TRANS #1.

2-1
June 18, 2015
MEASUREMENT OF BLOOD PRESSURE || Dr. Guzman

TOPIC OUTLINE
I.
II.

III.
IV.
V.
VI.
VII.
VIII.
IX.
X.

Factors Affecting Blood Pressure

Aneroid Device
a. Selecting the Correct Cuff
b. Marking the Cuff
c. BP Cuff Sizes, Arm Circumference Range, and
Bladder Width & Length
The Stethoscope
Steps to Ensure Accurate BP Measurement
Steps in Measuring the BP
BP Measurement in the Leg
JNCVII BP Classification
Techniques of BP Measurement in the Diagnosis of
HTN
5 Korotkoff Sounds
Special Problems

o
o

Proper measurement and interpretation of the blood

pressure (BP) is essential in the diagnosis and
management of hypertension.
Observational studies suggest that most physicians
do not follow one or more of the recommendations
leading to error in diagnosis and management.
There is a need for repeated training on BP
measurement
o Because major health decisions and
treatments are based on readings taken in
the clinic, the most rigid quality control
should be in place in the day-to-day
measurement of BP in the clinic.

ANEROID DEVICE

FACTORS AFFECTING BP MEASUREMENT

Home BP and average 24-hr ambulatory BP

measurements are generally lower than
clinic BP.
BP tends to be higher in the early morning
hours, soon after waking, than at other times
of day.
Nighttime BPs are generally 10 to 20% lower
than daytime BPs.
White Coat Hypertension patient manifests
a higher BP in a hospital setting; at risk for
developing sustained hypertension

20 to 30% of patients with office

hypertension are normotensive at
home
Masked Hypertension patient manifests
with normal BP but ambulatory BP is high

Delicate system of gears and bellows that can be

easily damaged
Up to 30% in all are out of calibration (too low
readings)
Ensure:
o No cracks on face
o Needle at 0
Regular calibration with mercury manometer is
required.

Instrumentation
o BP apparatus: Mercury, Aneroid, Digital
o BP cuff (sizes), area of arm covered
Aneroid Device

Needs regular calibration with mercurial

manometer
Initial position of needle at 0
Can be easily damaged

Mercury Device

Should be read at eye level, vertical on

a lever surface

Technique of BP measurement
Patient factor (e.g. smoking, caffeine intake)
Environment

TRANSCRIBERS: NikoDags

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MEDICINE I

MEASUREMENT OF BLOOD PRESSURE

Selecting the Correct Cuff

Marking the Cuff

Apply cuff so that the center of inflation bag is over

the brachial artery. Ensure that the index line falls
between the two range lines. If it does not, a larger or
smaller cuff may be required. It can be used on either
right or left arm.

BP cuff sizes, Arm Circumference Range, and Bladder

Width & Length

Cuff Sizes
Too small cuff can cause overestimation of systolic
BP by 10 to 50 mmHg (particularly among obese
patients)
o Length of bladder

75 to 80% of the circumference of

the upper arm
o

Width

Child
Small Adult
Adult
Large Adult
Adult Thigh

More than 50% of the length and

40% of the circumference of the
upper arm (approximately 12 to 14
cm in the average adult)

Standard cuff size (Bates): 12x23 cm (appropriate for

circumferences up to 28 cm)
Measure the tip of the acromial process at the top of
the shoulder to the olecranon. Divide the distance and
mark the outside of the arm.
Measure arm circumference here and use to select
correct cuff size.
Center cuff over the brachial artery that courses
between the biceps and triceps muscles on the inner
aspect of the arm.
If the cuff is too small (narrow), BP will read high.
If the cuff is too large (wide), BP will read low on a
small arm and high on a large arm.

TRANSCRIBERS: NikoDags

Bladder
Width (cm)

Bladder
Length (cm)

8
10
13
16
20

21
24
30
38
42

THE STETHOSCOPE

ArmCircumference
Range at
Midpoint
16 21
22 26
27 44
35 44
45 52

Earpiece should face forward in the ear canal.

Must have thick tubing 12 16 inches in length
Use the bell to detect low-frequency Korotkoff.

STEPS TO ENSURE ACCURATE BP MEASUREMENT

Instruct patient to avoid smoking or drinking

caffeinated beverages 30 minutes prior to BP
measurement.
Ensure that the examining room is quiet and
comfortably warm.
Ask the patient to sit quietly for 5 minutes in a chair
with feet on the floor, rather than on the examining
table.
Make sure that the arm selected is free of clothing.
There should be no arteriovenous fistulas for dialysis,
scarring from prior brachial artery cutdowns, or signs
of lymphedema.

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MEDICINE I

MEASUREMENT OF BLOOD PRESSURE

Palpate the brachial artery to confirm that it has viable

pulse.
Position the arm so that the brachial artery (located at
the antecubital crease) is at heart level (roughly level
th
with the 4 interspace at its junction with the sternum.
If the patient is seated, rest the arm on a table a little
above the patients waist. If standing, try to support
the patients arm at the midchest level.
o If brachial artery is 7 to 8 cm below the heart
level, BP will read 6 cm higher.
o If brachial artery is 6 to 7 cm higher, BP will
read 5 cm lower.

5.

Inflate the cuff rapidly again to the level just

determined, and then deflate it slowly at a rate of
about 2 to 3 mmHg per heart beat (Bates: per
second). Note the level at which you hear the sounds
of at least 2 consecutive beats. This is the systolic
blood pressure (SBP).

6.

Continue to lower the pressure slowly until the sounds

become muffled and then disappear. To confirm the
disappearance of sounds, listen as the pressure falls
another 10 to 20 mmHg. Then, deflate the cuff rapidly
to zero. The disappearance point, which is usually
only a few mmHg below the muffling point, provides
the best estimate of true diastolic blood pressure
(DBP) in adults.

STEPS IN MEASURING THE BP

1.

2.

3.
4.

Center the inflatable bladder over the brachial artery.

The lower border of the cuff should be about 2.5 cm
above the antecubital crease. Secure the cuff snugly.
Position the patients arm so that it is slightly flexed at
the elbow.
To determine how high to raise the cuff pressure, first
estimate the systolic pressure by palpation. As you
feel the radial artery with the fingers of one hand,
rapidly inflate the cuff until the radial pulse
disappears. Read this pressure on the manometer
and add 30 mmHg to it. Use of this sum as the target
for subsequent inflations prevents discomfort from
unnecessarily high cuff pressures. It also avoids the
occasional error caused by auscultatory gap a silent
interval that may be present between the systolic and
diastolic pressures.
Deflate the cuff promptly and completely and wait 15
to 30 seconds.
Now, place the bell of a stethoscope lightly over the
brachial artery, taking care to make an air seal with its
full rim. Because the sounds to be heard, the
Korotkoff sounds, are relatively low in pitch, they are
generally better heard with the bell.

SBP
pressure at which the brachial pulse
can be first palpated or first heard by
auscultation (Korotkoff Phase I)
DBP
disappearance of the pulse on
auscultation (Korotkoff Phase V) in most
patients
abrupt muffling of pulse (Korotkoff
Phase IV) in those with more than 10 mmHg
between phase IV and phase V (anemia,
aortic regurgitation, thyrotoxicosis, high
output states)
7.

TRANSCRIBERS: NikoDags

Read both systolic and the diastolic levels to the

nearest 2 mmHg.

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MEDICINE I

MEASUREMENT OF BLOOD PRESSURE

Note:

Measure BP at least twice per visit, allowing 1 to

2 minutes of interval between measurements.

If there is more than 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.

Blood pressure should be taken in both arms at

least once. Normally, there may be a difference
in pressure of 5 mmHg and sometimes up to 10
mmHg.

Subsequent readings should be made on the arm

with the higher pressure.

Conditions That Increase Pulse Pressure

(difference between SBP and DBP):

Pheochromocytoma

Thyrotoxicosis

Hyperkinesia

Unequal BP in both arms:

o Atherosclerosis of brachial artery orifice
develops 10:1 on left side leading to
lower pressure in the left arm.
o Coarctation of aorta can occur proximal
to the left subclavian artery giving lower
BP in left arm and leg

JNCVII BP CLASSIFICATION
Category
Normal
Prehypertension
Hypertension
- Stage I
- Stage II

Systolic
(mm Hg)
<120
120-139

Diastolic
(mm Hg)
<80
80-89

140-159
160

90-99
100

The 7th Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High BP
(JNCVII) recommended using the mean of 2 or more
properly measured seated BP readings, taken on 2 or
more visits, for the diagnosis of HTN. BP should be
verified on the contralateral arm.
If the systolic and diastolic pressures fall under
different categories, use the higher category (e.g. If
the systolic pressure is 141 mmHg and the diastolic
pressure is 87 mmHg, the category is Stage 1 HTN.).
Effects of HTN on various organs:
o Eyes hypertensive retinopathy
o Heart left ventricular hypertrophy
o Brain neurologic deficits suggesting stroke

TECHNIQUES OF BP MEASUREMENT
IN THE DIAGNOSIS OF HTN
BP MEASUREMENT IN THE LEG

Use a wide, long thigh cuff that has a bladder size of

18 x 42 cm, and apply it to the midthigh.
Center the bladder over the posterior surface. Wrap it
securely and listen over the popliteal artery. If
possible, the patient should be prone.
Alternatively, ask the supine patient 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, BP should be equal in the two areas.
The usual arm cuff, improperly used on the leg, gives
a falsely high reading.
o A systolic pressure lower in the legs than in
the arms is abnormal. Usually, systolic
pressure in the legs is 10 to 20% higher than
in the arms.
o A femoral pulse that is smaller and 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.

TRANSCRIBERS: NikoDags

Timing of BP Measurement
o Diagnosis of HTN

Multiple readings taken at various

times throughout the waking hours
o Monitoring of HTN therapy

BP should be measured prior to

intake of anti-hypertensive
medications to determine the trough
or nadir effect

Extraneous variables that may affect BP

o The following should be avoided 60 minutes
(accdg. to Doc Guzman) prior to evaluation:

Food intake

Exercise

Intake of caffeine (Bates 30 mins)

Smoking (Bates 30 mins)

o
o

Cool environment (12 C or 54 F)

Patient talking during BP

measurement

Patient Position
o Usually taken while sitting slouched on the
chair

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MEDICINE I

MEASUREMENT OF BLOOD PRESSURE

Supine position increases SBP or

decreases DBP by 2 to 3 mmHg
Measure both sitting and standing BP to
detect postural hypotension or the sudden
drop in BP upon standing (common among
elderly and DM patients)

th

th

***If the 4 and 5 Korotkoff sounds have >/= 10

th
mmHg difference, consider the 4 Korotkoff sound as
the DBP.

Patient and Physician Position

SPECIAL PROBLEMS

o
o
o
o

Sitting: feet flat on the floor

Arm supported at heart level
Viability of brachial pulse confirmed by
palpation
Bell used for detection of low-pitched sounds

The Apprehensive Patient

o Anxiety is a frequent cause of high BP,
especially during an initial visit.
o Try to relax the patient.
o Repeat the measurement later in the
encounter.
o Some patients will say their BP is only
elevated In the office (White Coat HTN) and
may need to have their BP measured
several times at home or in a community
setting.

The Obese or The Very Thin

o For obese patients, use a wide cuff (15 cm).

If arm circumference exceeds 41

cm, use a thigh cuff (18 cm wide).
o For the very thin patients, use a pediatric
cuff.

Weak Korotkoff Sounds

o To rule out coarctation of the arota, consider:

Technical problems: wrong

placement of the stethoscope,
failure to make full skin contact with
bell, venous engorgement of the
arm from repeated inflations of the
cuff
o Consider shock

5 PHASES OF KOROTKOFF SOUNDS

Korotkoff Sounds sounds produced by the flow of blood as
the constricting BP cuff is gradually released
Phase
I
II

III

IV

Description
First 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

Disappearance of
Korotkoff sounds

TRANSCRIBERS: NikoDags

Remarks
Represents systolic
BP

Due to increased blood

flow through the
constricted artery
Due to diminished
constriction of the
artery; arterial diastolic
pressure is
approached
Represents diastolic
BP in most paitents
Is normally within 10
mmHg from Phase IV
(abnormal if >10
mmHg differences;
Phase IV is abruptly
muffled)

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MEDICINE I

MEASUREMENT OF BLOOD PRESSURE

Inaudible Korotkoff Sounds

o Estimate SBP via palpation. Alternative
methods such as Doppler techniques or
direct arterial pressure tracings may be
necessary.
o To intensify the Korotkoff sounds, these may
be done:

Raise the arm before and while you

inflate the cuff. Then, lower the arm
and determine the BP.

Inflate the cuff. Ask the patient to

make a fist several times. Then,
take the BP.

Arrhythmias
o Irregular rhythms produce variations in
pressure and therefore unreliable
measurements.
o Ignore the effects of an occasional
premature contraction
o With frequent premature contractions or
atrial fibrillation, determine the average of
several observations and note that your
measurements are approximate.
o Ambulatory BP is recommended.

Hypertensive Patient with Unequal BP in the Arms

and Legs
o To detect coarctation of the aorta, make 2
further BP measurements at least once in
every hypertensive patient.
o Compare BP in the arms and legs.
o Compare the volume and timing of the radial
and femoral pulses. Normally, the volume is
equal and the pulses occur simultaneously.
o Coarctation of the aorta arises from
narrowing of the thoracic aorta, usually
proximal but sometimes distal to the left
subclavian artery.
o Coarctation of the aorta and occlusive aortic
disease are distinguished by HTN in the
upper extremities and low BP in the legs and
by diminished or delayed femoral pulse.

TRANSCRIBERS: NikoDags

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