence of capillaries. Thirty
years later, Marcello Malpighi was the first to view capillaries microscopically
(Stevens, 1978).
The first person to measure BP was Stephen Hales in 1733. An English
physiologist, clergyman, and amateur scientist, Hales inserted a brass pipe
into the carotid artery of a mare and then attached the pipe to a windpipe
taken from a goose. The flexible goose windpipe was then attached to a
12-foot glass tube. Although the experiment had little practical application at
the time, it did provide valuable information about BP (Wain, 1970).
Although Ritter von Basch experimented with a device that could measure
the BP of a human without breaking the skin, the prototype design of the
sphygmomanometer was devised in 1896 by Scipione Riva-Rocci (Lyons,
1987). He introduced a method for indirect measurement of BP based on
measuring the external pressure required to compress the brachial artery so
that arterial pulsations could no longer be transmitted through the artery.
The Riva-Rocci sphygmomanometer was described by Porter (1997) as “an
inflatable band that was wrapped around the upper arm; air was pumped in
until the pulse disappeared; it then was released from the band until the
pulse reappeared, and the reading was taken.”
In 1905, a Russian physician named Korotkoff first discovered the
auscultatory sounds that are heard while measuring BP. While the artery is
occluded during BP measurement, transmitted pulse waves can no longer be
heard distal to the point of occlusion. As the pressure in the bladder is reduced
by opening a valve on the inflation bulb, pulsatile blood flow reappears
through the generally compressed artery, producing repetitive sounds
generated by the pulsatile flow. The sounds, named after Korotkoff, change in
quality and intensity. The five phases of these changes are characterized in
Table 4-1. Around the turn of the 20th century, BP became an accepted clinical
measurement. As data increased, physicians and other clinicians were able
to establish normal BP ranges and identify abnormalities.
René Laënnec is credited with the invention of the stethoscope in 1816,
which became a convenience for physicians who preferred not to place their
ears directly on the chest wall of a patient. In 1905, Korotkoff tried using the
stethoscope to monitor the pulse while the sphygmomanometer was inflated.
He discovered a more accurate BP reading and that the pulse disappeared as
the cuff pressure decreased at a point in consonance with the expanding of
Various theories about circulation and blood pressure (BP) emerged about
400 BC. Hippocrates knew about arteries and veins, but he believed veins
carried air. Six hundred years later, Galen demonstrated that both arteries
and veins carried blood; however, he also thought that the heart was a
warming machine for two separate types of blood. He was convinced that
veins and arteries were not connected and that blood flowed both backward
and forward from the heart. Subsequently Galen’s teachings remained
unchallenged for over 1000 years (Stevens, 1978).
It was William Harvey, in 1616, who disagreed with Galen by demonstrating
one-way circulation of blood and theorized the existence of capillaries. Thirty
years later, Marcello Malpighi was the first to view capillaries microscopically
(Stevens, 1978).
The first person to measure BP was Stephen Hales in 1733. An English
physiologist, clergyman, and amateur scientist, Hales inserted a brass pipe
into the carotid artery of a mare and then attached the pipe to a windpipe
taken from a goose. The flexible goose windpipe was then attached to a
12-foot glass tube. Although the experiment had little practical application at
the time, it did provide valuable information about BP (Wain, 1970).
Although Ritter von Basch experimented with a device that could measure
the BP of a human without breaking the skin, the prototype design of the
sphygmomanometer was devised in 1896 by Scipione Riva-Rocci (Lyons,
1987). He introduced a method for indirect measurement of BP based on
measuring the external pressure required to compress the brachial artery so
that arterial pulsations could no longer be transmitted through the artery.
The Riva-Rocci sphygmomanometer was described by Porter (1997) as “an
inflatable band that was wrapped around the upper arm; air was pumped in
until the pulse disappeared; it then was released from the band until the
pulse reappeared, and the reading was taken.”
In 1905, a Russian physician named Korotkoff first discovered the
auscultatory sounds that are heard while measuring BP. While the artery is
occluded during BP measurement, transmitted pulse waves can no longer be
heard distal to the point of occlusion. As the pressure in the bladder is reduced
by opening a valve on the inflation bulb, pulsatile blood flow reappears
through the generally compressed artery, producing repetitive sounds
generated by the pulsatile flow. The sounds, named after Korotkoff, change in
quality and intensity. The five phases of these changes are characterized in
Table 4-1. Around the turn of the 20th century, BP became an accepted clinical
measurement. As data increased, physicians and other clinicians were able
to establish normal BP ranges and identify abnormalities.
René Laënnec is credited with the invention of the stethoscope in 1816,
which became a convenience for physicians who preferred not to place their
ears directly on the chest wall of a patient. In 1905, Korotkoff tried using the
stethoscope to monitor the pulse while the sphygmomanometer was inflated.
He discovered a more accurate BP reading and that the pulse disappeared as
the cuff pressure decreased at a point in consonance with the expanding of
the heart. Subsequently, the term Korotkoff sounds came to be used (Lyons,
1987).
According to Grim and Grim (2000):
Indirect BP measurement is one of the most frequently performed health
care procedures. Because BP measurement is a simple procedure, it is
taken for granted that all graduates from medical training programs have
the ability to record accurate, precise, and reliable BP readings. However,
research since the 1960s has shown this assumption to be false. Most
health professionals do not measure BP in a manner known to be accurate
and reliable.
The authors describe two factors that contribute to inaccurate BP measurement:
(1) lack of depth in the instruction of basic skills in professional
education; and (2) relying on nonmercury devices. Subsequently, every
clinician who takes BP measurements should know and understand the
principles and steps needed to obtain accurate indirect auscultatory BP
measurement. The measurement taken is an important tool in screening and
diagnosis, which is why it is considered one of the patient’s “vital signs.”
For the accurate indirect measurement of BP, the American Heart
Association (AHA) recommends that the cuff size be based solely on the limb
circumference. Manning, Kuchirka, and Kaminski studied prevailing cuffing
habits, compared them with AHA guidelines, and reported their findings in
Circulation in 1983. They found that “miscuffing” occurred in 65 (32%) of 200
BP determinations in 167 unselected adult outpatients, including 61 (72%) of 85
readings taken on “nonstandard-size” arms. Undercuffing large arms was the
most frequent error, accounting for 84% of the miscuffings. They concluded
that undercuffing elevates the BP readings by an average of 8.5 mm Hg
systolic and 4.6 mm Hg diastolic. It is critical, therefore, that the clinician
choose the appropriate size cuff based on the circumference of a patient’s
bare upper arm. The bladder (inside the cuff) length should encircle 80% and
the width should cover 33% to 50% of an adult’s upper arm. For a child
younger than 13 years of age, the bladder should encircle 100% of the child’s upper arm. A cuff that is too narrow or too large for an arm may result in an
incorrect BP reading. Cuffs that are generally available usually have been
classified by the width of the bladder rather than by the length and are
labeled newborn, infant, child, small adult, adult, large adult, and thigh.
Over- and underestimation of BP by using an inappropriate cuff size has
been well documented in the literature. Health care settings should have
easy access to small, standard, and large cuffs (Graves, 2001).
1987).
According to Grim and Grim (2000):
Indirect BP measurement is one of the most frequently performed health
care procedures. Because BP measurement is a simple procedure, it is
taken for granted that all graduates from medical training programs have
the ability to record accurate, precise, and reliable BP readings. However,
research since the 1960s has shown this assumption to be false. Most
health professionals do not measure BP in a manner known to be accurate
and reliable.
The authors describe two factors that contribute to inaccurate BP measurement:
(1) lack of depth in the instruction of basic skills in professional
education; and (2) relying on nonmercury devices. Subsequently, every
clinician who takes BP measurements should know and understand the
principles and steps needed to obtain accurate indirect auscultatory BP
measurement. The measurement taken is an important tool in screening and
diagnosis, which is why it is considered one of the patient’s “vital signs.”
For the accurate indirect measurement of BP, the American Heart
Association (AHA) recommends that the cuff size be based solely on the limb
circumference. Manning, Kuchirka, and Kaminski studied prevailing cuffing
habits, compared them with AHA guidelines, and reported their findings in
Circulation in 1983. They found that “miscuffing” occurred in 65 (32%) of 200
BP determinations in 167 unselected adult outpatients, including 61 (72%) of 85
readings taken on “nonstandard-size” arms. Undercuffing large arms was the
most frequent error, accounting for 84% of the miscuffings. They concluded
that undercuffing elevates the BP readings by an average of 8.5 mm Hg
systolic and 4.6 mm Hg diastolic. It is critical, therefore, that the clinician
choose the appropriate size cuff based on the circumference of a patient’s
bare upper arm. The bladder (inside the cuff) length should encircle 80% and
the width should cover 33% to 50% of an adult’s upper arm. For a child
younger than 13 years of age, the bladder should encircle 100% of the child’s upper arm. A cuff that is too narrow or too large for an arm may result in an
incorrect BP reading. Cuffs that are generally available usually have been
classified by the width of the bladder rather than by the length and are
labeled newborn, infant, child, small adult, adult, large adult, and thigh.
Over- and underestimation of BP by using an inappropriate cuff size has
been well documented in the literature. Health care settings should have
easy access to small, standard, and large cuffs (Graves, 2001).
INDICATIONS
As one of the vital signs, peripheral BP measurement is an indirect method
of determining cardiovascular function. Its use is indicated for evaluation of
both healthy and unhealthy patients to assess cardiac status. BP measurement
is a part of every complete physical or screening examination and is
performed to screen for hypertension or hypotension.
As one of the vital signs, peripheral BP measurement is an indirect method
of determining cardiovascular function. Its use is indicated for evaluation of
both healthy and unhealthy patients to assess cardiac status. BP measurement
is a part of every complete physical or screening examination and is
performed to screen for hypertension or hypotension.
CONTRAINDICATIONS
There are no absolute contraindications to measuring BP. Relative contraindications
include physical defects and therapeutic interventions, such as
indwelling intravenous catheters and renal dialysis shunts.
There are no absolute contraindications to measuring BP. Relative contraindications
include physical defects and therapeutic interventions, such as
indwelling intravenous catheters and renal dialysis shunts.
POTENTIAL COMPLICATIONS
Complications from measurement of BP occur as a result of improper
training of the individual performing the assessment. Overinflation or prolonged
time of inflation may lead to tissue or vascular damage at the
measurement site. Lack of proper care of equipment or flawed equipment
may give an inaccurate reading.
Complications from measurement of BP occur as a result of improper
training of the individual performing the assessment. Overinflation or prolonged
time of inflation may lead to tissue or vascular damage at the
measurement site. Lack of proper care of equipment or flawed equipment
may give an inaccurate reading.
REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
In most clinical settings, BP is measured by the indirect technique of using a
sphygmomanometer placed over the brachial artery of the upper extremity.
The brachial artery is a continuation of the axillary artery, which lies medial
to the humerus proximally and gradually moves anterior to the humerus as
it nears the antecubital crease (Fig. 4-1). Placement of the bladder and cuff of
the sphygmomanometer circumferentially over the brachial artery allows
inflation of the cuff to create adequate pressure so that the artery is fully
occluded when the pressure exceeds the systolic pressure within the
brachial artery.
AND PHYSIOLOGY
In most clinical settings, BP is measured by the indirect technique of using a
sphygmomanometer placed over the brachial artery of the upper extremity.
The brachial artery is a continuation of the axillary artery, which lies medial
to the humerus proximally and gradually moves anterior to the humerus as
it nears the antecubital crease (Fig. 4-1). Placement of the bladder and cuff of
the sphygmomanometer circumferentially over the brachial artery allows
inflation of the cuff to create adequate pressure so that the artery is fully
occluded when the pressure exceeds the systolic pressure within the
brachial artery.
Indirect measurement of the BP involves the auscultatory detection of the
initial presence and disappearance of changes and the disappearance of
Korotkoff sounds, which are audible with the aid of a stethoscope placed
over the brachial artery distal to the BP cuff near the antecubital crease.
Korotkoff sounds are low-pitched sounds (best heard with the stethoscope
bell) that originate from the turbulence created by the partial occlusion of
the artery with the inflated BP cuff.
As long as the pressure within the cuff is so little that it does not produce
even partial occlusion (or intermittent occlusion), no sound is produced
when auscultating over the brachial artery distal to the cuff. When the cuff
pressure becomes great enough to occlude the artery during at least some
portion of the arterial pressure cycle, a sound becomes audible over the
brachial artery distal to the cuff. This sound is audible with a stethoscope
and correlates with each arterial pulsation.
There are five phases of Korotkoff sounds used in determining systolic and
diastolic BP (see Table 4-1). Phase I occurs as the occluding pressure of the
cuff falls to a point that is the same as the peak systolic pressure within the
brachial artery (Fig. 4-2). The tapping sound that is produced is clear and
generally increases in intensity as the occluding pressure continues to
decrease. Phase II occurs at a point approximately 10 to 15 mm Hg lower than
at the onset of phase I, and the sounds become softer and longer with a
quality of intermittent murmur. Phase III occurs when the occluding pressure
of the cuff falls to a point that allows for large amounts of blood to cross the
initial presence and disappearance of changes and the disappearance of
Korotkoff sounds, which are audible with the aid of a stethoscope placed
over the brachial artery distal to the BP cuff near the antecubital crease.
Korotkoff sounds are low-pitched sounds (best heard with the stethoscope
bell) that originate from the turbulence created by the partial occlusion of
the artery with the inflated BP cuff.
As long as the pressure within the cuff is so little that it does not produce
even partial occlusion (or intermittent occlusion), no sound is produced
when auscultating over the brachial artery distal to the cuff. When the cuff
pressure becomes great enough to occlude the artery during at least some
portion of the arterial pressure cycle, a sound becomes audible over the
brachial artery distal to the cuff. This sound is audible with a stethoscope
and correlates with each arterial pulsation.
There are five phases of Korotkoff sounds used in determining systolic and
diastolic BP (see Table 4-1). Phase I occurs as the occluding pressure of the
cuff falls to a point that is the same as the peak systolic pressure within the
brachial artery (Fig. 4-2). The tapping sound that is produced is clear and
generally increases in intensity as the occluding pressure continues to
decrease. Phase II occurs at a point approximately 10 to 15 mm Hg lower than
at the onset of phase I, and the sounds become softer and longer with a
quality of intermittent murmur. Phase III occurs when the occluding pressure
of the cuff falls to a point that allows for large amounts of blood to cross the
partially occluded brachial artery. The phase III sounds are again crisper and
louder than phase II sounds. Phase IV occurs when there is an abrupt
muffling and decrease in the intensity of the sounds. This occurs as the
pressure is close to that of the diastolic pressure of the brachial artery.
Phase V occurs when the blood vessel is no longer occluded by the pressure
in the cuff. At this point, the tapping sound disappears completely.
louder than phase II sounds. Phase IV occurs when there is an abrupt
muffling and decrease in the intensity of the sounds. This occurs as the
pressure is close to that of the diastolic pressure of the brachial artery.
Phase V occurs when the blood vessel is no longer occluded by the pressure
in the cuff. At this point, the tapping sound disappears completely.
PATIENT PREPARATION
Ideally, the environment should be relaxed and peaceful. BP levels may be
affected by emotions, physical activity, or the environment. Subsequently,
the examiner should minimize any and all disturbances that may affect the
reading. The procedure should be explained to the patient.
The patient is asked to be seated or to lie down with the back supported,
making sure that the bare arm is supported horizontally at the level of the
heart. According to Mourad and Carney (2004):
Choosing the dependent arm is a behavior likely to lead to the overdiagnosis
of hypertension and inappropriate treatment of hypertension because the
dependent arm falsely elevates both systolic and diastolic blood pressure.
These results should encourage national and international organizations
to reaffirm the importance of the horizontal arm in the measurement of
blood pressure.
The clinician should avoid an arm that appears injured or has a fistula or an
IV or arterial line. If the patient has undergone breast or axilla surgery, avoid
the arm on the same side. It is important to note that rolling up the sleeves
Ideally, the environment should be relaxed and peaceful. BP levels may be
affected by emotions, physical activity, or the environment. Subsequently,
the examiner should minimize any and all disturbances that may affect the
reading. The procedure should be explained to the patient.
The patient is asked to be seated or to lie down with the back supported,
making sure that the bare arm is supported horizontally at the level of the
heart. According to Mourad and Carney (2004):
Choosing the dependent arm is a behavior likely to lead to the overdiagnosis
of hypertension and inappropriate treatment of hypertension because the
dependent arm falsely elevates both systolic and diastolic blood pressure.
These results should encourage national and international organizations
to reaffirm the importance of the horizontal arm in the measurement of
blood pressure.
The clinician should avoid an arm that appears injured or has a fistula or an
IV or arterial line. If the patient has undergone breast or axilla surgery, avoid
the arm on the same side. It is important to note that rolling up the sleeves
has the potential of compressing the brachial artery and may have an even
greater effect on the BP than if the shirt is left under the manometer’s cuff
(Lieb, 2004) The patient should avoid smoking or ingesting caffeine for
30 minutes before the BP is recorded.
greater effect on the BP than if the shirt is left under the manometer’s cuff
(Lieb, 2004) The patient should avoid smoking or ingesting caffeine for
30 minutes before the BP is recorded.
Materials Utilized for Blood Pressure
Measurement
■ Stethoscope
■ Calibrated sphygmomanometer (a mercury, aneroid, or hybrid
sphygmomanometer with a calibrated scale for measuring pressure;
inflatable rubber bladders; tubes; and valves). There continues to be
environmental concern over the use of mercury sphygmomanometers
because of the hazards of mercury spills and potential exposure (see
“Note”). As a result, more automated devices are being used
(Valler-Jones, 2005). One of the factors affecting the accuracy of BP
measurement is the equipment used. Defects or inaccuracy of aneroid
sphygmanometers may be a source of error in BP measurement.
■ Recording instruments (Fig. 4-3)
Measurement
■ Stethoscope
■ Calibrated sphygmomanometer (a mercury, aneroid, or hybrid
sphygmomanometer with a calibrated scale for measuring pressure;
inflatable rubber bladders; tubes; and valves). There continues to be
environmental concern over the use of mercury sphygmomanometers
because of the hazards of mercury spills and potential exposure (see
“Note”). As a result, more automated devices are being used
(Valler-Jones, 2005). One of the factors affecting the accuracy of BP
measurement is the equipment used. Defects or inaccuracy of aneroid
sphygmanometers may be a source of error in BP measurement.
■ Recording instruments (Fig. 4-3)
■ Appropriate size cuff: A cuff that has an antimicrobial agent to help
prevent bacterial growth is recommended. It has been reported that BP
cuffs can carry significant bacterial colonization and actually can be a
source of transmission of infection (Base-Smith, 1996).
Note: Modern sphygmomanometers are less likely to spill mercury if
dropped. If a spill occurs, however, mercury is fairly simple to clean up
unless it is spilled within heated devices or is trapped in upholstery,
carpeting, or other surfaces. Unfortunately, mercury in the organic form is
extremely toxic via skin contact, inhalation, and ingestion and may require
the calling of a hazardous materials team. If mercury manometers are used,
a mercury spill kit is recommended.
prevent bacterial growth is recommended. It has been reported that BP
cuffs can carry significant bacterial colonization and actually can be a
source of transmission of infection (Base-Smith, 1996).
Note: Modern sphygmomanometers are less likely to spill mercury if
dropped. If a spill occurs, however, mercury is fairly simple to clean up
unless it is spilled within heated devices or is trapped in upholstery,
carpeting, or other surfaces. Unfortunately, mercury in the organic form is
extremely toxic via skin contact, inhalation, and ingestion and may require
the calling of a hazardous materials team. If mercury manometers are used,
a mercury spill kit is recommended.
SPECIAL CONSIDERATIONS
THE APPREHENSIVE PATIENT OR “WHITE
COAT” HYPERTENSION
Ambulatory blood pressure measurement (ABPM) is increasingly being used
in clinical practice (O’Brien, 2003). ABPMs correlate better than clinical
measurements on patients with end-organ injury (Verdecchia, 2000). Twentyfour-
hour ABPM is the most efficient means for assessing white coat hypertension
(WCH), particularly in the absence of end-organ disease. WCH has
been defined as clinical BP greater than 140 mm Hg systolic and 90 mm Hg
diastolic (Al-Hermi, 2004). Ambulatory measurements are also valuable in
assessing patients with apparent drug resistance, low BP symptoms, and in
patients taking antihypertensive medications. There is now wider acceptance
of BP readings taken by patients in their homes. Patients should be encouraged
to monitor their BP at home with validated devices followed by appropriate
recording and reporting to their clinician.
in clinical practice (O’Brien, 2003). ABPMs correlate better than clinical
measurements on patients with end-organ injury (Verdecchia, 2000). Twentyfour-
hour ABPM is the most efficient means for assessing white coat hypertension
(WCH), particularly in the absence of end-organ disease. WCH has
been defined as clinical BP greater than 140 mm Hg systolic and 90 mm Hg
diastolic (Al-Hermi, 2004). Ambulatory measurements are also valuable in
assessing patients with apparent drug resistance, low BP symptoms, and in
patients taking antihypertensive medications. There is now wider acceptance
of BP readings taken by patients in their homes. Patients should be encouraged
to monitor their BP at home with validated devices followed by appropriate
recording and reporting to their clinician.
THE OBESE OR LARGE ARM
It is well known that BP measurement with a standard 12- to 13-inch (27- to
34-cm) wide cuff is inappropriate for large or obese arms. If the arm circumference
of the patient exceeds 13 inches (34 cm), use a thigh cuff 17 to
20 inches (18 cm) wide on the patient’s upper arm. Table 4-2 gives acceptable
bladder dimensions for adult arms of different sizes. In patients with extremely
large arms, place the cuff on the patient’s forearm and listen over the radial
artery. Occasionally, it may be necessary to determine the BP in the leg; this
may be required to rule out coarctation of the aorta or if an upper extremity
BP determination is contraindicated. To do this, use a wide, long thigh cuff
It is well known that BP measurement with a standard 12- to 13-inch (27- to
34-cm) wide cuff is inappropriate for large or obese arms. If the arm circumference
of the patient exceeds 13 inches (34 cm), use a thigh cuff 17 to
20 inches (18 cm) wide on the patient’s upper arm. Table 4-2 gives acceptable
bladder dimensions for adult arms of different sizes. In patients with extremely
large arms, place the cuff on the patient’s forearm and listen over the radial
artery. Occasionally, it may be necessary to determine the BP in the leg; this
may be required to rule out coarctation of the aorta or if an upper extremity
BP determination is contraindicated. To do this, use a wide, long thigh cuff
with a bladder size of 45 to 52 cm and apply it to the mid-thigh. Center the
bladder over the posterior surface, wrap it securely, and listen over the
popliteal artery (Perloff, 1993).
According to Pickering and colleagues (2005), “wrist monitors may be useful
in very obese patients if the monitor is held at heart level. Finger monitors
are not recommended.” Block and Schulte (1996) discussed ankle BP measurements
and found that mean BP readings obtained at the arm and at the ankle
were statistically equivalent and concluded that ankle cuff placement provided
a reliable alternative to the placement of the cuff on the arm.
bladder over the posterior surface, wrap it securely, and listen over the
popliteal artery (Perloff, 1993).
According to Pickering and colleagues (2005), “wrist monitors may be useful
in very obese patients if the monitor is held at heart level. Finger monitors
are not recommended.” Block and Schulte (1996) discussed ankle BP measurements
and found that mean BP readings obtained at the arm and at the ankle
were statistically equivalent and concluded that ankle cuff placement provided
a reliable alternative to the placement of the cuff on the arm.
INFANTS AND CHILDREN
Measuring BP in infants and children presents special problems to the
clinician. The same measuring techniques are used as in adults. As mentioned
earlier, pediatric cuff sizes are available to ensure that the bladder
completely encircles the upper arm. Various techniques can enforce patient
compliance—using relaxation techniques for the child, having the mother
inflate the BP cuff, and/or demonstrating BP measurement on a stuffed animal.
Measuring BP in infants and children presents special problems to the
clinician. The same measuring techniques are used as in adults. As mentioned
earlier, pediatric cuff sizes are available to ensure that the bladder
completely encircles the upper arm. Various techniques can enforce patient
compliance—using relaxation techniques for the child, having the mother
inflate the BP cuff, and/or demonstrating BP measurement on a stuffed animal.
ELDERLY PATIENTS
In elderly patients, who may have significant atherosclerosis, it is likely that
the systolic pressure is overestimated by the indirect method of BP measurement.
BP tends to be more labile in elderly patients, so it is important to
obtain several baseline measurements before making any diagnostic or
therapeutic decisions (Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, 2003). ABPM is very
useful in this age group.
In elderly patients, who may have significant atherosclerosis, it is likely that
the systolic pressure is overestimated by the indirect method of BP measurement.
BP tends to be more labile in elderly patients, so it is important to
obtain several baseline measurements before making any diagnostic or
therapeutic decisions (Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, 2003). ABPM is very
useful in this age group.
ASSESSMENT OF ORTHOSTATIC BLOOD
PRESSURE
The measurement of orthostatic BP is an essential clinical tool for the
assessment and management of patients suffering from many common
medical disorders. The most common causes are volume depletion and
autonomic dysfunction. According to Carlson (1999), orthostatic hypotension,
which is a decline in BP when standing erect, is the “result of an impaired
hemodynamic response to an upright posture or a depletion of intravascular
volume. The measurement of orthostatic blood pressure can be done at the
bedside and is therefore easily applied to several clinical disorders.”
Orthostatic hypotension is detected in 10% to 20% of community-dwelling
older individuals (Mader, 1987). This condition is frequently asymptomatic,
but disabling symptoms of light-headedness, weakness, unsteadiness,
blurred vision, and syncope may occur.
PRESSURE
The measurement of orthostatic BP is an essential clinical tool for the
assessment and management of patients suffering from many common
medical disorders. The most common causes are volume depletion and
autonomic dysfunction. According to Carlson (1999), orthostatic hypotension,
which is a decline in BP when standing erect, is the “result of an impaired
hemodynamic response to an upright posture or a depletion of intravascular
volume. The measurement of orthostatic blood pressure can be done at the
bedside and is therefore easily applied to several clinical disorders.”
Orthostatic hypotension is detected in 10% to 20% of community-dwelling
older individuals (Mader, 1987). This condition is frequently asymptomatic,
but disabling symptoms of light-headedness, weakness, unsteadiness,
blurred vision, and syncope may occur.
The American Academy of Neurology’s consensus statement (1996) defines
orthostatic hypotension as a “reduction of systolic blood pressure of at least
20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes
of standing.”
Many clinicians use a combination of a decrease in BP combined with an
increase in heart rate to determine the presence of orthostatic hypotension.
Performing these orthostatic measurements requires adequate techniques
in BP measurement, appropriate positioning of the patient, and proper timing
of the measurements.
orthostatic hypotension as a “reduction of systolic blood pressure of at least
20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes
of standing.”
Many clinicians use a combination of a decrease in BP combined with an
increase in heart rate to determine the presence of orthostatic hypotension.
Performing these orthostatic measurements requires adequate techniques
in BP measurement, appropriate positioning of the patient, and proper timing
of the measurements.
Materials Utilized for Measuring Orthostatic Blood
Pressure
This technique requires the same equipment as previously mentioned for
measuring BP.
Pressure
This technique requires the same equipment as previously mentioned for
measuring BP.
FOLLOW-UP CARE AND
INSTRUCTIONS
The results of the BP measurements dictate the follow-up actions and patient
instructions. Long-term observations have been made on the contributions
of high BP to illness and death. It is important to note that the classification
of BP has changed over the years. In 2003, the seventh report of the Joint
National Committee (JNC-VII) on prevention, detection, evaluation, and
treatment recommended the classification found in Table 4-3.
INSTRUCTIONS
The results of the BP measurements dictate the follow-up actions and patient
instructions. Long-term observations have been made on the contributions
of high BP to illness and death. It is important to note that the classification
of BP has changed over the years. In 2003, the seventh report of the Joint
National Committee (JNC-VII) on prevention, detection, evaluation, and
treatment recommended the classification found in Table 4-3.
Clinicians should explain the meaning of their BP readings to patients and
advise them of the appropriate need for periodic follow-up care and remeasurement.
Table 4-4 demonstrates a suggested follow-up form to be given
to patients after their BP has been taken.
The measurement of orthostatic BP is a simple technique that requires the
same equipment as previously mentioned in this chapter for measuring BP.
Practical applications include the detection of intravascular volume
depletion and autonomic dysfunction and the treatment of hypertension,
congestive heart failure, and other clinical disorders.
advise them of the appropriate need for periodic follow-up care and remeasurement.
Table 4-4 demonstrates a suggested follow-up form to be given
to patients after their BP has been taken.
The measurement of orthostatic BP is a simple technique that requires the
same equipment as previously mentioned in this chapter for measuring BP.
Practical applications include the detection of intravascular volume
depletion and autonomic dysfunction and the treatment of hypertension,
congestive heart failure, and other clinical disorders.
REFERENCES
Al-Hermi B, Abbas B: The role of ambulatory blood pressure
measurements in adolescence and young adults. Transplant Proc
36:1818-1819, 2004.
American Academy of Neurology: Consensus statement on the
definition of orthostatic hypotension, pure autonomic failure, and
multiple system atrophy. Neurology 46:1470, 1996.
Al-Hermi B, Abbas B: The role of ambulatory blood pressure
measurements in adolescence and young adults. Transplant Proc
36:1818-1819, 2004.
American Academy of Neurology: Consensus statement on the
definition of orthostatic hypotension, pure autonomic failure, and
multiple system atrophy. Neurology 46:1470, 1996.
Base-Smith V: Nondisposable sphygmomanometer cuffs harbor
frequent bacterial colonization and significant contamination by
organic and inorganic matter. AANA 64:141-145, 1996.
Block FE, Schulte GT: Ankle blood pressure measurement: An
acceptable alternative to arm measurements. Int J Clin Monit Comput
13:167-171, 1996.
Carlson JE: Assessment of orthostatic blood pressure: Measurement,
technique, and clinical applications. South Med J 92:167-173, 1999.
Graves J: Prevalence of blood pressure cuff sizes in a referral practice
of 430 consecutive adult hypertensives. Blood Press Monit 6:17-20,
2001.
Grim CM, Grim C: Manual blood pressure measurement—Still the gold
standard: Why and how to measure blood pressure the old-fashioned
way. Hypertension Medicine October, 131-145, 2000.
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure: The seventh report of the Joint
National Committee (JNC-VII) on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. JAMA 289:2560-2572, 2003.
Lieb M, Holzgreve H, Schultz M, et al: The effect of clothes on
sphygmomanometric and oscillometric blood pressure measurement.
Blood Press 13:279-282, 2004.
Lyons SA, Petrucelli RJ: Medicine: An Illustrated History. New York,
Abradale Press, 1987.
Mader SL, Josephson KR, Rubenstein LZ: Low prevalence of postural
hypotension among community-dwelling elderly. JAMA 258:1511-1514,
1987.
Manning DM, Kuchirka C, Kaminski J: Miscuffing: Inappropriate blood
pressure cuff application. Circulation 68:763-766, 1983.
Mourad A, Carney S: Brief communication: Arm position and blood
pressure: An audit. Intern Med J 34:290-291, 2004.
O’Brien E: Ambulatory blood pressure monitoring in the management of
hypertension. Heart 89:571-576, 2004.
Perloff D, Grim C, Flack J, et al: Human blood pressure by
sphygmomanometry. Circulation 88:2460-2470, 1993.
Pickering TG, Hall JE, Appel LJ, et al: Recommendations for blood
pressure measurement in humans: An AHA scientific statement from
the Council on High Blood Pressure Research Professional and Public
Education Subcommittee. J Clin Hypertens (Greenwich) 7:102-109,
2005.
Porter R: The Greatest Benefit to Mankind: A Medical History of
Humanity. New York, WW Norton, 1997.
Stevens G: Famous Names in Medicine. East Sussex, England, Wayland
Publishers, 1978.
Valler-Jones T, Wedgbury K: Measuring blood pressure using the
mercury sphygmomanometer. Br J Nurs 14;145-150, 2005.
Verdecchia P: Prognostic value of ambulatory blood pressure.
Hypertension 35:844-851, 2000.
Wain H: A History of Medicine. Springfield, Ill, Charles C Thomas, 1970.
frequent bacterial colonization and significant contamination by
organic and inorganic matter. AANA 64:141-145, 1996.
Block FE, Schulte GT: Ankle blood pressure measurement: An
acceptable alternative to arm measurements. Int J Clin Monit Comput
13:167-171, 1996.
Carlson JE: Assessment of orthostatic blood pressure: Measurement,
technique, and clinical applications. South Med J 92:167-173, 1999.
Graves J: Prevalence of blood pressure cuff sizes in a referral practice
of 430 consecutive adult hypertensives. Blood Press Monit 6:17-20,
2001.
Grim CM, Grim C: Manual blood pressure measurement—Still the gold
standard: Why and how to measure blood pressure the old-fashioned
way. Hypertension Medicine October, 131-145, 2000.
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure: The seventh report of the Joint
National Committee (JNC-VII) on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. JAMA 289:2560-2572, 2003.
Lieb M, Holzgreve H, Schultz M, et al: The effect of clothes on
sphygmomanometric and oscillometric blood pressure measurement.
Blood Press 13:279-282, 2004.
Lyons SA, Petrucelli RJ: Medicine: An Illustrated History. New York,
Abradale Press, 1987.
Mader SL, Josephson KR, Rubenstein LZ: Low prevalence of postural
hypotension among community-dwelling elderly. JAMA 258:1511-1514,
1987.
Manning DM, Kuchirka C, Kaminski J: Miscuffing: Inappropriate blood
pressure cuff application. Circulation 68:763-766, 1983.
Mourad A, Carney S: Brief communication: Arm position and blood
pressure: An audit. Intern Med J 34:290-291, 2004.
O’Brien E: Ambulatory blood pressure monitoring in the management of
hypertension. Heart 89:571-576, 2004.
Perloff D, Grim C, Flack J, et al: Human blood pressure by
sphygmomanometry. Circulation 88:2460-2470, 1993.
Pickering TG, Hall JE, Appel LJ, et al: Recommendations for blood
pressure measurement in humans: An AHA scientific statement from
the Council on High Blood Pressure Research Professional and Public
Education Subcommittee. J Clin Hypertens (Greenwich) 7:102-109,
2005.
Porter R: The Greatest Benefit to Mankind: A Medical History of
Humanity. New York, WW Norton, 1997.
Stevens G: Famous Names in Medicine. East Sussex, England, Wayland
Publishers, 1978.
Valler-Jones T, Wedgbury K: Measuring blood pressure using the
mercury sphygmomanometer. Br J Nurs 14;145-150, 2005.
Verdecchia P: Prognostic value of ambulatory blood pressure.
Hypertension 35:844-851, 2000.
Wain H: A History of Medicine. Springfield, Ill, Charles C Thomas, 1970.
Posts
No comments:
Post a Comment