3.5 Checklist for Manual Blood Pressure
Open Resources for Nursing (Open RN)
Use the checklist below to review the steps for obtaining a “Manual Blood Pressure.”
Note: The two-step method includes the first step of inflating the cuff and palpating the radial pulse to estimate the systolic blood pressure before obtaining the blood pressure reading. This procedure is based on current AHA recommendations.[1]
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: blood pressure cuff and stethoscope. (Select an appropriately sized cuff for the patient.)
- The width of the cuff should be 40% of the person’s arm circumference, and the length of the cuff’s bladder should be 80–100% of the person’s arm circumference.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Cleanse the stethoscope and blood pressure cuff prior to placing it on the patient’s skin.
- Place the patient in a relaxed reclining or sitting position. The patient should be seated quietly for at least five minutes in a chair prior to blood pressure measurement. Ask the patient which arm they prefer to use. Be aware of conditions that contraindicate the use of an arm for blood pressure measurement, such as a previous mastectomy or the presence of a fistula. During the procedure, both feet should be on the floor and the arm should be supported at heart level.
- Adapt the procedure to life span considerations of the patient.
- Remove or rearrange clothing so the cuff and the stethoscope are on bare skin.
- Center the bladder of the blood pressure cuff over the brachial artery with the lower margin 1″ above the antecubital space. Fit the cuff evenly and snugly. Palpate the brachial artery in the antecubital space.
- Locate the radial pulse.
- Inflate the cuff rapidly (while palpating the radial or brachial pulse) to the level at which pulsations are no longer felt and inflate the cuff 30 mmHg above the palpated pressure or the patient’s usual blood pressure. Note the level and rapidly deflate the cuff; wait 30 seconds.
- With the eartips of the stethoscope placed downward and forward, place the bell/diaphragm lightly on the brachial artery and rapidly inflate the cuff to 30 points above where the brachial or radial pulse is no longer felt.
- Deflate the cuff gradually at a constant rate by opening the valve on the bulb (2-3 mm Hg/second) until the first Korotkoff sound is heard. Note the systolic pressure.
- Continue to deflate the cuff slowly at 2 mm Hg/second. Note the point at which Korotkoff sounds disappear completely as the diastolic pressure.
- Deflate the cuff completely and remove the patient’s arm from the cuff.
- Inform the patient of the blood pressure reading.
- Cleanse the stethoscope and blood pressure cuff.
- Perform proper hand hygiene.
- Ensure five safety measures before leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAIL: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Document findings and report significant deviations from norms according to agency policy.
- Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., Jones Jr., D. W., Materson, B. J., Oparil, S., Wright Jr., J., Roccella, E. J., & National High Blood Pressure Education Program Coordinating Committee. (2003). Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension, 42(6), 1206-1252. https://doi.org/10.1161/01.HYP.0000107251.49515.c2 ↵