a.IfupperarmscannotbeusedforBPmea-surementorifthemaximumsizeBPcuffdoesnotfittheupperarm,BPmaybemeasuredintheforearm.

b.ConsideruseofthighandcalfforBPmea-surementiftheupperarmsandforearmscannotbeused.

3. MeasurebaselineBPinbothupperarms.ForclinicallysignificantdifferencesinBP(>10mmHg),usethearmwiththehigherpressure.[levelD]

4. Positioningofpatient:TheappropriatereferencelevelforNIBPmeasurementistheheart.[levelD]

a.Patientshouldbeseatedwithbackandarmssupported,feetonfloor,andlegs

AACN Practice Alert

Scope and Impact of the Problem Bloodpressure(BP)ismeasuredinvirtuallyall

patientsreceivinghealthcare.AccuratemeasurementofBPisessentialtoguidemanagementdecisionsandpreventadverseoutcomes.NoninvasiveBP(NIBP)monitoringisconsideredasafepractice;however,complicationscanoccur.Bruisingandskinirritationfromcompressionarethemostcommonlyoccurringcomplications.1ProlongedperiodsoffrequentNIBPmeasurementshavebeenassociatedwithrarecom-plications,includingpain,limbedema,2phlebitis,3compartmentsyndrome,peripheralneuropathy,thrombophlebitis,venousstasis,ecchymosis,andpetechiae.2,3Conditionsthatplacepatientsathighriskforcomplicationsincludediabetes,4,5arterialorvenousinsufficiency,preexistingperipheralneuropa-thies,decreasedlimbperfusion,thrombolytictherapy,anticoagulationtherapy,2increasedarmactivity(eg,seizures,shivering),irregularcardiacrhythms,anddecreasedlevelofconsciousness.3

Expected Practice1. MeasureBPintheupperarm(betweenthe

shoulderandtheelbow)usingtheoscillatoryorauscultatorymethod.[levelD]

2. Useappropriate-sizeBPcuffandfollowinstruc-tionsforfitandplacementpermanufacturer’srecommendations.[levelD]

©2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2016590

Obtaining Accurate Noninvasive Blood Pressure Measurements in Adults

e12 CriticalCareNurse Vol 36, No. 3, JUNE 2016 www.ccnonline.org

AACN Levels of EvidenceLevel A Meta-analysis of quantitative studies or metasyn-

thesis of qualita tive studies with results that consis tently support a specific action, intervention, or treatment (including systematic review of randomized controlled trials)

Level B Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment

Level C Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

Level D Peer-reviewed professional and organizational standards with the support of clinical study recommen-dations

Level E Multiple case reports, theory- based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations

Level M Manufacturer’s recommendations only

uncrossedwithupperarmatheartlevel(phlebostaticaxis:4thintercostalspace,halfwaybetweentheanteriorandposteriordiameterofthechest;Figure1).

b.Ifpatientcannotbeseated,positionpatientsupine(Figure2)orwithheadofbedatacomfortablelevel(Figure3)andwithupperarmsupportedatheartlevel.

5. ThepatientandthecaregivershouldnotspeakwhileBPisbeingmeasured.[levelB]

6. Minimizecomplicationsbyusingthemaximum(leastfrequent)NIBPcycletimefortheshortesttimeperiodandbyensuringpropercuffplace-ment.[levelE]

Supporting EvidenceUse of NIBP Monitoring

1. StudiescomparingoscillatoryBPswithintra-arterial6,7and/orauscultatoryBPs8-15werereviewed.Eachmanufacturerofautomaticoscil-latorydeviceshasitsownalgorithmforderivingsystolicanddiastolicpressuresfromthedetectedmeanarterialpressure;readingsfromonedevicemaydifferfromreadingsfromanother.Thus,comparisonbetweenstudiesisdifficultifdiffer-entoscillometricdevicesanddatacollectionproceduresareused.

2. Topromoteaccuracy,nursesshoulduseoscillatorydevicesthatmeettheAssociationfortheAdvance-mentofMedicalInstrumentationstandards(meandifference,±5mmHgandstandarddevi-ation≤8mmHgwhencomparedwithausculta-torymethod)16andtheappropriatesizecuff.

3. Stiffnessofthearteries,particularlyinolderpatients,alsoinfluencesamplitudeoftheoscilla-tionsandmaycauseunderestimationofmeanarterialpressure.8,15Accuracyoftheautomateddevicemayalsobelimitedifpatientsarehyper-tensive,8hypotensive,10and/orhavecardiacdysrhythmia.17

4.Withbeat-to-beatvariationinBPinpatientswithatrialfibrillation,bothauscultationandoscillatoryBPmeasurementsmayvary,andtherearerecommendationstoperform3consecutivemeasurementsinoutpatientsettings.18Studiesarelimited,withmarkedheterogeneity,andhave

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Figure 1 Correct cuff and arm positioning in sitting patient. Used with permission from Cristiana Hospital, Newark, DE.

Figure 2 Correct cuff and arm positioning in supine patient. Used with permission from Cristiana Hospital, Newark, DE.

Figure 3 Correct cuff and arm positioning with head of bed elevated. Used with permission from Cristiana Hospi-tal, Newark, DE.

e14 CriticalCareNurse Vol 36, No. 3, JUNE 2016 www.ccnonline.org

yieldedvariedresultstoeitherrecommendornotrecommendtheuseofoscillatoryBPmea-surementinpatientswithatrialfibrillation.17,19

Cuff Size and Placement1. SelectionofaBPcuffoftheappropriatesizeis

necessaryforaccuratemeasurementofBP.Stud-ieshaveshownthattheuseofacuffthatistoonarrowresultsinanoverestimationofBP,andacuffthatistoowideyieldsunderestimatesofBP.Afalselyhighpressurereadingmayresultwhenthecuffistoosmallrelativetothepatient’sarmcircumference.Ifthecuffistoolarge,falselylowpressurereadingscanresult.Acuffwithablad-derofanadequatesizecapableofgoingaround80%ofthearmisrecommended.16,20-22Ifthethighorcalfisused,thesameattentiontoselec-tionofpropercuffsizeisnecessary.

2.ResearchhasshownthatBPmeasurementsintheforearmandupperarmarenotinterchange-able.Iftheforearmisused,selectionofthepropercuffsizeandpositioningoftheforearmattheleveloftheheartarenecessary.23-30

3.Resultsofcomparisonsofautomatic,NIBPmeasurementsintheupperarmandcalfofadultsvary.OverallsystolicBPmeasurementswerehigherinthecalfthanthearminpatientsundergoingsurgery,colonoscopy,andcaesareandeliveryunderspinalanesthesia.31-33DifferencesinmeanBPanddiastolicBPwerenotconsistent.Largedifferencesforsomeindividualsmakeitdifficulttodeviseapredictiveformulathatwouldbeapplicableinallsituations.34Inadults,calfBPsshouldbeusedonlyiftheupperarmorforearmarenotaccessible31,35oriftheappro-priatesizecuffisnotavailable.

4. Althoughnoevidence-basedresearchisavailable,multipleguidelinesandpatienteducationsourcesstatereasonswhyanextremitymaynotbesuitableforBPmeasurement.Reasonsincludedeepveinthrombosis,grafts,ischemicchanges,arteriovenousfistula,arteriovenousgrafts,andperipherallyinsertedcentralcathetersormid-linecatheters.33-40Forpatientswhohavehadamastectomyorlumpectomy,donotusethe

involvedarm(s)forBPmeasurementsiflymph-edemaispresent.20,41

5. Wrapcuffsnuglyaroundupperarmsothattheendofthecuffis2to3cmabovetheantecubitalfossatoallowroomforplacementofthestetho-scopeformanualBPmeasurement.20Alignthecufftoensurethatthemarkonthecuffforarteryisplacedovertheartery.

6. Ifusingtheforearm,positionthecuffmidwaybetweentheelbowandthewrist.Ifusingthecalf,positiontheloweredgeofthecuffapproximately2.5cmabovethemalleoli.Ifusingthethigh,posi-tionthecuffoverthelowerthirdofthethighsothattheloweredgeofthecuffisapproximately2to3cmabovethepoplitealfossa.31,35

7. CalfBPmeasurementisalsoreferredtoasanankleBP.Ifastethoscopeisused,Korotkoffsoundsareauscultatedovereitherthedorsalispedisorposteriortibialartery(forcalfBP)orthepopli-tealartery(forthighBP).

8. Patientswithaorticdissection,congenitalheartdisease,coarctationoftheaorta,peripheralvasculardisease,andunilateralneurologicalandmusculoskeletalabnormalitiesmaydemon-strateadifferenceinBPbetweenthe2arms.21,22Additionally,researchhasshownthatupto20%to40%ofpersonswithoutthejust-listedcondi-tionsmayalsohaveameasurabledifferenceof10to20mmHginsystolicanddiastolicBPbetweentheleftandrightarms.20-22ResearchmethodsincludedoscillatoryorauscultatoryBPmeasurements,withbothmethodsyieldingsimilarfindings.Agewasafactorinonestudy21withhighermeandifferencesinbothsystolicBPanddiastolicBPinolderparticipants.Ifthereisaconsistentinterarmdifference,usethearmwiththehigherpressure.20

Positioning of Patients1. Bodypositionandarmpositioninfluencethe

measurementofBP.20,42,43Withthearmplacedatheartlevelandthepatientsupine,thesystolicBPreadingsareapproximately8mmHghigherthanwiththepatientsitting.20,44,45Studiesalsoshowthatifthearmisbelowtheleveloftherightatriumor“heartlevel,”theBPreadingswillbe

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higher.Conversely,ifthearmisaboveheartlevel,theBPreadingswillbelower.ThismeanBPdifferenceofupto10mmHgwhenthearmisnotatheartlevelisattributedtotheeffectsofhydrostaticpressure.20,44,45

2. ForcalfBPmeasurements,positionthepatientsupine.29,30PlacethepatientproneforthighBPmeasurements.Ifthepatientcannotbeplacedprone,positionthepatientsupinewithkneeslightlybent.29,30

3. SystolicanddiastolicBPsofhypertensiveandnormotensivepatientsincreasewithtalking.45

Patient Safety1. Tominimizecomplications,ensurepropercuff

placement.Thecuffshouldnotbeplacedoverabonyprominence,superficialnerve,46orjoint.Usethemaximum(leastfrequent)NIBPcycletimefortheshortesttimeperiodpossible.Duringprolongedmonitoring,inspectthecuffsiteandextremity3,47andconsideralternatingbetweenlimbs.2Considerarterialpressuremonitoringforprolongedsurgery,severehypotension,andshock.3

Actions for Nursing PracticeDetermine thebestsiteandmethodofNIBP

measurementforyourpatient.Use theappropriatesizecuffforthepatient’ssize

andtheextremitytoensurethebestresults.Followyourfacility’sproceduresforBPmeasure-

ment,includingdocumentationofsiteandinterarmdifferences.

Promptly reportanyBPmonitoringequipmentorcuffsthatarenotworkingproperlyandtakethemoutofserviceuntiltheycanbeinspectedbythebio-medicaldepartment.

EnsureappropriatepositioningofpatientsduringBPmeasurement.

Compareacquiredvalueswiththeactualassess-mentofthepatientandhisorherclinicalcondition.

EvaluateskinatthesiteandcirculationintheextremitybeingusedforBPmeasurement.

Make surethatallpersonnelarecompetentinuseofthetypesofequipmentavailableonyourunit.

Need More Information or Help?1. Contactaclinicalpracticespecialistforaddi-

tionalinformation:gotowww.aacn.org/practice-resource-network.

Original Author: Maureen A. Seckel, MSN, APN, ACNS-BC, CCNS, CCRN, FCCMMay 2006

Contributing Authors: Maureen A Seckel, MSN, APN, ACNS-BC, CCNS, CCRN, FCCM, Elisabeth G. Bradley, MS, APN, ACNS-BC, AGPCNP-BC, and Heidi Thompson, RN, MSN, CCRNDecember 2015

ReviewedandapprovedbytheAACNClinicalResourcesTaskForce,December2015

FinancialDisclosuresNonereported.

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