Measurements and Vital Signs
Measuring Blood Pressure
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Purpose
- Blood pressure is the amount of force that blood exerts against artery walls. Blood pressure is part of the vital signs.
- Systole is the period of heart muscle contraction, when the heart pumps blood. Diastole is the period of heart muscle relaxation, when the heart is at rest.
- You measure systolic and diastolic pressures. Systolic pressure is the pressure in the arteries when the heart contracts. It is the higher pressure. Diastolic pressure is the pressure in the arteries when the heart is at rest. It is the lower pressure.
- Blood pressure is measured in millimeters of mercury (mm Hg). It is recorded with the systolic pressure over the diastolic pressure, such as 120/80 mm Hg.
- For an adult, the normal systolic pressure is 90 to 120 mm Hg. The normal diastolic pressure is 60 to 80 mm Hg. Blood pressure increases with age. It is lowest in infants and children. It is highest in older adults. Other factors can affect blood pressure.
- In hypertension, the blood pressure is 140/90 mm Hg or higher. In hypotension, the blood pressure is below 90/60 mm Hg. Report a systolic pressure at or above 120 mm Hg or below 90 mm Hg. Report a diastolic pressure at or above 80 mm Hg or below 60 mm Hg.
Equipment
Roll cursor over items to see labels. For the purposes of clearly depicting the equipment, a barrier is not shown in this photo. When providing care, a barrier should always be placed on the surface before placing the equipment.
Sphygmomanometer with the correct size cuff
Stethoscope
Antiseptic wipes
Electronic sphygmomanometer (if indicated)
PrintableDelegation
- Follow delegation guidelines. Before measuring blood pressure, obtain this information from the nurse and care plan:
- When to measure blood pressure
- What arm to use
- The person’s normal blood pressure range
- Any nursing concerns about certain patients or residents
- If the person needs to be lying down, sitting, or standing
- What size cuff to use—regular, child-size, extra large, or bariatric
- What observations to report and record
- When to report the blood pressure measurement
- What patient or resident concerns to report at once
Preparation
- Observe quality-of-life measures.
- Review the information under Delegation and Safety and Comfort.
- Let the patient rest quietly for 10 to 20 minutes before taking the blood pressure.
- Make sure that the room is quiet.
- Practice hand hygiene.
- Collect the equipment.
- Identify the person. Check the ID bracelet against the assignment sheet. Also call the person by name.
- Provide for privacy.
Safety
- Handle a mercury manometer carefully. If it breaks, call for the nurse at once. Do not touch the mercury.
- Do not take the blood pressure on:
- an arm with an IV infusion, a cast, or a dialysis access site.
- an arm that has an injury or has undergone surgery.
- the same side as breast surgery.
- Make sure that the blood pressure cuff fits snugly on the patient’s bare upper arm. Use a larger cuff on an obese or large arm. Use a smaller cuff on a very small arm.
- Tell the nurse if you cannot hear the blood pressure or if you find an abnormal blood pressure.
Comfort
- Inflate the cuff only to the extent necessary. This helps avoid discomfort.
Procedure Video
Audio Description: OFFFollow-up Care
- If you are not sure of an accurate measurement, wait 30 to 60 seconds and take the blood pressure again. Ask the nurse to take the blood pressure if you are unsure of the measurement
- Provide for comfort.
- Place the signal within reach.
- Unscreen the person.
- Complete a safety check of the room.
- Clean the ear-pieces and diaphragm with the wipes.
- Return the equipment to its proper place.
- Practice hand hygiene.
Reporting/Recording
- Report and record the blood pressure. Note which arm was used.
- Report an abnormal blood pressure at once.
Review Questions
Select the best answer.
1. What is the normal systolic blood pressure for an adult?
INCORRECT. For an adult, the normal systolic pressure is 90 to 120 mm Hg. A systolic pressure below 90 mm Hg is abnormally low. One above 120 mm Hg is abnormally high.
CORRECT. For an adult, the normal systolic pressure is 90 to 120 mm Hg. A systolic pressure below 90 mm Hg is abnormally low. One above 120 mm Hg is abnormally high.
INCORRECT. For an adult, the normal systolic pressure is 90 to 120 mm Hg. A systolic pressure below 90 mm Hg is abnormally low. One above 120 mm Hg is abnormally high.
INCORRECT. For an adult, the normal systolic pressure is 90 to 120 mm Hg. A systolic pressure below 90 mm Hg is abnormally low. One above 120 mm Hg is abnormally high.
Select the best answer.
2. What is the normal diastolic blood pressure for an adult?
INCORRECT. For an adult, the diastolic pressure normally is 60 mm Hg or higher but lower than 80 mm Hg. A diastolic pressure below 60 mm Hg is abnormally low. One above 80 mm Hg is abnormally high.
INCORRECT. For an adult, the diastolic pressure normally is 60 mm Hg or higher but lower than 80 mm Hg. A diastolic pressure below 60 mm Hg is abnormally low. One above 80 mm Hg is abnormally high.
CORRECT. For an adult, the diastolic pressure normally is 60 mm Hg or higher but lower than 80 mm Hg. A diastolic pressure below 60 mm Hg is abnormally low. One above 80 mm Hg is abnormally high.
INCORRECT. For an adult, the diastolic pressure normally is 60 mm Hg or higher but lower than 80 mm Hg. A diastolic pressure below 60 mm Hg is abnormally low. One above 80 mm Hg is abnormally high.
Select the best answer.
3. Which term describes a blood pressure above 140/90 mm Hg?
INCORRECT. In hypertension, the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
CORRECT. In hypertension, the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
INCORRECT. In hypertension, the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
INCORRECT. In hypertension, the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
Select the best answer.
4. Which patient position is appropriate for measuring blood pressure?
Supine with the arm below the heart and the palm down- Standing with the arm at the side and the palm up
- Side lying with the arm at shoulder level and the palm up
Seated with the arm at heart level and the palm up
INCORRECT. For blood pressure measurement, the patient may sit, lie, or stand, as ordered. The arm should be at heart level with the palm up.
INCORRECT. For blood pressure measurement, the patient may sit, lie, or stand, as ordered. The arm should be at heart level with the palm up.
INCORRECT. For blood pressure measurement, the patient may sit, lie, or stand, as ordered. The arm should be at heart level with the palm up.
CORRECT. For blood pressure measurement, the patient may sit, lie, or stand, as ordered. The arm should be at heart level with the palm up.
Select the best answer.
5. When measuring blood pressure, how should you place the blood pressure cuff on the person’s arm?
- Position the bottom of the cuff 1 inch above the elbow and place the cuff’s arrow over the artery.
- Position the top of the cuff 2 inches below the shoulder and place the cuff’s bladder over the elbow.
- Position the bottom of the cuff over the brachial artery and place the cuff’s arrow over the forearm.
- Position the top of the cuff 2 inches above the elbow and place the cuff’s arrows over the vein.
CORRECT. For accurate blood pressure measurement, place the cuff’s arrow over the brachial artery. Wrap the cuff around the upper arm at least 1 inch above the elbow.
INCORRECT. For accurate blood pressure measurement, place the cuff’s arrow over the brachial artery. Wrap the cuff around the upper arm at least 1 inch above the elbow.
INCORRECT. For accurate blood pressure measurement, place the cuff’s arrow over the brachial artery. Wrap the cuff around the upper arm at least 1 inch above the elbow.
INCORRECT. For accurate blood pressure measurement, place the cuff’s arrow over the brachial artery. Wrap the cuff around the upper arm at least 1 inch above the elbow.
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