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Cardiopulm Phys Ther J. 2011 Jun; 22(2): 5–12.

Blood Pressure Measurement Guidelines for Physical Therapists

Ethel Thou Frese, PT, DPT, MHS, CCS, corresponding author 1 Ann Fick, PT, DPT, MS, CCS,2 and H. Steven Sadowsky, PT, RRT, MS, CCS3

Ethel M Frese

1Department of Concrete Therapy and Athletic Training, Saint Louis University, St. Louis, MO

Ann Fick

twoSection of Concrete Therapy, Maryville University, St. Louis, MO

H. Steven Sadowsky

3Department of Physical Therapy and Movement Scientific discipline, Northwestern University, Chicago, IL

Abstruse

Vital sign measurement and cess are important components of the review of systems in a concrete therapy examination for individuals with and without documented cardiopulmonary illness. The measurement of claret pressure gives the therapist information regarding the patient's baseline cardiovascular status, response to exercise/activity, and guides practice prescription. Accurate measurement of blood pressure is critical for making appropriate clinical decisions especially if physical therapists wish to play an of import function as primary wellness intendance providers. The purpose of this paper is to nowadays recommended guidelines for blood pressure measurement by physical therapists and physical therapist administration.

Cardinal Words: blood pressure level measurement, vital sign assessment, guidelines

Blood PRESSURE MEASUREMENT GUIDELINES FOR Concrete THERAPISTS

Equally stated in the Guide to Physical Therapist Practice, assessment and monitoring of vital signs are important components of the review of systems in a physical therapy exam for individuals with and without documented cardiopulmonary disease.1 The U.S. Preventive Services Job Forcefulness recommends screening for loftier blood pressure in adults xviii years of age and older.2 Blood pressure screening should occur every two years in people with blood pressures less than 120/eighty mm Hg, and every twelvemonth for people with systolic claret pressure level 120 mm Hg to 139 mm Hg, or diastolic blood pressure 80 mm Hg to 89 mm Hg. The measurement of blood pressure gives the therapist data regarding the patient's baseline cardiovascular status, response to practice/activeness, and guides exercise prescription.

The 7th Written report of the Joint National Commission on Prevention, Detection, Evaluation, and Handling of High

Claret Pressure (JNC 7) provides a scheme for classifying blood pressure level for adults (≥ 18 years of age) and defines hypertension every bit start at systolic and diastolic pressures of 140/90 mm Hg, respectively.three Tabular array ​ i presents the JNC 7 classification of hypertension, which is based on an average of at least two seated claret pressure measurements, properly measured with well-maintained equipment in a single visit. In society for the diagnosis of hypertension to be established, an elevated claret pressure measurement must occur in at to the lowest degree 2 split visits to the health care provider's clinic or office.3

Table 1

Nomenclature of Hypertensioniii , 4

Classification Systolic Blood Pressure (mm Hg) Diastolic Blood Pressure (mm Hg)
Normal <120 <80
Prehypertension 120–139 80–89
Stage 1 hypertension 140–159 xc–99
Stage 2 hypertension ≥160 ≥100

Hypertension is the most common primary diagnosis in the United States. It is a major chance factor for coronary heart illness, stroke, and renal failure, and affects 29% of the adult Us population.3 , 4 20-two percent of persons who take hypertension are unaware that they accept it.3 In addition, one-fourth of the population twenty years and older is estimated to be prehypertensive, which is defined equally a systolic blood force per unit area of 120-139 mm Hg, and/or a diastolic blood pressure of lxxx-89 mm Hg. Prehypertension contributes to about 15% of blood pressure related deaths for coronary artery disease.4 Pulse pressure level (systolic blood pressure minus diastolic claret pressure), which is normally around 40 mm Hg, has been postulated to be a better predictor of cardiovascular gamble than hateful arterial pressure level.5 , half dozen Elevated pulse pressures (> 60 mm Hg) are associated with higher cardiovascular morbidity and mortality rates among all arterial claret pressure data.v , 6

Hypertension and prehypertension in children and adolescents 8 to 17 years erstwhile have increased since 1999, and both are frequently undiagnosed in children three to 18 years of historic period.5 , 13 Childhood blood pressure is a strong predictor of blood pressure levels in adulthood, and hypertension and prehypertension are a significant health issue in the young, especially with the prevalence of childhood obesity.7 , eight Therefore information technology is very important for both young and older individuals with hypertension and prehypertension to exist identified and treated.7 , 9 , 10

Accurate measurement of blood pressure is critical for making appropriate clinical decisions in management of high blood pressure level to reduce cardiovascular risk and prevent target organ harm. An inaccurate measurement of blood pressure could pb to a patient being falsely classified as hypertensive or falsely classified as having high normal or normal blood force per unit area as well as pb to faulty clinical decisions regarding patient progression in an do program.11 , 12

Error can exist minimized when a standard measurement protocol and a standard training protocol are used.thirteen Nonetheless, health care providers oftentimes do not comply with established guidelines for measuring blood pressure and guidelines are non always consistent with each other.14 To our knowledge there are no published guidelines for blood pressure measurement with an emphasis for concrete therapists and physical therapist assistants. The purpose of this paper is to present recommended guidelines for blood force per unit area measurement past concrete therapists and concrete therapist assistants.

SOURCES OF ERROR IN BLOOD Pressure MEASUREMENT

Controlling for fault in blood pressure measurement techniques is important if authentic readings are to be obtained. I common source of inaccurate blood force per unit area interpretation, specially among older men and women, is the white coat effect that occurs when claret pressure is elevated just in the presence of the wellness care worker taking the measurement. White coat effect has been defined every bit a "persistently elevated average role blood pressure of greater than 140/90 mm Hg with an average awake ambulatory reading of less than 135/85".12 Arrhythmias and strong (poorly compliant) arteries, which frequently occur in elderly individuals, contribute to the variability of claret pressure measurement. Medications, feet, time of day, groundwork racket, room temperature, and stimuli such as food, alcohol, caffeine, nicotine, and do within xxx minutes before blood pressure measurement also bear on the reading. Crossing legs, talking, and doing mental tasks while the measurement is beingness done increases blood pressure.four , eight , 13 A non-exhaustive list of additional common error sources for blood pressure measurement is presented in Table ​ two.

Table two

Near Common Sources of Error in Blood Pressure Measurement Technique4 , xi

  • Cuff size and awarding

  • Arm position

  • Differences in arm size

  • Rest period prior to measurement

  • Inflation/deflation method

  • Concentration of the measurer

  • Digit bias (tendency to record a zero as the final digit)

  • Lack of repeated measures

  • Time between repeated measures

  • Lack of scale/maintenance of measurement devices

  • Body position

  • Muscle tension

  • Quality of stethoscope

  • Level of grooming of measurer

The trouble of "miscuffing" constitutes the well-nigh frequent mistake in the measurement of blood pressure.fifteen The most recent American Heart Clan guidelines specify that the proper cuff has a bladder length of 80% and a width of at least xl% of arm circumference.4 The therapist must make up one's mind the proper cuff size by determining the circumference of the arm at the one-half-manner point betwixt the olecranon and the acromion processes.iv , seven , 16 , 17 Although it is important to use the correct size gage when measuring claret pressure, it is by and large recognized that the measurement mistake is greater with an undersized gage than information technology is with an oversized cuff. Table ​ iii presents recommendations for ideal cuff sizes to be used clinically.

Table 3

Recommended "Platonic" Cuff Sizes for Newborns, Infants, Children, and Adultsfour , vii

Arm Circumference (cm) Gage Size (cm)
Upward to ten 4 × 8 newborn7
>10 to 1 five 6 × 12 babe7
15 to 22 9 × 18 child7
22 to 26 12 × 22 smalladult4
27 to 34 16 × 30 adult (standard)iv
35 to 44 sixteen × 36 large adult4
45 to 52 16 × 42 adult thighfour
Optimal ratios for arm width and length to circumference are presented simply for the small and standard adult cuff sizes, because the ideal width: circumference ratio is not clinically practical for the large adult and thigh cuffs (although the ideal lengthxircumference ratio is presented).

MEASUREMENT FOR BASELINE/DIAGNOSTIC PURPOSES

Certain physical and cognitive competencies are required in order for all health care providers to perform a blood pressure measurement process. Among the physical requirements, are the eye/paw/ear coordination to use the valve mechanism of mercury or aneroid sphygmomanometers, the ability to hear and differentiate the Korotkoff sounds, and the ability to encounter the meniscus of the mercury cavalcade or the punch of the manometer from 3 feet away.

Standardizing blood pressure measurement and training techniques is of import for physical therapy pedagogy programs and for clinical practice to improve the accuracy of claret force per unit area measurement by concrete therapists. The recommended procedures to be followed in obtaining baseline or diagnostic blood pressure level measurement are discussed below and summarized in the Appendix 1. In order to minimize measurement error, the equipment to be used, whether aneroid, electronic, or mercury, should be regularly inspected and calibrated. Equipment users should be trained regularly in the proper, standardized technique.4 , 18 – 21 Unless otherwise specified, blood pressure measurements are, by convention, understood to have been obtained from the upper arm of the patient/client. Although many clinicians believe that claret pressure readings obtained in either the seated or supine positions are equivalent, such has non proven to be the case.22 The present consensus suggests that patients/clients should be seated quietly in a chair with back support, with both anxiety apartment on the flooring for at least five minutes prior to obtaining a measurement.iii , four , 19 The initial visit blood force per unit area should be measured in both arms. According to Pickering et al4 "the patient should be instructed to relax as much every bit possible and to not talk during the measurement procedure." Blood pressure should also be measured in continuing for those patients who are at risk for postural hypotension (eg, elderly, patients with diabetes, and patients on antihypertensive medications).4

To date, the mercury sphygmomanometer remains the "gilt standard" device for blood pressure measurement.4 , 19 , 23 However, considering they are being replaced due to environmental concerns in many practice settings (eg, having been banned in Veterans Administration Hospitals), there is a role for other types of devices (eg, aneroid sphygmomanometers and digital electronic pressure transducers).4 , 24 There is controversy regarding the accuracy of blood pressure level measurement using automatic devices. Evidence has shown that automated devices tend to underestimate both systolic and diastolic blood pressures in adults,25 and overestimate both systolic and diastolic pressures in children and adolescents 5 to 17 years of age.26 The blood pressure gage should be placed on the patient'south bare arm. If necessary, clothing should be removed, and the patient/client draped, to adequately expose the arm. The sleeve should not simply be rolled up in order to gain access to the arm; it creates a tourniquet effect above the cuff. When placing the gage on the arm, the midline of the inflatable bladder should be positioned over the brachial artery (the artery coursing between the biceps and triceps muscles, on the medial aspect of the arm) at the mid-point of the upper arm. The lower-almost edge of the cuff should be at to the lowest degree 1 inch (two.5 cm) to a higher place the antecubital crease and then that the bell (preferred) or the diaphragm of the stethoscope can be placed over the indicate of the strongest palpable brachial avenue pulse in the antecubital fossa without encroaching beneath the cuff.3 , 4 , 19 If necessary, the claret pressure tin exist measured with the cuff placed on the forearm with auscultation over the radial artery, but this may yield a falsely high systolic claret pressure level.3

Because of the effects of hydrostatic pressure, the position of the arm when the blood force per unit area is measured can likewise have a major bear on on the force per unit area observed.16 , xix The magnitude of this effect is 1 to ii mm Hg for every 2.five cm to a higher place or below the level of the heart. If the cuff and the upper arm are maintained above the level of the right atrium, the readings obtained will be too low.12 , 22 , 27 , 28 Besides, if they are below the level of the centre, the readings volition exist too high.12 , 22 , 27 , 28 Thus, when taking the measurement, the therapist should support the arm and so that the gage is at the level of the correct atrium with the arm direct and the antecubital fossa "faces upward." Since muscle contraction raises blood pressure, care should also be taken to avoid the patient/client helping to elevate the limb; if bachelor, pillows or bolsters may also exist used to properly position and support the arm.

In order to avert over inflation of the cuff, and to accommodate any systolic auscultatory gap, the clinician should estimate a maximum inflation signal past palpating the radial pulse while incrementally inflating the gage until the pulse disappears. The therapist should and then look at least one minute after deflating the cuff before reinflating the cuff to 30 mm Hg above the point where the pulse previously disappeared. Alternatively, 1 may auscultate the brachial avenue while incrementally inflating the cuff to 30 mm Hg above the point at which the borer racket (Korotkoff sounds) disappears. Blood pressure results are significantly influenced by the charge per unit of gage deflation–too rapid a rate leads to marked underestimation of systolic and overestimation of diastolic pressure. Therefore, the recommended deflation rate is 2 mm Hg per second (or per pulse when the centre rate is below 60 beats per infinitesimal).4 , 20 Systolic blood pressure should be recorded equally the indicate at which auscultatory pulsations (Korotkoff stage I) are heard as the cuff is deflated. The disappearance of the auscultatory pulsations (Korotkoff stage V) defines the diastolic pressure in adults. In some circumstances (eg, children, specially young adolescents, pregnancy, do) when sounds are heard to near zero the Korotkoff stage IV (muffling of sounds) is used to indicate the diastolic force per unit area, and the reading at each of the 3 phases should be recorded (eg, Phase I=120, Stage Four=60, Phase V=0).12 , 29 – 31 Therefore the claret pressure would exist recorded as 120/60/0 mm Hg. Pressures should be read to the nearest ii mm Hg when using aneroid or mercury devices.4

The accuracy of blood pressure measurements is of extreme importance. For example, in a recent review McAlister and Strauss32 suggested that almost 2-thirds of hypertensive individuals would be denied morbidity preventing treatment if the diastolic blood pressure were underestimated past five mm Hg; the number of persons diagnosed with hypertension would more than double if systolic pressure were over estimated past five mm Hg. Therefore, to strengthen the accurateness of blood pressure measurements, it is recommended that more than one reading exist taken.32 , 33 Although no clear rationale for a specific number of readings has emerged from the literature, Pickering et aliv recommend that the average of at least ii readings should be taken at an interval of at least one minute to represent the patient's/client'south blood pressure. If the departure between the starting time two readings is more than than 5 mm Hg, one or two additional readings should exist obtained, and the average of the multiple readings should be used.

Almost all studies accept reported finding differences between the blood pressures measured in both arms. These differences seem to arise more frequently when but a single measurement is taken in each arm, and they are not attributable to the handedness of the patient/customer.34 , 35 However, even when 3 measurements from each arm were analyzed, about xv% of subjects had inter-arm differences of greater than 10 mm Hg. Therefore, claret pressure should be checked in both arms at the offset examination, at least, and the arm with the higher force per unit area should be used for subsequent monitoring assessments.

As might be anticipated, the guidelines for obtaining baseline/diagnostic blood pressure measurements are more stringent than those for intra-session monitoring. Claret pressure measurement in these situations is usually performed to estimate vital signs or appraise specific interval changes in response to action rather than the presence or absence of hypertension. And, although they are not diagnostic, loftier readings or abnormal blood pressure level responses (eg, more than a ten mm Hg increase in systolic pressure per metabolic equivalent of work) are suggestive of a need for follow-upwardly.36 – 38

BLOOD PRESSURE MEASUREMENT IN CHILDREN

Blood pressure should be measured in children under iii years of age who have any item atmospheric condition warranting this evaluation such as congenital heart disease, renal disease, systemic diseases or medications that may cause hypertension, elevated intracranial pressure, malignancy, transplantation, or a previous status requiring intensive care treatment.eight Otherwise, blood pressure should be measured in children who are at to the lowest degree 3 years old.7 , 17 Equally in adults, the use of Korotkoff sounds via the auscultatory method is recommended since research has shown that oscillometric values tend to be less authentic than auscultated values in children.7 , 39 Although there is some debate as to which Korotkoff sound should be used to mensurate diastolic pressure, particularly in the pre-teenage years,40 use of the Korotkoff phase Five (sound disappears) is preferred.7 Korotkoff phase 4 (sound muffles) can be used in children where the Korotkoff sounds are audible until complete or most-complete cuff deflation.7 It is recommended that prior to labeling a kid'due south blood pressure every bit elevated at to the lowest degree iii repeated measures using the auscultatory method are needed.7 If an elevated finding is new and the patient is symptomatic, firsthand referral to the physician is imperative. This is especially important since the majority of children and adolescents who have hypertension and prehypertension are undiagnosed.17

Although the bodily technique of obtaining a child's blood pressure is performed similarly to the adult, a few tips for accurate blood pressure measurement in the pediatric population should exist taken into account:

The usual practice is to use the patient'south right arm for reliability and assessment when comparing systolic and diastolic blood pressure measures with the standard values. This is considering of the chance of coarctation of the aorta, which could result in an inaccurately low reading in the left arm.vii , 17

The main difference ane should consider when taking a pediatric patient's claret pressure is that body size and historic period are needed to decide normal values for each child. Reference tables using a child'due south sex, historic period, and height provide more verbal data.41 In order to determine the claret pressure range for a kid, the top percentile for age is beneficial. This data tin exist constitute at www.cdc.gov/growthcharts. Table ​ iv presents claret pressure ranges for girls and boys by age and height.7 The lower values in the table correspond to children of that age at the fifth percentile of height, while higher values employ to children at the 95th percentile of height. For example, a midrange blood pressure for a 5-twelvemonth-old girl at the fifth percentile of height would be 89/52 mm Hg; for the same girl, a blood pressure of 103/66 mm Hg would be interpreted every bit "pre-hypertension" since these values fall at the 90th percentile of the range. Similarly, a 5-yr-old daughter at the 95th percentile of height should have a blood pressure no higher than about 109/70. Blood pressure values that autumn within the 90-95th percentile ranges are interpreted as "pre-hypertension" and values greater than this are interpreted as "hypertension."

Table 4

Midpoint and 90th Percentile Blood Pressure Levels for Girls and Boys at the fifth and 95th Percentiles of Peak7

Age Range of Blood Pressure Girls Boys
*< 90th percentile is considered normal

  • SBP/DBP, mm Hg

  • *the lower numbers correspond to children at the 5th percentile of height

  • *the higher numbers correspond to children at the 95th percentile of tiptop

  • SBP/DBP, mm Hg

  • *the lower numbers correspond to children at the fifth percentile of top

  • *the higher numbers correspond to children at the 95th percentile of height
1 year old Midpoint of range 83–90/38–42 lxxx–89/34–39
90th percentile of range 97–103/52–56 94–1 03/49–54
3 year old Midpoint of range 86–93/47–51 86–95/44–48
90th percentile of range i 00–1 06/61–65 100–109/59–63
5 year one-time Midpoint of range 89–96/52–56 90–98/50–55
90th percentile of range 103–109/66–seventy 104–112/65–seventy
10 year old Midpoint of range 98–105/59–62 97–106/58–63
90th percentile of range 112–118/73–76 111–119/73–78
xv year former Midpoint of range 1 07–11 3/64–67 109–117/61–66
90th percentile of range **1 20/78–lxxx **120/76–80

BLOOD Pressure level MEASUREMENT IN SPECIAL SITUATIONS

Peripherally Inserted Central Catheters

Blood force per unit area measures, per expert opinion, should be avoided in the upper arm in which there is a peripherally inserted fundamental catheter (PICC) line present.42

Dialysis shunt or fistula

Claret pressure should be taken in the contrary arm if the patient has a working graft or arteriovenous fistula needed for dialysis.43 Per skillful opinion this is to avoid possible trauma or clot germination.

Patients with obesity

If the cuff that is available is too small, especially if upper arm circumference is > 50 cm, blood force per unit area can be measured in the forearm.iv

Forearm measurement of blood pressure

In cases where neither upper arm can be used for a claret pressure measurement, an alternative site would be the forearm. The systolic claret pressure measurement can be estimated by placing the cuff on the forearm with the forearm supported at the level of the heart and palpating for the appearance of the radial pulse as the cuff is deflated. Auscultation of Korotkoff sounds over the radial artery or using a Doppler likewise can exist done. Systolic blood pressure level tends to be higher in the forearm and can differ from upper arm measurements by upwards to 20 mm Hg.44 Validation of the accurateness of forearm measurement techniques has not been achieved.4 Therefore forearm and upper arm blood pressure measurements are not interchangeable and should exist labeled in whatever documentation to clearly bespeak the measurement site.

Radial artery recently used for CABG

Although information technology is skillful opinion, if the radial artery is used equally a graft during coronary artery bypass graft surgery, it is best to not perform blood force per unit area measurements in that arm for at least the initial days afterwards surgery.45

Cardiac dysrhythmias

If the centre rhythm is chaotic (eg, atrial fibrillation), claret pressure measures will fluctuate as the centre charge per unit changes. Therefore the recommendation is to take the average of more than i measurement. For slow eye rates, the speed of deflation of the gage too needs to be reduced for a more precise appraisal of claret pressure level.4

Elderly

It is recommended by Pickering et aliv that standing blood force per unit area measurements in the elderly, especially for those with diabetes, exist assessed to rule out possible postural hypotension. This is defined by a systolic pressure drop past more than 20 mm Hg or a diastolic pressure driblet by more than than ten mm Hg while the patient stands for up to 3 minutes. The patient may or may not take complaints such equally lightheadedness, dizziness, and blurred vision or the therapist may note cognitive changes.4

Lymphedema

Blood pressure should be measured in the contralateral arm in a patient who has had a unilateral mastectomy. There is controversy regarding whether the measurement of blood force per unit area damages the lymphatics and increases the likelihood of lymphedema.46 There is no information to support the theory that the tourniquet issue of the blood pressure cuff damages the lymphatic system and causes or increases edema. Evidence suggests that there is less risk of lymphedema occurring with blood pressure level measurement when the axillary nodes have not been dissected compared to when axillary node autopsy has been performed.xvi

Pregnancy

Blood pressure is of import to monitor in pregnant women because hypertension is the most mutual medical complication in pregnancy and occurs in up to 12% of this population.four Authentic monitoring of blood pressure during pregnancy is an of import aspect of good quality prenatal intendance. Blood pressure tends to decrease early in gestation and frequently is 10 mm Hg beneath pre-pregnancy levels. The mean claret pressure level in the second trimester is 105/60 mm Hg. The decline in blood force per unit area is due to peripheral vasodilatation the causes of which are not clearly understood.47

Other considerations

For patients with sounds not audible per auscultation (eg, those with weak Korotkoff sounds), a Doppler probe tin can be used over the brachial avenue to make up one's mind the patient's systolic pressure. The therapist also can palpate the return of the radial pulse equally the cuff deflates for an estimate of the systolic claret pressure and document the measurement as systolic blood pressure per palpation (eg, 100 mm Hg per palp). In both of these cases, a diastolic pressure cannot be obtained. If the upper arm is unable to be used for a blood pressure measurement, the cuff can be placed on the forearm with the examiner auscultating over the radial artery. As stated earlier, accurateness of forearm blood force per unit area measurement has not been validated.4 If the leg is the only alternative for blood pressure measurement, the cuff can be placed on the thigh. In this case, the popliteal avenue is used for auscultation. Systolic blood pressure measured in the leg (in the seated position) in normal subjects is typically 10% to 20% higher than systolic blood force per unit area measured in the brachial artery.16 Leg systolic claret pressure more than 10% lower than brachial avenue systolic blood pressure may indicate peripheral arterial disease.16

DOCUMENTATION

It is important to document on which side the claret pressure level was measured and state if the forearm was used. In order to achieve accurateness for repeated measures, information technology is critical for therapists to be consistent in their methodology of blood pressure measurement. Therefore it is imperative to document when the method of claret force per unit area measurement deviated from the standard protocol.

Conclusion

Physical therapists and physical therapist assistants are trained in the techniques of claret pressure level measurement as part of basic professional teaching. Withal, they cannot really claim to be adequately using this skill in the best interests of patients in our normal clinical practices unless it is properly and appropriately performed.48

If physical therapists wish to play an important role every bit primary health care providers, we must, as suggested past Frese and colleagues,48 exist more proactive in our assessments of blood pressure and the other vital signs. Only then, volition they exist able to optimally contribute to the identification and direction of blood pressure problems in the patients they serve while as well lending the greatest assistance to other health professionals.

Appendix. Recommended Technique for Measuring Claret Pressure3 , iv

  1. Measurements should be taken with a sphygmomanometer known to be accurate. A recently calibrated aneroid or a validated and recently calibrated electronic device can exist used. Aneroid devices or mercury columns need to be conspicuously visible at eye level.

  2. Choose a gage with an advisable bladder size matched to the size of the arm. For measurements taken by auscultation, bladder width should be shut to 40% of arm circumference and bladder length should cover eighty% to 100% of arm circumference. When using an automated device, select the cuff size as recommended by its manufacturer.

  3. Place the gage so that the lower border is at to the lowest degree ane in (2.5 cm) to a higher place the elbow crease and the float is centered over the brachial artery. The patient/client should be resting comfortably for 5 minutes in the seated position with back support. The arm should exist bare and supported with the antecubital fossa at heart level considering a lower position will event in erroneously higher systolic and diastolic blood force per unit area measurements. There should exist no talking, and patients' legs should not be crossed. At to the lowest degree two measurements should be taken in the same arm with the patient in the aforementioned position, and the mean should be recorded. Blood pressure also should be assessed later ii minutes of continuing (with arm supported) and at times when patients report symptoms suggestive of postural hypotension. Supine claret pressure measurements may as well be helpful in the cess of elderly and diabetic patients.

  4. Increase the pressure level rapidly to xxx mm Hg above the level at which the radial pulse is extinguished (to exclude the possibility of a systolic auscultatory gap).

  5. Place the bell or diaphragm of the stethoscope gently and steadily over the brachial artery.

  6. Open the control valve so that the rate of deflation of the gage is approximately ii mm Hg per heart beat (or per second if HR is less than 60 bpm). A cuff deflation rate of 2 mm Hg per shell is necessary for accurate systolic and diastolic estimation.

  7. Read the systolic level (the first advent of a clear borer audio [phase I Korotkoff]) and the diastolic level (the point at which the sounds disappear [phase 5 Korotkoff]). Go on to auscultate at least 10 mm Hg below phase V to exclude a diastolic auscultatory gap. Tape the claret pressure to the closest 2 mm Hg on the manometer (or 1 mm Hg on electronic devices), besides as the arm used and whether the patient was supine, sitting, or standing. Avoid digit preference past non rounding up or down. Record the heart rate. The seated blood force per unit area is used to determine and monitor treatment decisions. The standing claret pressure is used to examine for postural hypotension, if present, which may modify the treatment.

  8. If Korotkoff sounds persist as the level approaches 0 mm Hg, then the betoken of muffling of the sound is used (phase Four) to indicate the diastolic pressure level.

  9. In the instance of arrhythmia, additional readings may exist required to estimate the average systolic and diastolic pressure level. Isolated extra beats should exist ignored. Note the rhythm and pulse rate.

  10. To avoid venous congestion, it is recommended that at least ane minute should elapse between readings. Leaving the cuff partially inflated for also long will fill the venous system and make the sounds difficult to hear.

  11. Blood pressure should be taken in both arms on, at least, the first visit; if 1 arm has a consistently higher pressure, then that arm should be clearly noted and later used for blood pressure level measurement and estimation.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104931/

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