| Stethoscope bell and sphygmomanometer cuff placement The brachial artery is palpated on the anterior aspect of the elbow by gently pressing the artery against the underlying bone with the middle and index fingers. The brachial artery pulse will be used to measure blood pressure with a stethoscope and sphygmomanometer in the next demonstration. The lower end of the blood pressure cuff is placed 2-3 cm above the antecubital fossa, which should be at approximately the same vertical height as the heart while allowing room for the stethoscope. The cuff should be placed snugly around the upper arm, and the bladder of the cuff should cover at least 80% of the arm's circumference. Show
The bell of the stethoscope is placed over the brachial artery with a good seal using light pressure. Applying too much pressure with the bell of the stethoscope will cause it to act like the diaphragm, and high-pitched sounds will be heard better than low-pitched sounds. Blood pressure cuff and stethoscope bell placement are pictured to the right. Page 2Cuff inflation and deflationIn order to determine the estimated systolic pressure and how high the cuff will need to be inflated, baseline palpable systolic pressure will need to be performed. As you feel the radial artery of the extremity, you will be determining the patient’s blood pressure. Semi-rapidly inflate the cuff until the radial pulse disappears. This will establish an estimate of systolic pressure. When inflating the blood pressure cuff for actual measurement, you should inflate the cuff to 30 mmHg greater than the estimated systolic value. This avoids over-inflation and subsequent patient discomfort from increased pressure. It also avoids the error of an auscultatory gap. This gap is a silent interval sometimes occurring between phase I and phase V of the Korotkoff sounds. If this gap is unrecognized by a clinician, it can lead to a drastic underestimation of systolic pressure. The cuff should be deflated at a rate of 2-3 mmHg per second. You should note when the sounds first appear with two consecutive beats; this is the systolic pressure. Continue to lower the pressure at a rate of 2-3 mmHg per second until the sounds are muffled and disappear; this is the diastolic pressure. To confirm that this is the correct value, continue to deflate the cuff for another 10-20 mmHg, and then deflate the cuff completely. Blood pressure readings should be read to the nearest 2mmHg. It is then recommended to wait 2 or more minutes and repeat this procedure. If the first two readings differ by more than 5 mmHg, take additional readings. Page 3Effects of body position on blood pressureBlood pressure is commonly measured in the seated or supine position; however, the two positions give different measurement values. With that in mind, any time a value is recorded, body position should also be recorded. It is widely accepted that diastolic pressures while sitting are higher than when a patient is supine by as much as 5 mmHg. When the arm is at the level of the heart, systolic pressure can be 8 mmHg higher, such as when a patient is in the supine position rather than sitting. A patient supporting their own arm (isometric exercise) may increase the pressure readings. If the patient’s back is not supported (i.e., when a patient is seated on an exam table instead of a chair) the diastolic pressure may be increased by 6 mmHg. Crossing the legs also may raise systolic pressure by 2-8 mmHg. Arm position plays a dramatic role in value errors as well. If the arm is below the level of the heart, values will be too high; if the arm is above the level of the heart, values will be underestimated. For every inch the arm is above or below the level of the heart, a 2 mmHg difference will be found (Pickering et al. Circ 2005;111:697-716). Differences in bilateral measurements Page 4Section: Measuring Blood Pressure Page 6 of 15 Page 5Section: Measuring Blood Pressure Page 5 of 15 Page 6Classification of hypertension According to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the classification of hypertension is presented below:
Please click the icon if you would like to access the complete report: Evaluation, and Treatment of High Blood Pressure: National Institutes of Health and National Heart, Lung, and Blood Institute; 2004.  Page 7Section: Measuring Blood Pressure Page 3 of 15 Page 8Measuring blood pressureThe Korotkoff method typically includes the occlusion of the brachial artery by a cuff placed on the upper arm and inflated to a pressure above systolic pressure. When the cuff is inflated above systolic pressure, blood flow in the artery is completely occluded or stopped. The pressure is then gradually lowered at 2-3 mmHg per second until pulsatile blood flow occurs. This will cause intra-arterial sounds during auscultation over the brachial artery secondary to turbulent flow and oscillations of the arterial wall. The sounds are described to have five phases, which are as follows:
The fifth phase is the recorded value of the last audible sound. There is agreement among researchers that phase I corresponds to systolic pressure but tends to underestimate the systolic pressure recorded by intra-arterial measurement. There has been some debate in the past as to whether phase IV or V is the accepted value for diastolic pressure, but both are felt to occur before diastolic pressure is determined by intra-arterial recordings. Therefore, it is now accepted that phase V should be used, except when the disappearance of the sounds cannot be reliably determined because the sounds are audible even after complete deflation of the cuff. This situation can occur in pregnant women, patients with arteriovenous fistulas, and patients with aortic insufficiency. Page 9Section: Measuring Blood Pressure Page 1 of 15 The first experience with a home blood pressure monitor can be confusing. The cuff and how it gets positioned are what makes most people scratch their head. Reading the manual for your monitor is crucial for measurements. However, many people will ask, where does the arrow on a blood pressure cuff go? If the arrow on a blood pressure cuff is an artery marker, it should be pointed down the arm to the brachial artery at the elbow joint. If the arrow is not an artery marker, it typically points towards the size range indicator line on the cuff. The answer depends on what manufacturer cuff you have. You would think all cuffs would have the same arrow markings, but unfortunately they don’t. This blog post will go into complete detail on all of the popular scenarios and walk you through the steps with photos to guide you properly. BP Tip: Lower BP naturally by changing how you breathe? A device approved by the FDA and The American Heart Association guides your breathing a few minutes a day which has been proven to lower BP. You can check it out in the manufacturer’s website by clicking here. When The Arrow On A BP Cuff Is An Artery MarkerOn some blood pressure cuffs the arrow is meant to be an artery marker. When the arrow is an artery marker, it will point down towards the hand and should line up with the brachial artery in the elbow joint. On the right or left arm, this would be more towards the inner part of your arm towards your torso 1. On this style cuff, the majority of the cuffs will have the words artery or artery marker next to the arrow. Instead of an arrow some cuffs will use another symbol, like a circle with a line drawn through. When The Arrow On A BP Cuff Is A Size Indicator MarkerOn some blood pressure cuffs the arrow is not an artery marker and is meant to help indicate the cuff is properly sized. After securing the cuff and lining up the artery marker, the arrow should be pointing towards the size range indicator line on the cuff. Typically the arrow will point towards the upper part of the cuff towards the shoulder. Most cuffs will have the size range indicator line on the opposite side of the cuff from the artery marker. Depending on the manufacturer, the size indicator arrow may be labeled differently. The following are some of the more popular terms used: The size indicator line runs from left to right on the edge of the cuff. It is there to help make sure the cuff is the appropriate size for the upper arm. If the cuff is at the proper tightness and is the correct size for your arm, the arrow will point somewhere to the line. On my home monitor, the Welch Allyn 1700 Series, the artery marker is a small circle with a line drawn through it 2. There is an arrow on the other side pointing towards the size range line. Every manufacturer may have a slightly different marker for the artery. I have a detailed review of the Welch Allyn 1700 Series. If you want to check it out and see photos of it and the phone app, click here, Welch Allyn Home 1700 Series Blood Pressure Monitor Review. When There Is No Arrow On The BP CuffOn the Omron 10 Series monitor, the blood pressure cuff doesn’t have an arrow or an artery marker. Instead, they instruct you to line up the tubing on your left arm with your middle finger. On the right arm the tube should run along the side of the elbow, along the bottom of your arm 3. Always refer to the instruction manual for your home monitor for instructions. If you don’t have the manual, you can always find it by visiting the manufacturers website. In addition, most companies have a support phone number you can call. BP cuff arrow placement is one of 14 sections in my article about blood pressure cuffs. Learn more about BP cuffs, including how to apply them, errors made and sizes, here in the article, Blood Pressure Cuffs. Why Does A Blood Pressure Cuff Have An Artery Marker?When the artery marker is lined up with the brachial artery at the elbow, the cuff bladder is centered on the brachial artery 4. This helps to ensure when the cuff is inflated the bladder inside compresses the artery 5. If it took longer for the artery to get compressed, the cuff would have to keep inflating more than it should. This can result in an inaccurate reading and discomfort on your arm. BP Cuff Has Arrow OnlyI’ve seen some replacement cuffs with an arrow unlabeled. In addition, the cuff doesn’t have a size range indicator line. In this situation the arrow is an artery marker or instructing you which way to face the cuff when it’s wrapped around your arm. Blood Pressure Cuff Tubing PlacementOn a home monitor the blood pressure tubing always points down towards the hand when the cuff is positioned properly. On the left arm, when the artery marker is lined up correctly, the tubing should be lined up with the middle of the arm towards the middle finger. On the right arm, the tubing should run along the bottom of the arm towards the little finger. Does It Matter If The Blood Pressure Cuff Is Upside Down?It does matter if the blood pressure cuff is upside down. With the cuff upside down, it may be harder to line up the arrow or artery marker with the brachial artery. In addition, the air supply tubing will have to curve so it can point in the direction of the home monitor which is typically positioned in front of your body. Nurses will often turn the blood pressure cuff upside down in a hospital setting. This enables the lines to face away from the surgical field and keep them out of the way. I have done much research on this topic and nurses in the forums debate with each other if this affects the measurements or not. I was unable to find an answer to the question, does having the blood pressure cuff upside down change the blood pressure measurement? Therefore, I decided to conduct my own experiment and find out if it made a difference with me. I prepared properly for the measurement and rested quietly a full five minutes. I decided to use my right arm for the whole experiment and took three measurements with one minute rest in between. After turning the cuff upside down, I waited another five minutes so my body could return back to normal after some slight physical movement. These were my results: Blood pressure with the cuff in the recommended position:
Blood pressure with the cuff upside down. I did my best to line up the artery marker which was now at the top of the cuff:
You can see turning the cuff upside down didn’t make a difference in my blood pressure. I was extremely careful in estimating the artery marker which may have made a difference in consistency. It’s still recommended not to turn your cuff upside down. Doing so makes it more likely not to line up the cuff correctly or make an error while measuring your blood pressure. ( Lower Your BP Naturally, In Only 30 Days Or Pay Nothing…Visit Website By Clicking Here ) ( Get my free Ebook which includes a breathing technique proven to lower BP 6 mmHg. Click the photo above or here for the free PDF ) Read Next – My Blog Posts on Related BP Cuff IssuesPetechiae From A Blood Pressure Cuff Blood Pressure Cuff Complications Blood Pressure Cuff Placement How To Use A Welch Allyn Blood Pressure Cuff How To Use A Wrist Blood Pressure Cuff Blood Pressure Cuff Too Small Article Resources: Blood Pressure Explained follows strict guidelines to ensure our content is the highest journalistic standard. It's our mission to provide the reader with accurate, honest and unbiased guidance. Our content relies on medical associations, research institutions, government agencies and study resources. Learn more by reading our editorial policy. |
When placing a blood pressure cuff on a patients arm the arrow on the cuff should be centered over which artery?
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