Blood pressure is usually measured on the upper arm. If this is not possible, due to burns, plaster cast etc., the blood pressure is measured on the forearm or on the leg on the thigh or above the ankle.
• The patient is informed of the reason, method and frequency of measuring the blood pressure.
• The patient is informed about cooperation when measuring the blood pressure.
• The patient is informed of the measured blood pressure value.
• The patient is informed of the physiological blood pressure values.
• The patient is informed of the potential treatment.
• The patient must not smoke or drink black coffee before measuring BP.
• The patient must rest for at least 5 minutes before measuring.
• It is important to obtain all information from the patient regarding other treatments (possibility of influencing BP).
• BP is always measured in the same position of the patient, and if permitted by their condition, also on the same limb.
• Patient, who is concerned about the procedure or is nervous and unstable, need to be fully reassured; wait a while then repeat the BP measuring after about 30 minutes.
• The patient is put into an appropriate position, usually sitting or lying down on the left arm.
Auscultation method of BP measurement with mercury tonometer and an aneroid tonometer
• When measuring BP on the upper arm, the arm is stretched with the palm facing upwards.
• The tonometer must be level with the patient's chest and the mercury column at eye level of the person measuring.
• Wrap the cuff around the patient's arm so that the bottom edge is 3 to 4 cm above the cubital fossa.
• The centre of the rubber cuff with the tubing is placed over the centre of the cubital fossa.
• Feel the a.brachialis in the cubital fossa.
Place the diaphragm of the stethoscope on the point where the pulse is palpated.
• Put the stethoscope eartips in the ears.
• The stethoscope is held by the thumb on the non-dominant hand.
• Close the valve on the balloon and inflate the cuff until the sound of the heart cannot be heard.
• Release the valve on the balloon with the thumb and fingers of the dominant hand.
• Watch the mercury descend and listen carefully to the first, clearly audible beat, which indicates the systolic blood pressure level; the heart sounds begin to get gradually louder, the last clearly audible beat indicates the diastolic blood pressure level.
• If the measured BP was not clearly audible, the air is released from the cuff and the measuring process is repeated.
• The patient is notified of the measured values.
• Pathological changes in the measured values of BP are reported to a doctor.
• The measured values are recorded in the nursing documentation, the daily record as is customary on the ward.