Bp Measure

7/30/2019 Bp Measure

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Remove the cuff, stethoscope, pressure gauge, and bulb (also known as a "bladder") from

the kit, taking care to untangle the various tubes.

Sit down at a table or desk where you can easily rest your arm so that when you bend your

elbow, your elbow is parallel to your heart.

Sit down at a table or desk where you can easily rest your arm so that when you bend your

elbow, your elbow is parallel to your heart. (Some experts recommend you use your left arm;

others suggest you test both arms. But while you're first adjusting to self-testing, use the left arm

if you're right-handed, or vice versa.)

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Bend the arm you're going to test.

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Wrap the cuff around your upper arm (upper middle arm), slipping the top part of the cuff

through the metal bar that's attached to the cuff.

Wrap the cuff around your upper arm (upper middle arm), slipping the top part of the cuff

through the metal bar that's attached to the cuff. If your shirt has long sleeves, roll them up

first. You can put the cuff over very thin clothing. Most cuffs have Velcro, making it easy to

keep the cuff in place.

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Make sure the cuff is snug, but not too tight -- if you cut off your circulation and become

agitated, you're going to get an alarming blood pressure reading!.

Make sure the cuff is snug, but not too tight -- if you cut off your circulation and become

agitated, you're going to get an alarming blood pressure reading!

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Gently put the earpieces of the stethoscope in your ears.Gently put the earpieces of the stethoscope in your ears. They should feel comfortable in your

ears. If not, try holding the stethoscope out in front of you and slightly shifting the earpiecesaway from you.

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Place the wide head of the stethoscope (the diaphragm) entirely on your skin just above the

elbow, on the inside of your now straightened arm; the brachial artery. Do not hold the head

of the stethoscope with your thumb-your thumb has its own pulse and this will confuse you while

you try to obtain a reading. A good method is to hold the chestpiece between your index and

middle fingers with your fingertips in the vertical space between the diaphragm and bell. Youwill not normally hear a thumping until you have begun to inflate the cuff. To aid in finding this

you can press two fingers (not your thumb) to the area where it should be and move around until

you feel a pulse.

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If the pressure gauge is clipped to the cuff, unclip it and attach the clip to something

sturdy, such as a hardcover book, that you can place on the table so you can watch it. It's

important to keep the gauge anchored and stable. Make sure there is adequate light and you cansee the needle and pressure markings well before you begin to test.

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Take the rubber bulb and tighten the valve at the base.

Take the rubber bulb and tighten the valve at the base. Be sure to turn the valve all the way

clockwise to shut it off so that air doesn't escape when you pump. DO NOT OVER-TIGHTEN

THE VALVE. This is key, doing so will not allow you to release air from the cuff slowlyenough at first. This is because you will twist it open too far and let out air too fast due to the

force needed to open it. Only turn the valve closed until you feel it stop. 10

Pump the bulb using slow but very steady pressure until the needle on the gauge is at about

20-30 points above your usual systolic (top) number. Now, gently turn the bulb's valve

counter-clockwise slightly so that air is released slowly and steadily. Doing this yourself as you

listen is a little tricky, you should release the valve with the hand on your cuff arm and hold

the stethoscope with your free arm. The needle should ideally be moving down at a rate of two

marks per second for accuracy.

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As you watch the needle fall back down the gauge, listen for a thumping sound (The clinicalname for this is "Korotkoff sounds").

As you watch the needle fall back down the gauge, listen for a thumping sound (The clinicalname for this is "Korotkoff sounds"). Keep your eyes on the gauge -- when you first hear

thumping, you have yoursystolic number, which represents the greatest amount of pressureexerted on the artery walls as your heart pumps blood.

12Keep watching the gauge and listening to the beats. Eventually the hard thumping sound willturn into a "whooshing" sound (these are called the 4th Korotkoff sounds). These sounds are

helpful to listen to because they tell you that you are close to your diastolic blood pressure. When
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Technique of blood pressure measurement in the diagnosis of hypertension

Norman M Kaplan, MD

Burton D Rose, MD Jun 3, 1999

Proper measurement and interpretation of the blood pressure (BP) is essential in the diagnosisand management of hypertension. The following recommendations have been made to achieve

maximum accuracy in this process (show figure 1)[1,2]. However, observational studies suggest

that most physicians do not follow one or more of these recommendations, leading to potential

errors in diagnosis and management [2,3]. As an example, among medical students who had

completed a course on how to properly measure the blood pressure, only 5 percent adhered to

course guidelines one year later[3].

TIME OF MEASUREMENT If possible, the BP should be measured 30 to 60 minutes before

antihypertensive medications are to be taken to estimate the trough or nadir effect. If, on the

other hand, the patient is evaluated 1 to 2 hours after drug ingestion, the BP may be normal or


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even below normal and then will gradually increase to potentially hypertensive levels until the

next dose is taken. This acute response is most likely with short-acting drugs (such ascaptopril

ornifedipine) and with combination therapy.

Extraneous variables that can influence the blood pressure should be avoided in the 60 minutes

prior to evaluation [1]. These include food intake, strenuous exercise (which can lower the BP),

and the ingestion of caffeine or smoking. Smoking, for example, transiently raises the BP; thus,

the office BP may underestimate the usual BP in a heavy smoker who has not smoked for more

than 30 minutes before the measurement is made. (See "Smoking and caffeine and

hypertension"). In addition, taking the BP in a cool room (12C or 54F) or while the patient is

talking can rise the measured value by as much as 8 to 15 mmHg [2].

CUFF TYPE AND SIZE Mercury sphygmomanometers provide the most accurate

measurement of BP. Aneroid sphygmomanometers, which are used in many offices, should be

checked against a mercury device since the air gauge may be in error[2].

Use of a proper-sized cuff is essential. The length of the bladder should be at least 75 to 80

percent of the circumference of the upper arm, and the width of the bladder should be more than

50 percent of the length of the upper arm and approximately 40 percent of the circumference of

the upper arm [2,4]. If a smaller cuff is used, the pressure generated by inflating the cuff may not

be transmitted to the brachial artery; in this setting, the pressure in the cuff may be considerably

higher than the intraarterial pressure. This can lead to overestimation of the systolic pressure by

10 to as much as 50 mmHg in obese patients.

Pseudohypertension A similar problem, in which compression of the brachial artery requires acuff pressure greater than systolic, can occur in patients with stiff vessels due to marked arterial

calcification. This phenomenon, called pseudohypertension, is characterized by systolic and

diastolic pressures estimated from the sphygmomanometer that are 10 mmHg or more above the

directly measured intraarterial pressure [5,6]. (See "Resistant hypertension"for a review of the

mechanisms responsible for pseudohypertension and the settings in which it should be

suspected).

PATIENT POSITION The BP is usually taken in the sitting position; supine values tend to be

slightly different with the systolic pressure rising by two to three mmHg and the diastolic

pressure falling by a similar degree [7]. Supine and standing measurements should always be

taken in the elderly to detect postural hypotension. (See "Mechanisms and causes of orthostatic

and postprandial hypotension").

The patient should sit quietly for five minutes before the BP is measured. Even under optimal

conditions, many patients are apprehensive when seeing the physician, resulting in an acute rise


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in BP. Twenty to 30 percent of patients with hypertension in the physician's office are

normotensive outside of the office [8]. This phenomenon is called "white coat" hypertension; it

should be suspected in any patient with marked hypertension in the absence of end-organ

damage or with normal ambulatory blood pressures taken at work or at home [6]. The presence

of white coat hypertension can be confirmed by 24-hour ambulatory BP monitoring or self-

recorded readings; it can usually be minimized by having a nurse measure the BP (show figure 2)

[9]. This effect of lower measurements by a nurse can persist for years (show figure 3). (See

"Ambulatory blood pressure monitoring and white coat hypertension").


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TECHNIQUE OF MEASUREMENT When the BP is taken, the cuff should be inflated to a

pressure approximately 30 mmHg greater than systolic, as estimated from the disappearance of

the pulse in the brachial artery by palpation. Initial estimation of the systolic pressure by

palpation avoids potential problems with an auscultatory gap [10]. In some patients, the

Korotkoff sounds transiently disappear as the cuff is deflated. As an example, the Korotkoff

sounds in a patient with a systolic pressure of 180 mmHg may be first heard at 180 mmHg,disappear at 165 mmHg, and then be reheard at 140 mmHg. If the cuff is only inflated to a

pressure of 160 mmHg, no sounds will be heard until 140 mmHg; as a result, the latter value will

be mistakenly considered to be the systolic pressure. The auscultatory gap is associated with

increased arterial stiffness and carotid atherosclerosis; it may therefore identify patients at

increased risk of cardiovascular disease [11].

Once the cuff is adequately inflated, the following steps should be followed:

The stethoscope should be placed lightly over the brachial artery, since the use of excessive

pressure can increase turbulence and delay the disappearance of sound. The net effect is that the

diastolic pressure reading may be artifactually reduced by up to 10 to 15 mmHg [12].

The BP should always be taken with the patient's arm supported at the level of the heart.

Allowing the arm to hang down when the patient is sitting or standing will result in the brachial

artery being 15 cm below the heart. As a result, the measured BP will be elevated by 10 to 12

mmHg due to the added hydrostatic pressure induced by gravity [13]. The mercury manometer


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should be visible but does not have to be at the level of the heart [1].

The cuff should be deflated slowly at a rate of 2 to 3 mmHg per heartbeat. The systolic

pressure is equal to the pressure at which the brachial pulse can first be palpated as blood flow is

restored through the previously compressed vessel; the systolic pressure is also equal to the

pressure at which the pulse is first heard by auscultation (Korotkoff phase I).

As the cuff is deflated below the systolic pressure, the pulse continues to be heard until there

is abrupt muffling (phase IV) and, approximately 8 to 10 mmHg later, disappearance of sound

(phase V) [14]. The diastolic pressure is generally equal to phase V, although the point of

muffling should be used in those patients in whom there is more than a 10 mmHg difference

between phases IV and V [1,2]. This can occur in children and in high-output states such as

thyrotoxicosis, anemia, and aortic regurgitation.

The BP should be measured initially in both arms. If there is a disparity due to a unilateralarterial lesion, the arm with higher pressure should be used.

The BP should be taken at least twice on each visit, with the measurements separated by one

to two minutes to allow the release of trapped blood. If the second value is more than 5 mmHg

different from the first, continued measurements should be made until a stable value is attained.

The recorded value on the patient's chart should be the average of the last two measurements [2].

BLOOD PRESSURE MEASUREMENT AT HOME OR WORK There are also several

errors that can occur when the BP is taken at home or work by the patient or spouse, even if the

sphygmomanometer is accurate. One possible problem with self-measurement, for example, isthat the muscular activity used to inflate the cuff can acutely raise the BP by as much as 12/9

mmHg, an effect that dissipates within 5 to 20 seconds [15]. Thus, inflating the cuff to at least 30

mmHg above systolic and then allowing the sphygmomanometer to fall no more than 2 to 3

mmHg per heartbeat is desirable both for accurate measurement and to permit this exertional

effect to disappear. The BP should also be taken at roughly the same time each day and the

relation to meals and medications noted.

MULTIPLE BLOOD PRESSURE MEASUREMENTS The above recommendations for BP

measurement by the physician apply to a single visit. It is also important to emphasize that, in the

absence of end-organ damage, the diagnosis of mild hypertension should not be made until the

blood pressure has been measured on at least three to six visits, spaced over a period of months.

Sequential studies have shown that the BP drops by an average of 10 to 15 mmHg between visits

one and three in newly diagnosed patients [16,17], with a stable value not being achieved until

more than six visits in some cases [16]. Thus, many patients considered to be hypertensive at the


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initial visit are in fact normal. (See "Ambulatory blood pressure monitoring and white coat

hypertension").

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