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9 June
2014

Blood pressure measurement

Alfredo Guzman, M.D.
People find it far easier to forgive others for being wrong than being right.
Albus Dumbledore, Harry Potter & The Half-Blood Prince
CALIBRATING THE ANEROID

Paulo Coelho
TOPIC OUTLINE
I.
II.

III.

IV.
V.
VI.
VII.

VIII.
IX.
X.
XI.
XII.

Blood Pressure Measurement

BP Apparatus/ Sphygmomanometer
A. Mercury Manometer
B. Aneroid Device
Selecting the Correct BP Cuff
A. BP Cuff Sizes
B. Selecting the Most Accurate Cuff
A. Marking the Cuff
The Stethoscope
5 Phases of Korotkoff Sounds
Technique of BP Measurement
Technique of BP Measurement in the Dx of HPN
A. Timing of BP Measurement
B. Patient Position
C. Patient & Physician Position
Observers Skill in BP Measurement
Unequal BP in Both Arms
Steps in Measuring the BP
Definitions of Normal & Abnormal Levels
Special Problems
A. Leg Pulses & Pressures
B. The Apprehensive Patient
C. The Obese or Very Thin
D. Weak/ Inaudible Korotkoff Sounds
F. When Korotkoff Sounds Cant be Heard at All
G. Arrhythmias
H. The Hypertensive Patient w/ Unequal BP in Both
Arms

BP MEASUREMENT

Proper measurement & interpretation - essential in the dx &

management of HPN
Home BP & average 24-hr ambulatory BP are generally lower than
clinic-taken BP
BP tends to be higher in the early morning, soon after walking, than
any other time of the day
Night time BP is generally 10-20% lower than day time BP
White Coat HPN
Px manifests a higher BP in a hospital/clinical setting. They
are at risk of developing sustained HPN.
FACTORS AFFECTING BP MEASUREMENTS

Instrumentation
o BP Apparatus: Mercury, Aneroid, Digital
o BP cuff size
Area of arm covered
Technique of BP Measurement
Patient Factor
Environment

SELECTING THE CORRECT BP CUFF

*Bates
Width about 40% of upper arm circumference (ave 12-14cm in
ave adult)
Length about 80% of upper arm circumference
Standard cuff size 12 x 23cm, appropriate for circumstances up
to 28cm
BP CUFF SIZES

Cuff Sizes

Arm
Circumference
Range at
Midpoint

Bladder
Width
(cm)

Bladder
Length
(cm)

Child
16 - 21
8
21
Small Adult
22 26
10
24
Adult
27 34
13
30
Large Adult
35 44
16
38
Adult Thigh
45 52
20
42
If the cuff is too small (narrow), the BP will read high
If the cuff is too large (wide), the BP will read low on a small arm &
high on a large arm
SELECTING THE MOST ACCURATE CUFF

BP APPARATUS / SPHYGMOMANOMETER
MERCURY MANOMETER

Standard for all BP measurements

Large tube for rapid & in pressure
2mm graduated markings on tube
Mylar-wrapped glass or plastic tube preferred
Mercury is at zero and column rises and falls rapidly
TESTING THE MERCURY MANOMETER

Check the 0. Top of meniscus should rest at the zero mark

Inflate to 200 mmHg. Wait 1 min. Record Pressure.
o If <170 mmHg, theres leak, Release Pressure.
Note wheter Hg rises & falls smoothly
Locate & correct leaks
Date device to indicate it was inspected & repaired
ANEROID DEVICE

Needs regular calibration w/ mercurial manometer

Initiall position of needle at zero, can be easily damaged

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

MARKING THE CUFF

Apply cuff so that the center of inflation bag is over brachial artery
Be sure INDEX line falls between the 2 RANGE lines. If it does
not, a larger of smaller cuff may be required.

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Blood pressure
measurement

Can be used on either right or left arm,

THE STETHOSCOPE

Earpiece should face forward in the ear canal

Must have thick tubing 12-15 inches long
Bell for low pitched sounds
o Used to detect low frequency Korotkoff sounds
Diaphragm for high pitched sounds
5 PHASES OF KOROTKOFF SOUNDS

Korotkoff Sounds produced by the flowing of blood as the cuff

is released
Phase
I

II

III

Description
st

1 appearance of clear,
tapping sound
Soft murmurs that
replace Phase I sounds
Loud murmurs that
replace Phase II
sounds
Sudden muffling of
Phase III sounds

Remarks
Represents Systolic P
(SBP)
Due to blood flow
through constricted artery

Due to constriction of
the artery; arterial
IV
diastolic P is
approached
Disappearance of
Represents Diastolic BP
Korotkoff sounds
(DBP) in most pxs is
normally w/n 10mmHg
V
from Phase IV
(abnormal if >10mmHg
difference; Phase IV is
abruptly muffled)
The usual BP reading involves Phase I and Phase V Korotkoff
sounds for SBP and DBP, respectively.
If there is a significant difference (>10mmHg) between Phase IV
and V, both pressures should be recorded (e.g. 130/70/10
mmHg); seen in anemia, aortic regurgitation, thyrotoxicosis.
In chronic, severe aortic regurgitation or a large arteriovenous
fistula, where the disappearance point may reach 0 mmHg, Phase
IV is much closer to the intraarterial diastolic pressure than Phase
V. All 3 pressures should be noted (e.g. 140/60/0 mmHg).
Difficulty in Hearing Korotkoff Sounds
Condition

Pathology

Severe aortic stenosis

Arterial P rises at a slow rate

Shock
Severe heart failure

Markedly constricted arteries

Markedly constricted arteries

Korotkoff sounds represented during BP measurement. Note the

auscultatory gap.
TECHNIQUES IN BP MEASUREMENT

1. Support arm at the level of the heart

2. Inflate cuff 30 mmHg above the palpatory BP
3. Release pressure at a rate of 2-3 mmHg/s
Initially, measure BP on both arms
Use arm w/ higher BP on subsequent measurements
Measure BP at least twice per visit; allow 1-2 minutes in between
measurements
If there is >5 mmHg difference between 2 consecutive
measurements, additional or continued measurements should be
made
Take the average of the last 2 BP measurements and record
TECHNIQUE OF BP MEASUREMENT IN THE DX OF HPN
I. TIMING OF BP MEASUREMENT

For Dx: Multiple readings taken at various times throughout

waking hours
For Monitoring: Measure prior to intake of anti-hypertensive
medication to determine trough or nadir effect
II. PATIENT POSITION

Usually taken while sitting slouched on the chair

o Supine position SBP & DBP by 2-3 mmHg
Allow patient to rest and sit quietly for 5 minutes
o Apprehension increases BP
Measure both sitting and standing BP to detect postural
hypotension (sudden drop in BP upon standing; in elderly, DM)

III. PATIENT & PHYSICIAN POSITION

Sitting; feet flat on the floor

Arm supported at heart level
Confirm viability of brachial pulse by palpation
Use bell (detection of low-pitched sounds)

Opening and closing the fist repeatedly can help dilate blood
vessels of the arms and make Korotkoff sounds more audible.

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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Blood pressure
measurement

OBSERVERS SKILL IN BP MEASUREMENT

The brain must be programmed to follow the proper guidelines

every time the P is measured.
Must be able to store the systolic and diastolic P & recall them
accurately.
Must be able to hear the Korotkoff sounds and knowhow to
interpret them.
Must be able to recall and write down correctly & legibly the sounds
heard.
Must be able to find & feel the pulses needed for BP measurement.
UNEQUAL BP IN BOTH ARMS

below the muffling pt, provides the best estimate of true diastolic P
in adults.
Read both the systolic & diastolic levels to the nearest 2mmHg.
Wait 2 mins & repeat. Average your findings. If the 1st 2 readings
differ by 5mmHg, take additional readings,
Avoid slow/ repetitive inflations of the cuff, because the resulting
venous congestion can cause false readings.
BP should be taken in both arms at least once. Normally, there
may be a difference in P of 5mmHg & sometimes up to 10mmHg.
Subsequent readings should be made on the arm w/ the higher
pressure.
o
o
o
o

Loose cuff/bladder = false high readings

Earpiece should face forward in the ear canal.
Bell of the stethoscope is used for low-frequency sounds
Auscultatory gaps are associated w/ arterial stiffness &
atherosclerotic disease
o P difference of >10-15mmHg seen in subclavian steal syndrome
& aortic dissection
o BP of 110/70 is usually normal, but could indicate significant
hypotension if previous readings are high
DEFINITIONS OF NORMAL & ABNORMAL LEVELS

CATEGORY

STEPS IN MEASURING THE BP

STEPS TO ENSURE ACCURATE BP MEASUREMENT

Instruct px to avoid smoking/drinking caffeinated drinks 30 mins

prior to BP measurement
Make the examining room as quiet & comfy as possible
Arm should be supported at heart level. Ask px to sit quietly for 5
mins on chair
Make sure the arm is free of clothing. There should be NO
arteriovenous fistulas for dialysis, scarring from prior brachial
artery cutdowns, or signs of lymphedema
Palpate the arm so that the brachial artery (located at the
antecubital crease) is at heart level (roughly level w/ the 4 th
interspace at its junction w/ the sternum
If the px is seated, rest the arm on a table a little above the pxs
waist, if standing, try to support the pxs arm at the mid-chest level
STEPS IN MEASURING THE BP

Center the inflatable bladder over the brachial artery. Lower border
of cuff should be 2.5cm above the antecubital crease. Secure
the cuff snugly. Position arm so that it is slightly flexed at the
elbow,
To determine how high to raise the cuff P, 1st estimate the systolic
pressure by palpation. As you feel the radial artery w/ the fingers
of one hand, inflate the cuff until the radial pulse disappears. Read
this P on the manometer & add 30 mmHg to it. Use of this sum as
the target for the next inflation prevents discomfort from
unnecessary high cuff P. This also avoids the occasional error
caused by an auscultatory gap (a silent interval that may be
present between the systolic & diastolic pressure)
Deflate cuff promptly & completely & wait 15-30 seconds
Next, place the bell of a stethoscope lightly over the brachial artery,
taking care to make an air seal w/ its full rim. Because the sounds
to be heard, the Korotkoff sounds, are relatively low pitched,
they are better heard w/ the bell.
Inflate the cuff rapidly again to the level determined, then deflate it
slowly (2-3mmHg/sec), Note the level at w/c you hear the sounds
of at least 2 consecutive beats. This is the Systolic Pressure.
Continue to lower the P slowly until the sounds become muffled &
then disappear. To confirm the disappearance of sounds, listen as
the P falls another 10-20mmHg. Then deflate the cuff rapidly to
zero. The disappearance point, w/c is usually only a few mmHg

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

SBP
(mmHg)
< 120
120 - 139

DBP
(mmHg)
< 80
80 - 89

Normal
and
Prehypertension
or
Hypertension
Stage 1
140 159
or
90 99
Stage 2
160
or
100
BP goal for pxs w/ HPN, DM, or renal disease is <130/80
The Joint National Committee on Prevention, Detection,
Evaluation, & Treatment of High BP recommended using the mean
of 2 properly measured seated BP readings, taken on 2 visits,
for the dx of HPN, BP should be verified on the contralateral arm.
If the systolic & diastolic P fall under different categories, use the
category of the systolic P (e.g. if systolic P is 141 & diastolic P is
87, the category is Stage 1 HPN)
Effects of HPN on various organs
Eyes hypertensive retinopathy
Heart left ventricular hypertrophy
Brain neurologic deficits suggesting stroke
Additional Notes
Normal RR: 12-20 rpm
Normal HR: 60-100 bpm
o High HR leads to low diastolic time
o Low HR leads to high diastolic time (goal of some cardiac
meds)
Normal Temp: 36.5-37.5
o Hyperpyrexia: 41.5 deg C and up
o Hyperthermia: normal range but px cannot cope
Malignant hyperthermia due to
o anesthesia
o idiosyncrasy
SPECIAL PROBLEMS
LEG PULSES

To rule out coartation of the aorta, 2 observations should be

made at least once w/ every hypertensive px
o Compare the volume & timing of the radial & femoral pulses
o Compare BP in the arm & leg
BP MEASUREMENT IN THE LEG

Use a wide, long thigh cuff that has a bladder size of 18 42 cm,
and apply it to the mid-thigh.
Center the bladder over the posterior surface, wrap it securely, and
listen over the popliteal artery. If possible, the px should be prone.
Alternatively, ask the supine px to flex one leg slightly, with the heel
resting on the bed.
When cuffs of the proper size are used for both the leg and the
arm, BPs should be equal in the 2 areas. (The usual arm cuff,
improperly used on the leg, gives a false high reading.)
o A systolic P lower in the legs than in the arms is abnormal

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Blood pressure
measurement

o A femoral pulse that is smaller & later than the radial pulse
suggests coarctation of the aorta or occlusive aortic disease.
BP is lower in the legs than in the arms in these conditions.
THE APPREHENSIVE PATIENT

Try to relax the px

Repeat the measurement later in the encounter
Some px will say their BP is only elevated in the office (White Coat
HPN) & may need to have their BP measured several times at
home or in a community setting.
THE OBESE OR VERY THIN

For the obese, the a wide cuff (15cm)

If arm circumference exceeds 41cm, us a thigh cuff (18cm wide)
For the very thin arm, use a pediatric cuff
WEAK/ INAUDIBLE KOROTKOFF SOUNDS
To rule out Coartation of the aorta, consider:
Technical problems: wrong placement of stethoscope, failure to

make full skin contact w/ bell venous engorgement of the arm from
repeated inflations of the cuff
Consider shock
WHEN KOROTKOFF SOUNDS CANT BE HEARD AT ALL

Estimate systolic P via palpation. Alternative methods such as

Doppler techniques or direct arterial pressure tracings may be
necessary.
To intensify the Korotkoff sounds, these may be done:
o Raise the arm before & while you inflate the cuff. Then lower the
arm & determine the BP.
o Inflate the cuff. Ask the px to make a fist several times. Then take
the BP.
ARRHYTHMIAS

Irregular rhythms produce variations in Pand therefore unreliable

measurements.
Ignore the effects of an occasional premature contraction.
W/ frequent premature contractions or atrial fibrillation, determine
the average of several observations and note that your
measurements are approximate.
THE HYPERTENSIVE PX W/ UNEQUAL BP IN BOTH ARMS

To detect coarctation of the aorta, make 2 further BP

measurements at least once in every hypertensive px:
Compare BP in the arms and legs.
Compare the volume and timing of the radial and femoral pulses.
Normally, volume is equal and the pulses occur simultaneously.
Coarctation of the aorta arises from narrowing of the thoracic aorta,
usually proximal but sometimes distal to the left subclavian artery.
Coarctation of the aorta & occlusive aortic disease are
distinguished by hypertension in the upper extremities & low BP in
the legs and by diminished or delayed femoral pulse.

TRANSCRIBED BY: FRED, GEORGE, RON, BILL, GINNY

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