Download pdf - Obtaining Accurate Noninvasive Blood Pressure Measurements

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

www.ccnonline.org CriticalCareNurse Vol 36, No. 3, JUNE 2016 e13

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.


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

www.ccnonline.org CriticalCareNurse Vol 36, No. 3, JUNE 2016 e15

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.

References1. DobbinKR.Noninvasivebloodpressuremonitoring.Crit Care Nurse.

2002;22(2):123-124.2. SrinivasanC,KuppuswamyB.Rahbomyolysiscomplicatingnon-invasive

bloodpressuremeasurement.Indian J Anasth.2012;56:428-430.3. SutinKM,LongakerMT.Acutebicepscompartmentsyndromeassociated

withtheuseofanoninvasivebloodpressuremonitor.Anesth Analg.1996;83:1345-1346.

4. ChesterMW,BarwiseJA,HolzmanMD,PandharipandeP.Acutedermalcapillaryruptureassociatedwithnoninvasivebloodpressuremonitoring.J Clin Anesth.2007;19:473-475.

5. UzunG,KaragozH,MutlogluM,etal.Non-invasivebloodpressurecuffinducedlowerextremitywoundinadiabeticpatients.Eur Rev Med Phar-macol Sci.2012;16:707-708.

6. BurA,HirschlM,HerknerH,etal.Accuracyofoscillometricbloodpres-suremeasurementaccordingtotherelationbetweencuffsizeandupper-armcircumferenceincriticallyillpatients.Crit Care Med.2000;28:371-376.

7. BurA,HerknewH,VicekM,etal.Factorsinfluencingtheaccuracyofoscillometricbloodpressuremeasurementincriticallyillpatients.Crit Care Med.2003;31:793-799.

8. BraamRL,ThienT.Istheaccuracyofbloodpressuremeasuringdevicesunderestimatedatincreasingbloodpressurelevels?Blood Press Monit.2005;10:283-289.

9. ChangJJ,RabinowitzD,SheaS.SourcesofvariabilityinbloodpressuremeasurementusingtheDinamapPRO100automatedoscillometricdevice[abstract].Am J Epidemiol.2003;158:1218-1226.

10. DavisJ,DavisI,BenninkLD,etal.Areautomaticbloodpressuremeasure-mentsaccurateintraumapatients?J Trauma.2003;55:860-863.

11. ParkerSB,SteigerwalkSP.TheDinamapdilemma:inaccuracyofthecommonlyusedDinamap8100comparedtosimultaneousmercurymanometermeasurementinhospitalizedpatientsatdifferentlevelsofbloodpressure[abstract].Am J Hypertens.2004;17(suppl1):S52.

12. ShahriariM,RotenbergDK,NielsenJK,etal.Measurementofarmbloodpressureusingdifferentoscillometrymanometerscomparedtoauscultatoryreadings[abstract].Blood Press.2003;12:155-159.

13. TerraSG,BlumRA,WeiG,etal.Concordanceandvariabilityofbloodpres-suremeasurementbetweenautomatedandmanualreadingsinsubjectsreceivingphenylephrine[abstract].Clin Pharmacol Ther.2003;73:P71.

14. vanMontfransGA.Oscillometricbloodpressuremeasurement:progressandproblems.Blood Press Monit.2001;6:287-290.

15. vanPopeleNM,BosWJ,deBeerNAM,etal.Arterialstiffnessasunderly-ingmechanismofdisagreementbetweenanoscillometricbloodpressuremonitorandasphygmomanometer.Hypertension.2000;36:484-488.

16. AssociationfortheAdvancementofMedicalInstrumentation(AAMI).Manual, Electronic, or Automated Sphygmomanometers.ANSI/AAMISP10.Arlington,VA:AAMI;2002.

17. StergiouG,KolliasA,DestrounisA,etal.Automatedbloodpressuremeasurementinatrialfibrillation:asystematicreviewandmeta-analysis.J Hypertens.2012;30:2074-2080.

18. TheTaskForcefortheManagementofArterialHypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyof

45. NeteaRT,LendersJW,SmitsP,ThienT.Influenceofbodyandarmpositiononbloodpressurereadings:anoverview.J Hypertension.2003;21(2):237-241.

46. LinCC,JawanB,deVillaMV,ChenFC,LiuPP.Bloodpressurecuffcompressioninjuryoftheradialnerve.J Clin Anesth.2001;13:306-308.

47. DevbhandariMP,ShariffZ,DuncanAJ.Skinnecrosisinacriticallyillpatientduetoabloodpressurecuff.J Postgrad Med.2006;52:136-138.


Cardiology(ESC).2013ESH/ESCguidelinesforthemanagementofarterialhypertension.J Hypertens.2013;31:1281-1357.

19. PagonasN,SchmidtS,EyselJ,etal.Impactofatrialfibrillationontheaccuracyofoscillometricbloodpressuremonitoring.Hypertension.2013;62:579-584.

20. PickeringTG,HallJE,AppelLJ,etal.Recommendationsforbloodpres-suremeasurementinhumansandexperimentalanimals,part1:bloodpressuremeasurementinhumans—astatementforprofessionalsfromtheSubcommitteeofProfessionalandPublicEducationoftheAmeri-canHeartAssociationCouncilonHighBloodPressureResearch.Hyper-tension.2005;45:142-161.

21. LaneD,BeeversM,BarnesN,etal.Inter-armdifferencesinbloodpres-sure:whenaretheyclinicallysignificant?J Hypertens.2002;20:1089-1095.

22. CassidyP,JonesK.Astudyofinter-armbloodpressuredifferencesinprimarycare.J Hypertens.2001;5:519-522.

23. PalatiniP,LongoD,ToffaninG,etal.Wristbloodpressureoverestimatesbloodpressuremeasuredattheupperarm.Blood Press Monit.2004;9:77-81.

24. PierinAM,AlavarceDC,GusmaoJL,etal.Bloodpressuremeasurementinobesepatients:comparisonbetweenupperarmandforearmmeasure-ments.Blood Press Monit.2004;9:101-105.

25. DomianoK,HinchS,SavinskieD,etal.Comparisonofupperarmandforearmbloodpressure.Clin Nurs Res.2008;17:241-250.

26. SchellK,BradleyE,BucherL,etal.Aclinicalcomparisonofforearmandupperarmautomatic,noninvasivebloodpressures.Am J Crit Care.2005;14:232-241.

27. SchellK,LyonsD,BradleyE,etal.Clinicalcomparisonofautomatic,noninvasivemeasurementsofbloodpressureintheforearmandupperarmwiththepatientsupineorwiththeheadsofthebedraised45degrees:afollow-upstudy.Am J Crit Care.2006;15:196-205.

28. SchimanskiK,JullA,MitchellN,etal.Comparisonofupperarmandforearmnon-invasivebloodpressureinadultemergencydepartmentpatients.Int J Nurs Stud.2014;51(12):1575-1584.

29. SchraufC.Monitoringbloodpressure:domethodandbodylocationmatter?Nephrol Nurs J.2013;39:502-512.

30. RauenC,ChulayM,BridgesE,VollmanKM,ArbourR.Sevenevidence-basedpracticehabits:puttingsomesacredcowsouttopasture.Crit Care Nurse.2008;28(2):98-124.

31. JarvisC.Physical Examination and Health Assessment.6thed.StLouis,MO:Elsevier;2012:136-141.

32. WilkesJM,DiPalmaJA,Brachialbloodpressuremonitoringversusanklemonitoringduringcolonoscopy.South Med J.2004;97:939-941.

33. IntravenousNursesSociety.Arteriovenousfistulasandhemodialysiscatheters.J Infus Nurs.2006;29:S46-S47.

34. ZahnJ,BernsteinH,HossainS,etal.Comparisonofnoninvasivebloodpressuremeasurementsonthearmandcalfduringcesareandelivery.J Clin Monit Comput.2000;16:557-562.

35. LippincottOnLineProcedureManual.Bloodpressureassessment.2014.In:Lippincottprocedures.http://procedures.lww.com/.AccessedOctober30,2014.

36. NationalKidneyFoundation/DialysisOutcomesQualityInitiative.Clinicalpracticeguidelinesforvascularaccess.Am J Kidney Dis.2001;37:S137-S181.

37. NationalInstituteofDiabetesandDigestiveandKidneyDiseases.Vascularaccessforhemodialysis.http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/vascular-access-for-hemodialysis/.AccessedMarch14,2016.

38. NationalKidneyFoundation.KDOQIClinicalpracticeguidelinesandclinicalpracticerecommendationsfor2006updates:hemodialysisadequacy,peritonealdialysisadequacy,andvascularaccess.Am J Kidney Dis.2006;48:S1-S32.

39. RushingJ.Caringforapatient’svascularaccessforhemodialysis.Nurs Manage.2010;41(10):47.

40. InfusionNursingSociety.INSinfusionspotlight:PICCmanagement.http://www.ins1.org/files/public/01_18_13_Infusion_Spotlight.pdf.AccessedOctober12,2014.

41. AmericanCancerSociety.Lymphedema:whateverywomanwithbreastcancershouldknow.http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/lymphedema/whateverywomanwithbreastcancershouldknow/.AccessedMarch10,2016.

42. PetersGL,BinderSK,CampbellNR.Theeffectsofcrossinglegsonbloodpressure:arandomizedsingle-blindcross-overstudy.Blood Press Monit.1999;4:97-101.

43. Keele-SmithR,Price-DanielC.Effectsofcrossinglegsonbloodpressuremeasurement.Clin Nurs Res.2001;10:202-213.

44. NeteaRT,ElvingLD,LuttermanJA,ThienT.Bodypositionandbloodpressuremeasurementinpatientswithdiabetesmellitus.J Intern Med.2002;251:393-399.