NONINVASIVE BLOOD PRESSURE MONITORING

􀀻 Measure blood pressure (BP) in the upper arm using the oscillatory or
auscultatory method.

• If upper arms cannot be used for BP measurement or if the maximum

size BP cuff does not fit the upper arm, blood pressure may be
measure in the forearm.

• Consider use of thigh and calf for BP measurement if the upper arms
and forearms cannot be used.

􀀻 Use appropriate size BP cuff and follow instructions for fit and placement
per manufacturer’s recommendations.

􀀻 Measure baseline BP in both upper arms. For significant differences in

BP, use the arm with the higher pressure.

􀀻 Position patient:

• Patient should be seated with back and arms supported, feet on floor,
and legs uncrossed with upper arm at heart level (phlebostatic axis: 4th
intercostal space, halfway between the anterior and posterior diameter
of the chest) (Figure 1)

• If patient cannot be seated, position patient supine (Figure 2) or with

head of bed at a comfortable level (Figure 3) and with upper arm
supported at heart level.

􀀻 The patient and the caregiver should remain quiet throughout the
procedure of taking a BP.
Supporting Evidence:

• Studies comparing oscillatory BPs to intra-arterial and/or auscultatory BPs

were reviewed. Each manufacturer of automatic oscillatory devices has
its own algorithm for deriving systolic and diastolic from the detected
mean arterial pressure; readings from one device may differ from another.
Thus, comparison between studies is difficult if different oscillometric
devices and data collection procedures are used. To promote accuracy,
nurses should use oscillatory devices that meet the Association for the
Advancement of Medical Instrumentation standards (mean difference +
5mm Hg and standard deviation < 8mm Hg) when compared to
auscultatory method and the appropriate size cuff.

• Stiffness of the arteries, particularly in older patients, also influences

amplitude of the oscillations and may cause underestimation of mean
arterial pressure. Accuracy of the automated device may also be limited if
patients are hypertensive, hypotensive, and/or have cardiac dysrhythmia.
While some studies showed difference < 5mm Hg between BP
measurement methods, other studies demonstrated that individual
differences may be > 10mm Hg for some individuals. Vasopressors have
shown no significant effect on difference. (Level IV)

• Research has shown that the forearm and upper arm BPs are not
interchangeable. If the forearm is used, selection of the proper cuff size
and positioning of forearm at heart level are necessary.(Level VI)

• If using the forearm, position the cuff midway between the elbow and the
wrist. If using the calf, position the lower edge of the cuff approximately
2.5cm above the malleoli. If using the thigh, position the cuff over the
lower third of the thigh so that the lower edge of the cuff is
approximately 2 to 3cm above the popliteal fossa.

• If the thigh or calf is used for BP measurement, the same attention to

selection of proper cuff size is necessary. For calf BP measurements,
place the patient in the supine position. Placer the patient in the prone
position for thigh BP measurements. If the patient cannot be place prone,
position the patient supine with knee slightly bent. Normally, thigh
pressures are higher than upper arm pressures though no research was
found to substantiate this.(Level II) Research has demonstrated that calf
pressures are not interchangeable with upper arm pressures. (Level IV).
• Calf BP measurement is also referred to as an ankle BP. If a stethoscope is
used, Korotkoff’s sounds are auscultated over either the doralis pedis or
posterior tibial artery (for calf BP) or the popliteal artery (for thigh BP).
Results of comparisons of automatic, noninvasive upper arm and calf
BPs in adults vary. Overall systolic BP measurements were higher in the
calf than the arm in patients undergoing surgery, colonoscopy, and
caesarean delivery under spinal anesthesia.(Level V) Differences in mean
BP and diastolic BP were not consistent. Large differences for some
individuals make it difficult to devise a predictive formula that would be
applicable in all situations. In adults, calf BPs should be used only if the
upper arm is not accessible or if the appropriate size cuff is not available.

• Multiple reasons exist why an extremity may not be suitable for BP

measurement. BP cuffs should not be used on an extremity with a deep
vein thrombosis, grafts, ischemic changes, arteriovenous fistula, or
arteriovenous graft.BP cuffs should not be applied over a peripherally
inserted central catheter (PICC) or midline catheter site but may be
placed distally to the insertion site. BP measurements should not be taken
in extremities with peripheral IV while an infusion is running or any
trauma/incision. For patients who have had a mastectomy or lumpectomy,
do not use the involved arm(s) for BPs if there is lymphedema. (Level II)

• Wrap cuff snugly around upper arm so that the end of the cuff is 2 to 3cm
above the antecubital fossa to allow room for placement of the
stethoscope for manual B/P measurement. Align the cuff to ensure the
mark on the cuff for artery is placed over the artery.

• Selection of a BP cuff of the appropriate size is necessary for accurate

measurement of BP. Studies have shown that the use of a cuff that is too
narrow results in an overestimation of BP, and a cuff that is too wide
underestimates BP. A falsely high pressure reading may result when the
cuff is too small relative to the patient arm circumference. If the cuff is
too large, falsely low pressure readings can result. A cuff with a bladder
of an adequate size capable of going around 80% of the arm is
recommended. If the thigh or calf is used, the same attention to selection
of proper cuff size is necessary. (Level VI)

• Patients with aortic dissection, congenital heart disease, coarctation of the

aorta, peripheral vascular disease, and unilateral neurological and
musculoskeletal abnormalities may demonstrate a difference in inter-arm
 BP. Additionally, research has shown that up to 20% to 40% of
individuals without the above conditions may also have measurable
difference of 10 to 20mm Hg in systolic and diastolic BP between the left
and right arms. Research methodology included oscillatory or
auscultatory BP measurements with both methods demonstrating similar
findings. Age was a factor in one study with higher mean differences in
both systolic BP and diastolic BP in older participants. (Level V)

• Body position and arm position influence the measurement of BP.with the
arm placed at heart level and the patient supine, the systolic BP readings
are approximately 8mm Hg higher than in the sitting position. Studies
also show that if the arm is below the level of the right atrium or heart
level, the BP readings will be higher. Conversely, if the arm is above
heart level, the BP readings will be lower. This average BP difference of
up to 10mm Hg when the arm is not at heart level is attributed to the
effects of hydrostatic pressure. (Level VI)

• Systolic and diastolic BPs of hypertensive and normotensive patients

increase with talking. (Level V)

What You Should Do:

• Ensure that your units have a written practice document such as policy,
procedure, or standard of care for BP measurement that includes
documentation of site and inter-arm differences.

• Ensure proper size cuffs are readily available.

• Provide routine training and retraining of healthcare providers in BP

measurement and equipment use.

AACN Grading Level of Evidence

Level I: Manufacturer’s recommendations only
Level II: Theory based, no research data to support recommendations;
recommendations from expert consensus group may exist
Level III: Laboratory data, no clinical data to support recommendations
Level IV: Limited clinical studies to support recommendations
Level V: Clinical studies in more than 1 or 2 patient populations and
situations to support recommendations
Level VI: Clinical studies in a variety of patient populations and situations to
support recommendations.
REFERENCES:

1. Bur A, Hirschl M, Herkner H, et al. Accuracy of oscillometric blood

pressure measurement according to the relation between cuff size and
upper-arm circumference in critically ill patients. Crit Care Med.
2000;28:371-376.

2. Bur A, Herknew H, Vicek M, et al. Factors influencing the accuracy of

oscillometric blood pressure measurement in critically ill patients. Crit
Care Med. 2003;31:793-799.

3. Braam RL, Thien T. Is the accuracy of blood pressure measuring devices

underestimated at increasing blood pressure levels? Blood Press Monit.
2005;10:283-289.

4. Chang JJ, Rabinowitz D, Shea S. Sources of variability in blood

pressure measurement using the Dinamap PRO 100 automated
oscillometric device [abstract]. Am J ?Epidemiology. 2003;158:1218-
1226.

5. Davis J, Davis I, Bennink LD, et al. Are automatic blood pressure

measurements accurate in trauma patients? J Trauma. 2003;55:860-863.

6. Parker SB, Steigerwalk SP. The Dinamap dilemma: inaccuracy of the

commonly used Dinamap 8100 compared to simultaneous mercury
manometer measurement in hospitalized patients at different levels of
blood pressure [abstract]. Am J Hypertens. 2004;17(suppl 1):S52.

7. Shahriari M, Rotenberg DK, Nielsen JK, et al. Measurement of arm

blood pressure using different oscillometry manometers compared to
auscultatory readings [abstract]. Blood Press. 2003;12:155-159.

8. Terra SG, Blum RA, Wei G, et al. Concordance and variability of blood
pressure measurement between automated
PROPAGATION of ACTION POTENTIAL

 ATRIAL CONTRACTION: It takes about 70 msec to get from the SA-Node -->
depolarize the atria --> to the AV-Node.
 AV-NODAL DELAY: There is a delay in depolarization of about 90msec, once
the impulse reaches the AV-Node.
 The function of this delay is to separate the contraction of the atria (i.e.
atrial systole) from that of the ventricles (ventricular systole), so that more
blood has a chance to fill into the ventricles.
 The AV-Node depends on slow-conducting Ca+2 Channels for
depolarization, which helps to explain its slow rate of depolarization.
 A smaller cell-size also helps to explain the slow rate of conductance.
 BUNDLE OF HIS
 BUNDLE-BRANCHES: Two continuing branches of the Bundle of His.
 Left Bundle Branch: It depolarizes first. Depolarization goes from the
left side of the ventricular septum to the right side, accounting for the Q-
Wave.
 Right Bundle Branch: It depolarizes after the left side.
 PURKINJE SYSTEM: Very fast conduction.
 VENTRICULAR MUSCLE
 As depolarization proceeds in the ventricles, it moves from endocardium
--> epicardium. ]

 P-WAVE: Atrial depolarization. P-Wave duration is normally 80 msec.

 PR-INTERVAL: The distance from the beginning of the P-Wave to the
beginning of the Q-Wave.
 PR-Interval is the period from beginning of atrial depolarization to
the beginning of ventricular depolarization.
 PR-Interval is normally 180-220 msec.
 PR-SEGMENT: The distance from the end of the P-Wave and the
beginning of the Q-Wave.
 QRS-COMPLEX: Ventricular Depolarization. QRS Duration is normally 30-100
msec.
 Individual Components:
 Q-WAVE: Depolarization of the septum. On most leads ( except
III and aVR ) the Q-Wave points downward if it can be seen at all.
Septum depolarization goes from the left side of the septum to the
right side.
 R-WAVE: Depolarization of the ventricles. Sharp upward turn.
 S-WAVE: Return of volt-potential to zero, because all the
ventricular muscle has depolarized and is therefore once again
isoelectric.
  Sharp downward turn back to isoelectric point. The S-Wave
may go slightly negative before return back to isoelectric
point.
 QT-INTERVAL: From beginning of Q-Wave to end of T-Wave. QT-
Interval is normally 260-490 msec. This is the period from beginning of
ventricular depolarization to the end of repolarization.
 ST-SEGMENT: Short segment from end of S-Wave to beginning of T-
Wave.
 ST-INTERVAL: From end of S-Wave to end of T-Wave.
 RR-INTERVAL: Distance between QRS-Complexes, or the distance
between heart beats in a normal sinus rhythm.
 T-WAVE: Repolarization of Ventricles. Atrial repolarization masked by QRS-
Complex.
 Repolarization occurs in the opposite direction as depolarization, but the
vector still points in the same direction because the change in voltage also
has an opposite sign.
 In the ventricles, the first tissue to depolarize is the last tissue to
repolarize.

READING THE ECG

 Vertical Direction: 10 mm = 2 big boxes = 1 mV deflection.

 Horizontal Direction:
 1 mm = 40 msec.
 At standard speed, there are 25 mm, or 5 big boxes, in each second.
 Speeds:
 Standard Speed = 25 mm/sec
 Extra-Sensitivity Speed = 50 msec, at which point all values above must
be doubled.
 Calculating Heart Rate : Heart rate = 1500 / number of mm between beats ( beat
per minutes )

ECG ABNORMALITIES

 SINUS BRADYCARDIA: A heart rate slower than 60 SA-Nodal depolarizations

per minute. "Sinus" indicates that the cardiac impulse is originating from the SA-
Node as normal.
 SINUS TACHYCARDIA: Heart rate faster than 100 bpm, originating as normal
from the SA-Node.
 Tachycardia generally means you'll see a shorter RR-Interval (i.e. faster
heart rate).
 SINUS ARREST: No SA-Node depolarization.
 This can be artificially induced by carotid massage, which results in
overstimulation of the Vagus ---> SA-Node hyperpolarized.
 ATRIAL PAROXYSMAL TACHYCARDIA: Faster heart rate resulting from an
ectopic pacemaker in the atrial muscle.
  In the example the P-Wave points downward because the atrial
depolarization starts in the LA, because that is where the tissue is leaky.

 BUNDLE-BRANCH BLOCKS: There is some conduction block in the
Bundle of His (Left or Right Bundle branches), with results as below:

i. 1 BLOCK: Partial block. The PR-Interval is longer than normal because it

takes longer to conduct the impulse from SA-Node to AV-Node.
ii. 2 BLOCK: A QRS-Complex occurs only after every other P-Wave. In
other words, it takes two P-Waves to sufficiently excite the AV-Node to
conduct the impulse to the ventricles.
iii. 3 BLOCK: There is no temporal relationship between the P-Wave and
QRS-Complex. Atrial and ventricular depolarizations are being controlled
by their own independent pacemakers (the SA-Node and AV-Node
respectively).

 AV-NODAL TACHYCARDIA: Tachycardia, plus the P-Wave is insignificant or

absent.
 This is tachycardia, where the impulse originates from the AV-Node. The
inherent pacemaker of the AV-Node is faster than the SA-Node.
 PREMATURE VENTRICULAR CONTRACTION (PVC): A premature QRS-
Complex, or one that occurs without being preceded by a P-Wave.
 That means that the P-Wave didn't start the impulse, but it started
somewhere else.
 Ectopic Pacemaker: With PVC, the impulse originates in the ventricular
muscle itself, due to leaky membranes in the muscle.
 VENTRICULAR FIBRILLATION: Waves of depolarization traveling in
multiple directions all over the ventricular muscle. The pacemaker activity is lost.
 ATRIAL FIBRILLATION: Fibrillation in the atria is not serious in children, but
it is serious in old people.
 That's because in old people, atrial systole contributes a greater relative
blood volume to cardiac output than in children.