Blood Pressure Measurement
Category: Vital Signs
Overview
A fundamental vital sign assessment used to evaluate cardiovascular health and monitor patient status.
Indications
Routine vital sign monitoring, pre/post medication administration, cardiovascular assessment, hypertension screening, baseline measurements, monitoring for orthostatic hypotension.
Contraindications
Open wounds or injuries to the arm, severe edema, arteriovenous fistula or graft in the arm, recent mastectomy on the measurement side, burns or cellulitis at measurement site.
Equipment Needed
Stethoscope, appropriately sized blood pressure cuff, sphygmomanometer (manual or automatic), alcohol wipes, documentation materials. Note: Cuff should be 40% of arm circumference.
Procedure Steps
1. Explain procedure to patient and ensure privacy
2. Have patient rest for 5 minutes before measurement
3. Position patient comfortably with arm supported at heart level
4. Select appropriate cuff size (cuff bladder should encircle 80% of arm)
5. Wrap cuff snugly around upper arm, 1-2 inches above antecubital fossa
6. Locate brachial artery by palpation
7. Inflate cuff rapidly to 30 mmHg above estimated systolic pressure
8. Place stethoscope bell lightly over brachial artery
9. Slowly deflate cuff at 2-3 mmHg per second
10. Note first Korotkoff sound (systolic pressure)
11. Continue deflating until sounds completely disappear (diastolic pressure)
12. Completely deflate cuff and remove
13. Wait 1-2 minutes before repeat measurements
14. Document results and report abnormal findings immediately
Safety Considerations
Ensure proper cuff size to avoid inaccurate readings. Do not take BP on arm with IV, arteriovenous access, or recent surgery. Wait 30 minutes after caffeine, smoking, or exercise. Position arm at heart level for accurate measurement. Use appropriate pressure to avoid patient discomfort.
Potential Complications
Inaccurate readings from improper technique, pain or discomfort from over-inflation, potential nerve damage from prolonged cuff inflation, anxiety-induced elevated readings, bruising from excessive pressure.
Documentation
Record systolic and diastolic pressures, arm used, patient position, cuff size if non-standard, time of measurement, any factors affecting accuracy, and comparison to previous readings.
References
American Heart Association. (2017). 2017 AHA/ACC/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065