Download Clinical Guidelines for Taking a Non

CONTROLLED DOCUMENT
Clinical Guidelines for taking a non-invasive blood pressure
(BP) Measurement
CATEGORY:
Procedural
CLASSIFICATION:
Clinical
PURPOSE
To provide clear guidelines for all
relevant staff on performing noninvasive blood pressure (BP)
measurement. This includes taking
BP using manual and electronic
devices, from an arm and leg, and
lying and standing BP to assess for
orthostatic (postural) hypotension.
Controlled Document
Number:
CG218
Version Number:
1
Controlled Document
Sponsor:
Executive Chief Nurse
Controlled Document
Lead:
Clinical Nurse Specialist
Hypertension Services
Approved By:
Clinical Guidelines Group
On:
February 2016
Review Date:
February 2019
Distribution:
•
Essential
Reading for:
All clinical staff involved in
performing and interpreting blood
pressure (BP) measurement
•
Information for:
All clinical staff
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 1 of 23
Table of contents
Item
Subject
Page
1.
Introduction
3
2.
Statement of need
3
3.
Scope
3
4.
Consent
3
5.
Definitions
3
6.
Patient assessment when taking a blood pressure
4
6.1
6.2
6.3
6.4
6.4.1
4
4
5
5
6
Factors to consider
Limb choice
Leg blood pressure measurement
Procedure
Recommendations to gain an accurate reading
7.0
Lying and Standing Blood Pressure Measurement
6
8.0
Maintenance of Equipment
7
9.0
Education and Training
7
10.0
Monitoring of Guidelines
7
11.0
Clinical Incident Reporting and Management
8
12.0
References and Bibliography
8
Appendices
1.
Procedure for taking arm blood pressure measurement
using a manual blood pressure monitor
Illustrated Guide to Demonstrate Taking an Arm Blood Pressure
Measurement with MANUAL Blood Pressure Monitor
2.
3.
4.
Procedure for taking arm blood pressure measurement
using an electronic blood pressure monitor
11
12
13
Illustrated Guide to Demonstrate Taking an Arm Blood Pressure
Measurement with an ELECTRONIC Blood Pressure Monitor
14
Procedure for taking leg blood pressure measurement
15
Illustrated Guide to Demonstrate Taking an ANKLE Blood Pressure
Measurement with Electronic Blood Pressure Monitors
16
Procedure for taking lying and standing blood pressure
measurement
17
Illustrated Guide to Demonstrate Taking a LYING AND STANDING
Blood Pressure Measurement with a MANUAL Blood Pressure Monitor
19
5.
Selection of cuff size
20
6.
Leg blood pressure measurement poster
21
7.
Assessment criteria
22
8.
Competency document
23
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 2 of 23
1.0
Introduction
Blood pressure measurement is essential as a predictor of overall mortality and morbidity.
The accurate measurement of blood pressure is a vital element of clinical practice; to guide
treatment decisions, in the primary, secondary and tertiary prevention and / or deterioration
of cardiovascular, renal and cerebral disease and wider mortality and morbidity.
This guideline provides a practical guide to the accurate assessment of:
• Arm blood pressure measurement using a manual blood pressure monitor
• Arm blood pressure measurement using an electronic blood pressure monitor
• Leg blood pressure measurement
• Lying and standing blood pressure measurement
2.0
Statement of Need
The purpose of this guideline is to ensure that blood pressure measurements are taken
using a standardised approach in order to ensure accurate results are obtained to guide
treatment.
3.0
Scope
This document applies to all Trust staff involved in the process of taking blood pressure
measurements.
4.0
Consent
Although formal written consent is not required for minor procedures, verbal consent for the
measurement of a patient’s blood pressure must be obtained where possible. For further
information regarding consent and mental capacity please refer to the following documents:
• Department of Health Reference Guide to Consent for Examination or Treatment
(2009).
• The Trust’s Policy and Procedural document for consent to examination or
treatment (current version).
• Mental Capacity Act (2005).
5.0
Definitions
Blood pressure (BP)
Systolic
Diastolic
Hypertension
Hypotension
As the heart beats, blood is pumped around the body to
supply the energy and oxygen the body needs. As the
blood moves, it pushes against the sides of the blood
vessels. The strength of this pushing is the blood
pressure.
The upper number of a BP measurement relates to the
blood pressure when the heart contracts.
The lower number of a BP measurement relates to when
the heart relaxes and fills with blood.
High blood pressure.
Hypertension puts extra strain on the arteries and heart
and this may lead to cardiovascular disease especially
myocardial infarction and strokes, and renal impairment.
Low blood pressure.
Hypotension can restrict the amount of blood flowing to
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 3 of 23
Orthostatic (postural)
hypotension
6.0
the brain and other vital organs, which can cause
unsteadiness, dizziness or fainting. A blood pressure
reading under 90/60mmHg is usually regarded as
hypotension. In a hospital setting hypovolemia, from blood
loss, dehydration, vomiting and diarrhoea can be a leading
cause of hypotension.
A person’s inability to maintain blood pressure on
assuming an upright position, usually when moving from a
supine (lying) position. It is identified by recording blood
pressure in a lying and standing position. A drop of at
least 20mmHg in the systolic BP or at least 10mmHg in
the diastolic BP of along with symptoms of cerebral hypo
perfusion are diagnostic of orthostatic (postural)
hypotension (Gupta & Lipstiz 2007). It is important to
identify orthostatic hypotension as it can lead to falls,
which can have devastating consequences in frail elderly
and are associated with significant mortality and morbidity
(Gupta & Lipstiz 2007).
Patient assessment when taking a blood pressure
Inaccurate blood pressure measurement can lead to false results that under or
overestimate the blood pressure, which in turn can lead to under or overtreatment and
associated risk of falls.
6.1
Factors to consider
Performing the correct procedures for taking blood pressure measurement will maximise
effective recordings, diagnosis and treatments and reduce the risk of inaccurate
measurements and associated risk. The following factors must be considered prior to under
taking a blood pressure:
• General condition of the patient
• Reason for taking the blood pressure
• Choice of limb to use for the procedure
• Limb size
• Correct cuff size (refer to appendix 5)
• Recent patient injuries
• Recent patient activity
• Patient position, are they able to lay flat, seated, stand
• Choice of medical device for the procedure
6.2
Limb choice
There are occasions as listed below when a limb should be avoided due the risk of
complications to the patient, in this instance an alternative limb may be used and this must
be documented.
•
•
•
•
•
Limbs showing signs of an infection, cellulitis
Limbs where there are recent injuries, fractures, burns, paralysis/ CVA
Limbs with increased sensitivity
Swollen or oedematous areas
Axillary vein thrombosis
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 4 of 23
•
•
•
•
•
•
•
6.3
The arm on the side where lymph clearance or severance has taken place (e.g.
mastectomy with axillary node clearance)
Limb amputation
AV fistula present
Peripherally Inserted Central Catheter (PICC) or midline line in situ
Subclavian artery stenosis
Severe limb deformity
Morbid obesity
Leg blood pressure measurement
There are specific reasons for selecting a leg blood pressure measurement. The main
reason for measuring BP in the leg is in newly diagnosed younger hypertensive patients
(under the age of 50) to exclude the diagnosis of coarctation of the aorta (Giles et al, 2008;
Obeid, Pucci & Martin 2015). A leg BP of more than 20mmHg lower than the brachial BP
should raise suspicion of coarctation. (Giles et al, 2008; Obeid, Pucci & Martin 2015) Please
additionally refer to Poster appendix 6.
Additionally a leg blood pressure would be chosen when the arm has to be avoided due to
reasons as previously listed in point 6.2
Items to consider when taking a leg blood pressure measurement are:
• No BP machines currently validated to use to measure a leg BP.
• False high systolic pressure may be obtained in patients with diabetes because the
cuff may not be able to compress calcified distal arteries (University Hospitals
Birmingham NHS Foundation Trust (UHB) 2014).
• Peripheral vascular disease may give a lower systolic BP in the legs. (University
Hospitals Birmingham NHS Foundation Trust (UHB) 2014).
• Severe hypotension may give a lower systolic BP in the legs (Drake and Hill 2013).
• Generally systolic BP will be higher in the ankle than the arm (Hocken 1967; Wilkes
JM & DiPalma 2004; Moore et al 2008; Drake and Hill 2014; Goldstein, Wells & Silwa
2014).
• The diastolic BP in the ankle is similar to that observed in the arm (Hocken 1967;
Wilkes JM & DiPalma 2004; Moore et al 2008; Drake and Hill 2014; Goldstein, Wells
& Silwa 2014).
• No current diagnostic or therapeutic targets for leg BP but it is reasonable to assume
that leg BP systolic readings are at least 15mmHg higher than arm readings and this
should be taken into account to guide treatment (Obeid, Pucci, Sheppard & Martin
2015). Please note this is a preliminary finding. A full meta-analysis is in progress
and will be reported on late 2016.
6.4
Procedure
For the correct procedure for each type of blood pressure measurement refer to the
relevant appendix as detailed below:
Appendix 1: Arm blood pressure measurement with manual blood pressure monitors
Appendix 2: Arm blood pressure measurement with electronic blood pressure monitors
Appendix 3: Leg blood pressure measurement
Appendix 4: Lying and standing blood pressure measurement
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 5 of 23
6.4.1 Recommendations to gain an accurate reading
Patient assessment, limb choice and device choices are all important aspects to consider to
gain an accurate blood pressure measurement; the following should also be adhered to:
• Out patients or inpatients on admission: when taking arm BP take 3 readings, blood
pressure should be measured in both arms initially. The arm with the highest reading
should then be the one used. Take 6 readings when taking a leg blood pressure
• For the inpatient single readings can be taken for routine observations and vital sign
monitoring, it is important to review trends and not solely single readings in isolation,
BP readings should be repeated when outside the patients normal limits and the
trend parameters (NICE CG127)
• A manual blood pressure measurement should be taken in patients with known or
suspected atrial fibrillation and is the gold standard to diagnose orthostatic
hypotension
• Ensure limb, cuff and heart are at the same level (where possible)
• Encourage the patient to be rested for 5 minutes
• Encourage the patient not to cross their legs
• Encourage the patient not talk whilst the actual reading is being taken
• Ensure tight clothing does not constrict the limb
• Ensure the correct equipment is available and used correctly
• Ensure patient comfort and safety
• Review patient, medication, treatment, take action and document as appropriate
Further reading can be found BHS 2006, NICE 2011, NICE 2013
At the
Same level
= EQUALS
LIMB
CUFF
HEART
Accurate
Reading
Figure showing limb, cuff and heart must be at the same level where possible to gain an accurate reading
7.0
Lying and Standing Blood Pressure Measurement
Orthostatic (postural) hypotension is defined as the inability to maintain blood pressure on
assuming an upright position from laying down (supine), leading to a drop of 20mmHg in
systolic pressure or a reduction in diastolic pressure of at least 10mmHg. (NICE 2011) It
has a prevalence of up to 50% in older people due to a combination of age-related
physiological changes including increased baroreceptor sensitivity, and the side-effects of
an increased intake of medication with vasoactive potential, taken for a higher incidence of
chronic disease. (Maurer 2000, Bonema and Maddens 1992).
Orthostatic hypotension can cause cerebral hypo perfusion the symptoms of which include
dizziness, nausea, blurred vision, sweating, lethargy, falls and syncope (Gupta & Lipstiz
2007). It is important to identify orthostatic hypotension as it can lead to falls, which can
have devastating consequences in frail elderly and are associated with significant mortality
and morbidity (Gupta & Lipstiz 2007).
The recent national audit of inpatient falls, (Royal College of Physicians (RCP) 2015)
supports NICE 161(2013) guidance that recommends “all patients over 65 years (and those
over 50 at particular risk) have a lying and standing blood pressure performed as soon as
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 6 of 23
practicable and actions taken if there is a significant drop in blood pressure on standing.”
(Royal College of Physicians 2015)
In order to diagnose orthostatic hypotension (OH) it is essential that blood pressure
measurement is undertaken accurately using standardised guidelines and validated
equipment (Vloet et al 2002). The British Hypertension Society committee (BHS) was
consulted during this document development and have advised a manual BP measuring
device remains the gold standard for the diagnosis of OH.
A systolic blood pressure fall by 20mmHg or more on standing must be verified by taking a
series of manual BP readings, changes must not be made solely on the basis of an
individual BP reading.
For the procedure to follow when taking a lying and standing blood pressure measurement
refer to Appendix 4.
8.
Maintenance of Equipment
When measuring blood pressure you must ensure that the device being used is clinically
validated (NICE 2011 and BHS 2006). As with all medical devices, use should be in
accordance with procedures recommended by the manufacturer. The date of next servicing
and calibration must be clearly marked on the device (6-12 monthly according to device
used). It is important to have the monitor serviced and calibrated according to
manufacturer’s guidelines. All Trust devices will have Medical Engineering servicing stickers
attached and asset tag numbers.
NB: the Trust is a recognised clinical validation site
9.
Education and Training
All staff that perform blood pressure measurement must have evidence that they are
competent to perform the procedure, and this must be updated every 3 years. The
practitioner must be competent in the medical device being used (manual and automated
device as appropriate) and the care of the patient when taking a blood pressure. The
assessment criteria and competency documents are incorporated into this document and
can be found in appendices 7 and 8
Registered practitioners can assess themselves against Self-Assessment Criteria
Competency Checklist Guidelines Vital Signs monitor (Generic form) appendix 7; they must
sign the competency form appendix 8. Non-registered practitioners will use the same form
this must be countersigned by a competent Registered Practitioner. All competencies must
be returned to the Clinical Core Trainer and will be recorded on the EQUIP electronic
system.
10.
Monitoring of Guidelines
The Clinical Nurse Specialist Hypertension will lead the audit of this guideline in accordance
with the review date with support from the Falls Team, Medical Device Training Team and
the Practice Development Team and will include:
• Number of staff trained, competent or self-verified as competent
• Any untoward incidents reported via datix.
• Any complaints
The appropriate Health and Safety risk assessments must have been completed for the
clinical area.
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 7 of 23
11.
Clinical Incident Reporting and Management
Any untoward incidents and near misses must be reported via the Trust incident reporting
system, and where required escalated to the appropriate management team. In addition,
the Risk and Compliance Unit must be notified by telephone of any Serious Incidents (SI).
12.
References and Bibliography
Bonema J, Maddens M (1992) Syncope in elderly patients: why their risk is higher.
Postgraduate Medicine 91, 1, 129-132, 135-136, 142-144.
British Hypertension Society (2012) How to measure a blood pressure web page Website designed
and maintained by Hampton Medical Conferences Ltd.
Page last updated on 3rd August 2012. http://www.bhsoc.org/latest-guidelines/how-to-measureblood-pressure/ [accessed 18.11.2015]
British Hypertension Society (BHS) (2005) Blood Pressure Measurement. Fact file 12/2005
http://www.bhsoc.org/files/8913/3483/0407/BP_measurement_fact_file.pdf [accessed 18.11.2015]
Drake MJP, Hill JS (2013). Observational study comparing non-invasive BP measurement at
the arm and ankle during caesarean section. Anaesthesia. 68:461-66.
Department of Health (2009) Reference Guide to Consent for Examination or Treatment 2nd
Edn. HMSO London
European Society of Cardiology (ESC) (2009) Guidelines for the diagnosis and management
of syncope (version 2009) European Heart Journal (2009) 30, 2631–2671
http://eurheartj.oxfordjournals.org/content/ehj/30/21/2631.full.pdf [accessed 13.01.2016]
Firth J, Reeve, P, Newton J, (2013) Length of time required to achieve a stable baseline blood
pressure in the diagnosis of hypertension. Journal of the American Geriatrics Society. 61:14141438.
Giles R; Veldman BA; Aengevaeren WR; Schultze-Kool LJ; van Oort A; Lenders JW (2008)
Measurement of leg BP; the most straightforward way to the diagnosis. Netherlands Journal of
Medicine. 66;81-4.
Goldstein LN, Wells M, Sliwa K (2014). Blood pressure measurements in the ankle are not
equivalent to blood pressure measurements in the arm. South African Medical Journal. Vol./is.
104/12 p869-73.
Gupta V, Liptstiz Lewis A (2007) Orthostatic hypotension in the elderly: diagnosis and
treatment. The American Journal of Medicine. Oct, vol 120:10:841-7.
Hocken AG (1967). Measurement of blood-pressure in the leg. Lancet. Vol./is. 1/7488 p466-468.
Lakhal K, Macq C, Ehrmann S, Boulain T, Capdevila X (2012) . Nonivasive monitoring of BP in the
critically ill: Reliability according to the cuff site (arm, thigh, or ankle). Critical Care Medicine.40;
1207-1212.
Lister S & Doherty L (2015) Observations – blood pressures. Chapter 11 Royal Marsden Manual
of Clinical Nursing Procedures. 9th ED. Royal Marsden NHS Foundation Trust
http://www.rmmonline.co.uk/search?dc_type=&q=blood+pressures
Maurer M (2000) Upright posture and postprandial hypotension in elderly persons, Annals of
Internal Medicine, 133, 7, 533-536
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 8 of 23
Medicines and Healthcare products Regulatory Agency (2013) Blood Pressure Measurement
Devices Crown Copy right
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/403448/Blood_pressu
re_measurement_devices.pdf [accessed 16.02.2016]
Moore C, Dobson A, Kinagi M, Dillon B (2008). Comparison of BP measured at the arm, ankle
and calf. Anaesthesia. 1327:31.
National Institute for Health and Clinical Excellence (NICE) (2013) Falls in older people: assessing
risk and prevention. NICE guidelines (CG161) https://www.nice.org.uk/guidance/cg161
[accessed 13.01.2016]
National Institute for Health and Clinical Excellence (NICE) (2011) Hypertension in adults:
diagnosis and management NICE guidelines [CG127] 1 Guidance, 1.1 Measuring Blood
pressure http://www.nice.org.uk/guidance/cg127/chapter/1-Guidance#measuring-blood-pressure
[accessed 18.11.2015]
National Institute for Health and Clinical Excellence (NICE) (2011) Hypertension The clinical
management of primary hypertension in adults Clinical Guideline 127 Methods, evidence,
and recommendations (2004 amended 2011)
https://www.nice.org.uk/guidance/cg127/evidence/full-guideline-248588317
[accessed 18.11.2015]
National Institute for Health and Clinical Excellence NICE (2013) NHS Evidence provided by NICE
Hypertension: Evidence Update 32 March 2013 A summary of selected new evidence relevant
to NICE clinical guideline 127 ‘Clinical management of primary hypertension in adults’ (2011)
https://www.nice.org.uk/guidance/cg127/evidence/evidence-update-248584429
[accessed 18.11.2015]
Obeid, A; Pucci, M; Martin, U (2015) Leg blood pressure measurement: utility, pitfalls and
recommendations for clinical practice and future research. Poster presentation British
Hypertension Society Scientific Meeting 21st – 23rd September 2015.
Reeve P (2000) Assessing orthostatic hypotension in order people Nursing Older People
October Vol 12, No 7 27-28
Royal College of Physicians (2015) Falls and Fragility Fracture Audit Programme (FFFAP)
Royal College of Physicians National Audit for Inpatient Falls (NAIF) www.rcplondon.ac.uk/fffap
[accessed 13.01.2016]
Sheppard J, Holder R, Nichols L, Bray E, Hobbs FD Richard, Mant J, Little P, Williams B, Greenfield
S, McManus R (2014). Predicting out-of-office blood pressure level using repeated
measurementsd in the clinic: an observational cohort study. Journal of Hypertension.
November, vol 32 (11) p 2171-78. Lippincott William & Wilkins.
Takahashi O, Shimbo T, Rahman M, Okamoto S, Tanaka Y, Fukui T (2006). Evaluation of cuffwrapping methods for the determination of ankle BP. BP monitoring. 11:21-16.
University Hospitals Birmingham NHS Foundation Trust (current version) CD 298 Expanded
practice protocol for the assessment of patients with leg ulcers by registered practitioners
using Doppler ultrasound to measure the ankle/brachial pressure index. (Unpublished)
University Hospitals Birmingham NHS Foundation Trust (current version) Policy for consent to
examination or treatment, University Hospitals Birmingham NHS Foundation Trust
http://uhbpolicies/Microsites/Policies_Procedures/consent-to-examination-or-treatment.htm
[accessed 22.07.2015]
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 9 of 23
University Hospitals Birmingham NHS Foundation Trust (current version) Procedure for consent to
examination or treatment. University Hospitals Birmingham NHS Foundation Trust
http://uhbpolicies/Microsites/Policies_Procedures/consent-to-examination-or-treatment.htm
[accessed 22.07.2015]
University Hospitals Birmingham NHS Foundation Trust (current version) Working with carers:
common core principles, University Hospitals Birmingham NHS Foundation Trust
http://uhbhome/working-with-carers-common-core-principles.htm [accessed 22.07.2015]
University Hospitals Birmingham NHS Foundation Trust Risk Assessment Documentation
http://uhbhome/Resources/RiskAssessmentDocs/Home.aspx
[accessed 17.08.2015]
University Hospitals Birmingham NHS Foundation Trust (current version) Procedure For The
Management And Safeguarding Of Patients Less Than 18 Years Of Age
http://uhbpolicies/Microsites/Policies_Procedures/patients-under-18.htm
[accessed 17.08.2015]
Vloet L, Smiths R, Frederiks C, Hoefngals W, Jansen R (2002) Evaluations of skills and
knowledge on orthostatic blood pressure measurements in older people, Age and Ageing, 31:
211-216
Wilkes JM; DiPalma JA (2004). Brachial blood pressure monitoring versus ankle monitoring
during colonoscopy. Southern Medical Journal. October, vol./is.97/10 (939-41).
Worcester Acute Hospitals NHS Trust (2014) Identification of Orthostatic Hypotension. Clinical
guideline WHAT-NUR-008, approved 14th March 2014.
Guideline Developed and Reviewed by the Blood Pressure Focus Group
Amira Obeid
Alison Doyle
Wendy Madden
Becky Nketiah-Boateng
Ann Woodhead
Julia Redwood
Helen Edwards
Marian Amissah
Michelle Clement
Andrew MacLennan
Lisa Magill
Deborah Jackson
Clinical Nurse Specialist Hypertension
Lead Nurse Falls and Fractures
Falls Clinical Nurse Specialist
Hypertension Staff Nurse
Clinical Educator
Clinical Educator
Medical Devices Training Coordinator
Medical Devices Training Lead
Clinical Education Team Manager
Lead Clinical Skills Trainer
Practice Development Nurse
Practice Development Nurse
Additional reviewers
Dr Jonathan Treml
Consultant Geriatrician
Dr Una Martin
Consultant Physician, Endocrinology
Phillip Norman
Chief Nurse
Debbie Maughan
Matron for Out Patient Departments
Louise Denner
Lead Nurse Standards
Practice Development Team
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 10 of 23
Appendix 1
(Page 1 of 2)
Arm blood pressure measurement with manual blood pressure monitors
http://www.bhsoc.org/files/9013/4390/7747/BP_Measurement_Poster_-_Manual.pdf
(Reproduced from British Hypertension Society (BHS) 2006)
A manual blood pressure measurement should be taken in patients with known or suspected atrial
fibrillation. Blood pressure should be measured in both arms initially. The arm with the highest
reading should then be the one used
Equipment: Manual blood pressure monitor
Blood pressure cuff (for size selection refer to appendix 5)
Stethoscope
Procedure: Ensure you are familiar and competent to use related medical device
Action
Rationale
1 Explain procedure to patient, gain verbal
To ensure that the patient understands
the procedure and gives his/her valid
consent.
consent.
Ensure infection prevention and control
To minimize the risk of infection
practises are used through-out
2 The patient should be rested for at least 5
To ensure an accurate reading is
obtained. Normally blood pressure
minutes prior to reading.
readings are taken with the patient in a
Relaxed and not moving or speaking when
sitting position
taking the reading (where possible)
3 The arm must be supported at the level of
To obtain a correct reading
the heart. Ensure no tight clothing
constricts the arm
4 Place the cuff on neatly with the centre (cuff To ensure the cuff is in the correct
position and to prevent an inaccurate
artery index marker) over the brachial
reading due to pressure being exerted
artery. The bladder should encircle at least
on the brachial artery by the cuff
80% of the arm (but not more than 100%)
5 Estimate the systolic beforehand:
To estimate the systolic pressure
• Palpate the brachial artery
• Inflate cuff until pulsation disappears
• Deflate cuff
6 Then inflate to 30mmHg above the
Pressure exerted by inflated cuff
prevents blood flowing through the artery
estimated systolic level needed to occlude
the pulse
7 Place the stethoscope diaphragm over the
Apply gentle pressure on the
stethoscope to keep it in place and avoid
brachial artery and deflate at a rate of 2muffled sounds or sounds of distortion
3mm/sec until you hear regular tapping
sounds
8 Measure systolic (first sound) and diastolic
To ensure an accurate reading is
obtained
(disappearance) to nearest 2mmHg
9
Compare with previous readings, if BP
reading is out of patients normal
parameters, take appropriate action
10
Document in patient’s record, document
which arm was used any irregularities and
actions taken
11
Remove equipment and clean after use
Two or more readings are often taken to
represent a normal blood pressure
Taking more than one reading can
reduce anxiety and provide a more
accurate reading
To ensure adequate record keeping,
establish an audit trail and enable good
communication and continued care of
patient
Minimize the risk of infection
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 11 of 23
Appendix 1
(Page 2 of 2)
Illustrated Guide to Demonstrate Taking an Arm Blood Pressure Measurement with MANUAL Blood Pressure Monitor
1
Wash hands
2
Identify patient
Explain procedure
Gain consent
Ensure no contraindication
3
Select appropriate cuff
size for patient
Barrier nursed patients to
have single patient use
cuff
4
Palpate brachial artery
7
8
9
10
Attach machine lead to the
cuff
Position heart, limb and
cuff to the same level
Estimate the systolic
beforehand
Palpate the brachial artery
Inflate cuff until pulsation
disappears, estimated
systolic pressure
Deflate the cuff
Inflate cuff to 30mmHg
above the estimated
systolic level
Place the stethoscope
diaphragm over the
brachial artery and deflate
the cuff at a rate of 2 –
3mm/sec
Measure systolic (first
sound) and diastolic
(disappearance) to nearest
2mmHg
Clean equipment
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 12 of 23
5
Line cuff artery marker up
with brachial artery
11
Decontaminate hands
6
Ensure artery marker fits
within cuff range /
parameter markers
12
Document findings on
PICS, ensure all
observations completed to
allow SEWS score to be
generated
Appendix 2
(Page 1 of 2)
Arm blood pressure measurement with electronic blood pressure monitors
http://www.bhsoc.org/files/8413/4390/7770/BP_Measurement_Poster__Electronic.pdf
(Reproduced from British Hypertension Society (BHS) 2006)
Equipment: Electronic blood pressure monitor
Blood pressure cuff (for size selection refer to appendix 5)
Procedure: Ensure you are familiar and competent to use related medical device
Action
Rationale
1
2
3
4
5
6
7
8
Explain procedure to patient, gain verbal
consent.
Ensure infection prevention and control
practises are used through-out
The patient should be rested for at least 5
minutes prior to reading.
Relaxed and not moving or speaking when
taking the reading (where possible)
The arm must be supported at the level of
the heart. Ensure no tight clothing
constricts the arm
Place the cuff on neatly with the centre (cuff
artery index marker) is over the brachial
artery. The bladder should encircle at least
80% of the arm (but not more than 100%)
Ensure patients heart, cuff and monitor are
at the same level
Choose appropriate setting to inflate cuff.
Some monitors allow manual blood
pressure setting selection where you
choose the appropriate setting. Other
monitors will have automatically inflate and
re-inflate to the next setting if required.
For initial measurement repeat three times
record measurement as displayed. Test
blood pressure in both arms and use arm
with highest reading for subsequent
measurements.
Compare with previous readings, if BP
reading is out of patients normal
parameters, take appropriate action
9
Document in patient’s record, document
which arm was used any irregularities and
actions taken
10
Remove equipment and clean after use
To ensure that the patient understands
the procedure and gives his/her valid
consent.
To minimize the risk of infection
To ensure an accurate reading is
obtained. Normally blood pressure
readings are taken with the patient in a
sitting position
To obtain a correct reading
To ensure the cuff is in the correct
position and to prevent an inaccurate
reading due to pressure being exerted
on the brachial artery by the cuff
To ensure an accurate reading is
obtained
To ensure an accurate reading is
obtained
Two or more readings are often taken to
represent a normal blood pressure
Taking more than one reading can
reduce anxiety and provide a more
accurate reading
Trends often show correct readings,
when to repeat a blood pressure
measurement and when to call for
assistance
To ensure adequate record keeping,
establish an audit trail and enable good
communication and continued care of
patient
Minimize the risk of infection
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 13 of 23
Appendix 2
(Page 2 of 2)
Illustrated Guide to Demonstrate Taking an Arm Blood Pressure Measurement with an ELECTRONIC Blood Pressure Monitor
1
Check equipment
In working order and
cleaned
Cuff sizes available
Other observation
equipment present
7
Ensure artery marker fits
within cuff ranger /
parameter markers
2
Consider frequency
dependent on clinical
condition A-E assessment
Wash hands
8
Attach machine lead to
cuff
3
Identify patient
Explain procedure
Gain consent
Ensure no contraindication
9
Position arm at level of
heart
4
Select appropriate cuff
size for patient
Barrier nursed patients to
have single patient use
cuff
10
Switch on BP machine and
allow to calibrate
Ensure arm supported at
level of heart
Warn patient of cuff
becoming tight
Press BP cuff inflation
button-take reading
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 14 of 23
5
Palpate brachial artery
11
Clean equipment
Decontaminate hands
6
Line cuff artery marker up
with brachial artery
12
Document findings on
PICS, ensure all
observation completed to
allow SEWS score to be
generated
Appendix 3
Leg blood pressure measurement
Equipment: Manual blood pressure monitor
Blood pressure cuff (for size selection refer to appendix 5)
Procedure: Ensure you are familiar and competent to use related medical device
Action
Rationale
1
2
3
4
5
6
7
8
9
10
Explain procedure to patient, gain verbal
consent.
Ensure infection prevention and control
practises are used through-out
The patient should be lying down for at
least 5 minutes prior to the reading
Relaxed and not moving or speaking when
taking the reading (where possible)
The leg should be supported at the same
level as the heart and the cuff (Drake & Hill
2013; Obeid, Pucci & Martin 2015).
Ensure no tight clothing constricts the leg.
Place the cuff on the ankle neatly with the
centre of the bladder over the posterior
tibial artery (Moore et al 2008; Lakhal et al
2012; Obeid, Pucci & Martin 2015).
The bladder should encircle at least 80% of
the ankle (but not more than 100%).
Straight wrapping cuff method; same
method used for measuring arm BP
(Takahashi et al, 2006; Obeid, Pucci &
Martin 2015).
Use a standard adult arm cuff which will be
suitable for the vast majority of ankles
(Obeid, Pucci & Martin 2015).
For initial measurement repeat six times to
allow for white coat effect, record
measurement as displayed. Test blood
pressure in both ankles (where possible)
and use leg with highest reading for
subsequent measurements.
Compare with previous readings, if BP
reading is out of patients normal
parameters, take appropriate action
11
Document in patient’s record, document
which leg was used, any irregularities and
actions taken
12
Remove equipment and clean after use
To ensure that the patient understands
the procedure and gives his/her valid
consent.
To minimize the risk of infection
To ensure an accurate reading is
obtained.
Limb- Cuff- heart should be in alignment
where possible to gain an accurate
reading
To ensure an accurate reading is
obtained
To ensure an accurate reading is
obtained
Most modern cuffs have manufactures
marking to ensure correct fitting
To ensure an accurate reading is
obtained
To ensure suitable cuff fit
Six initial readings are taken to represent
a normal blood pressure
Taking more than one reading can
reduce anxiety and provide a more
accurate reading (Sheppard et al 2014;
Obeid, Pucci & Martin 2015).
Trends often show correct readings,
when to repeat a blood pressure
measurement and when to call for
assistance
To ensure adequate record keeping,
establish an audit trail and enable good
communication and continued care of
patient
Minimize the risk of infection
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 15 of 23
Appendix 3
(Page 2 of 2)
Illustrated Guide to Demonstrate Taking an ANKLE Blood Pressure Measurement with Electronic Blood Pressure Monitors
NB: meta-analysis (in progress) is demonstrating that leg systolic BP can be at least 15mmHg higher than arm readings and this should
be taken into account to guide treatment (Obeid, Pucci, Sheppard & Martin 2015)
1
Check equipment is in
working order and clean
Cuff sizes available
Other observation
equipment present
7
Attach machine lead to
cuff
2
Consider frequency
dependent on clinical
condition A – E
assessment
Wash hands
3
Identify patient
Explain procedure
Gain consent
Ensure no contraindication
8
9
Switch on BP machine and
allow to calibrate
Warn patient of cuff
becoming tight
Press BP cuff inflation
Confirm patient has been
lying flat for at least 5
minutes
Ensure limb cuff and heart
are at the same level
Take reading
4
Select appropriate cuff
size for patient
Barrier nursed patients to
have single use cuff
10
Clean equipment
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 16 of 23
5
6
Palpate the posterior tibial
artery
Line cuff artery marker up
with posterior tibial artery
11
12
Decontaminate hands
Ensure completion of all
observations to allow
SEWS score to be
generated. Compare
against trends. Take
appropriate actions as
required and document in
notes
Appendix 4
Lying and standing blood pressure measurement
In people with symptoms of postural
hypotension (falls or postural dizziness):
• Measure blood pressure with the person
laying down
• Measure the blood pressure again with the
person standing and subsequently 1, 3
and 5 minutes after standing
• Ensure patient safety
If the systolic blood pressure falls by
20mmHg or more when the person is
standing
• Ensure patient safety- as appropriate
validate readings with manual BP
• Refer to medical staff
• Review medication – do not change
medication solely on an individual
reading – ensure manual BP check
• Consider referral to specialist
Equipment: Manual or electronic blood pressure monitor
Blood pressure cuff (for size selection refer to appendix 5)
Procedure: Ensure you are familiar and competent to use related medical device
Action
Rationale
Explain
procedure
to
patient,
gain
verbal
To
ensure
that
the patient understands
1
2
3
4
5
6
7
8
9
consent.
Ensure infection prevention and control
practises are used through-out
The patient should be lying down for at
least 5 minutes prior to the reading
Relaxed and not moving or speaking when
taking the reading (where possible)
Measure the blood pressure at the brachial
artery where possible
The arm and cuff must be supported at the
level of the heart. Ensure no tight clothing
constricts the arm
Depending upon whether a manual or
electronic reading is being obtained follow
the principles in appendices 1 or 2
Select the correct cuff size for patients arm
size according to appendix 5
Place the cuff on neatly with the centre over
the brachial artery. The bladder should
encircle at least 80% of the arm (but not
more than 100%)
Follow direction for taking a blood pressure
manually or electronically as per
appendices 1 or 2
Lying down, rested measurement. For
initial measurement test blood pressure in
both arms and use arm with highest
reading for subsequent measurements.
Repeat three times record measurement as
displayed.
the procedure and gives his/her valid
consent.
To minimize the risk of infection
To ensure an accurate reading is
obtained.
To obtain a correct reading
To ensure an accurate reading is
obtained.
To use the most suitable device for the
patient and ensure an accurate reading
is obtained
To ensure an accurate reading is
obtained.
To prevent an inaccurate reading due to
pressure being exerted on the brachial
artery by the cuff
To ensure an accurate reading is
obtained.
Two or more readings are often taken to
represent a normal blood pressure
Taking more than one reading can
reduce anxiety and provide a more
accurate reading
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 17 of 23
10
11
12
13
14
15
16
17
18
19
20
21
Then measure again in the standing
position as per the regime below. If unable
to stand use whatever support, standing
aids or equipment is necessary. If still
unable to stand, or if intolerant of standing,
a sitting BP can be used as a rough
surrogate provided legs dangling and body
as close to vertical as possible and that this
is position this is documented
If any concerns for example if unable to
obtain a reading, accuracy of reading in
doubt, large differences in the readings
obtained, ensure a manual reading has
been attempted, seek advice as
appropriate
The blood pressure is recorded with the
arm supported at heart level:
a) Immediately on standing/upright
b) After 1 minutes standing/upright
c) After 3 minutes standing/upright
d) After 5 minutes standing/upright
Document the blood pressure
measurements at each position – ensure
the blood pressure measurement and
patient position are both recorded
To determine whether the patients’ blood
pressure drops from lying to standing
Record the time of the day that the
recordings were taken, in particular with
reference to recent meals and caffeine
consumption.
Record any symptoms that the patient
complains of; dizziness, light-headedness,
loss of balance, weakness, syncope or
fainting.
NB: A clinically significant drop in blood
pressure is classified as 20mmHg systolic
or 10mmHg diastolic.
If the patient has severe symptoms then
stop the measurement and lie the patient
back down until the symptoms ease.
Compare with previous readings, if BP
reading is out of patients normal
parameters, take appropriate action
To highlight times of greatest risk
Document in patient’s record, document
which arm was used, the patients position
as above, any irregularities and actions
taken
Ensure patient and blood pressure
measurements are available and reviewed
by medical teams or specialist teams as
appropriate
Remove equipment and clean after use
To determine risk of postural
hypotension and risk of falling on
standing
To influence care diagnosis and
treatment choices
To ensure accurate and validated
readings are obtained
To ensure electronic readings are
verified by a manual reading
To ensure patient safety
To determine whether the patients’ blood
pressure drops from lying to standing
and any time difference for the drop
To highlight changes in blood pressure
measurements
To highlight risk, influence care
To influence treatment
To ensure patient safety
Trends often show correct readings,
when to repeat a blood pressure
measurement and when to call for
assistance
To ensure adequate record keeping,
establish an audit trail and enable good
communication and continued care of
patient
To influence care, diagnosis and
treatment
Minimize the risk of infection
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 18 of 23
Appendix 4
(Page 2 of 2)
Illustrated Guide to Demonstrate Taking a LYING AND STANDING Blood Pressure Measurement using a Manual Blood Pressure
Monitor. NB: A systolic blood pressure fall by 20mmHg or more on standing is recognised as clinically significant
1
Check equipment is in
working order and clean
Cuff sizes available
Other observation
equipment present
7
Attach machine lead to
cuff
2
Decontaminate hands as
per protocol
Identify patient
Dependent on condition
perform A – E assessment
Explain procedure
Gain consent
8
Confirm patient has been
lying down for at least 5
minutes
Position arm at level of
heart
3
4
5
Ensure no contraindication
Palpate brachial artery
Line cuff artery marker up
with brachial artery
9
10
11
Palpate the brachial artery
Warn patient of cuff
becoming tight. Inflate
cuff to 30mmHg above the
estimated systolic level.
Place stethoscope
diaphragm over the artery
and deflate the cuff at a
rate of 2-3mm/sec.
Measure systolic (first
sound) and diastolic
(disappearance) to nearest
2mmHg
Leave the cuff in position.
With 2 members of staff
supporting, stand the
patient and repeat the
measurement
Select appropriate cuff
size for patient
Barrier nursed patients to
have single patient use
cuff
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 19 of 23
Clean equipment
Decontaminate hands
6
Ensure artery marker fits
within cuff ranger /
parameter markers
12
Document findings on
PICS, ensure both
readings and all
observation completed are
recorded to allow SEWS
score to be produced
Appendix 5
Selection of cuff size
The Welch Allyn medical devices are the portable BP recorders most often used in the trust.
When using an automated blood pressure recorder the patient should have the cuff
correctly sized prior to use (as stated in 5.2)
To ensure the cuff is correctly sized, the artery index marker on the cuff should be placed
over the brachial artery, this line should then be within the range markings on the cuff when
wrapped round the arm (see below).
If the index marker is outside the range then a smaller or larger cuff should then be used. A
range of cuff sizes should be kept with the BP monitor.
Cuff size section:
Indication
Width
(cm)*=
Length (cm)*=
Small Adult/Child
Standard Adult
Large Adult
Adult Thigh Cuff**
10-12
12-13
12-16
20
18 - 24
23 - 35
35 - 40
42
BHS Guidelines
Bladder width &
length (cms)*
12 x 18
12 x 26
12 x 40
< 53
Arm circ (cm)*
< 23
< 33
< 50
*The range for columns 2 and 3 are derived from recommendations from the British Hypertension Society
(BHS), European Hypertension Society (ESH) and American Heart Association. Columns 4 and 5 are derived
from only the BHS guidelines.
** Large bladders for arm circumferences over 42 cm may be required
*Bladders of varying sizes are available so a range is provided for each indication (applies to columns 2 and
3)
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 20 of 23
Leg Blood Pressure Measurement Poster
Appendix 6
Reproduced by kind permission of Amira Omid 2015
NB: subsequent meta-analysis (in progress) is demonstrating that leg systolic BP can be at least 15mmHg higher than arm
readings and this should be taken into account to guide treatment. Systemic review and meta-analysis due to be
completed end 2016 and these recommendations may change in line with findings.
(Obeid, Pucci, Sheppard & Martin 2015)
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 21 of 23
Appendix 7
Assessment Criteria
Blood Pressure and Pulse Oximeter Competency Checklist including
Vital Signs monitor (Generic form)
ASSESSMENT CRITERIA
Do you know how to / can you describe:
1.The reasons for taking a Blood Pressure and
the limb(s) to use
2. The factors that affect taking accurate blood
pressure readings
3.The preparation of the patient prior to taking a
BP reading
4.The care of the patient during the blood
pressure reading
5.How to document the measurement and when
to ask for assistance
6. The pre-use safety checks that should be
made on this device
7 Correctly charge the monitor’s battery and
store accessories ready for clinical use
8 Switch on the monitor and understand the
self-check that the monitor performs
9 Check cuff for wear and tear & demonstrate
correct alignment to Brachial Artery /Posterior
Tibial (Ankle) Artery of the blood pressure cuff
on the patient
10 Why selecting the correct cuff size is so
important in obtaining accurate readings
11 Obtain a single blood pressure reading and
describe what is happening
12 Stop a blood pressure determination
13 Set a 15-minute automatic blood pressure
cycle
14.Apply the Sp02 sensor and describe what is
displayed on the monitor
15.Silence Sp02 alarm when sensor is removed
16.Correctly respond to alarms/ error codes
17.Access alarm menu and alter alarm values
18.Review previous readings if required
19.Cleaning and infection control procedures
20.Who to report to if the device is faulty
RECOMMENDED ANSWER / ACTION
3 reasons stated for taking a blood pressure
measurement
Reasons to choose limb, how many readings to take,
reasons not to choose limb
Position of patient. Importance of placement of heart,
cuff and limb in relationship to each other
Situations when a manual BP machine should be used
i.e. clinical conditions such as atrial fibrillation,
orthostatic hypertension
Verbal consent. Correct preparation may include
position of patient, patient rested, removing tight
clothing, maintaining dignity
Being aware of reason for taking BP, for example if
taking lying and standing risk of fainting Requesting
patient to avoid talking whilst reading is taking place
Accurately document reading and any relevant
additional information on PICs or Portal. Request
assistance when for example there is an unusual
reading for patient
Check that the device is clean
Check for cracks or visible damage
Check EBME labels & Trust asset tag
Check that Electrical safety service tag is in date
Ensure it is connected to power supply/ battery is
charged
Device must be charged when not in use. Accessories
should be stored in the monitor basket
Switch on device using the power button or ON/OFF
button
Cuffs must be placed with artery index marker correctly
lined up
The use on an incorrect cuff size can give a higher or
lower blood pressure reading. Select the correct cuff
size using the range markings on the cuff as a guide
Press the start/stop button to initiate a reading
Press the start/stop button
Correctly select a 15-minute automatic blood pressure
cycle
Correctly apply the Sp02 sensor which is used to
determine Oxygen saturation in the blood
Pulse readings must be determined manually
Silence the alarm using the alarm silence button
Read alarm messages or codes and refer to quick
reference guides attached to the device/ manual and
respond appropriately
Access alarm menu and alter alarm values
Use the memory or review button
Clean using detergent wipes
Medical Engineering Department (EBME)
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 22 of 23
Appendix 8
Competence is undertaken by assessment against the following statements:
Self-Verification for all Registered Staff:
On an initial assessment you must be able to answer “yes” to all the questions before considering yourself to be competent.
For all Non Registered Staff:
You must be able to answer “yes” to all the questions except for those marked as not applicable (N/A).
Please note that you are not permitted to self-verify, your form must be countersigned by a registered member of staff.
Vital Signs Monitor (Generic form) Questions to ask yourself: Assessment date:
ARE YOU COMPETENT TO TAKE A BP? Do you know how to / can you describe:
1.The reasons for taking a Blood Pressure and the limb to use
2.The factors that affect taking accurate blood pressure readings
3.The preparation of the patient prior to taking a BP reading
4.The care of the patient during the blood pressure reading
5.How to document the measurement and when to ask for assistance
6. The pre-use safety checks that should be made on this device
7 Charge the monitor’s battery and store accessories ready for clinical use
8 Switch on the monitor and understand the self-check that the monitor performs
9 Check cuff for wear and tear & demonstrate correct alignment to Brachial Artery /
Posterior Tibial (Ankle) Artery of the blood pressure cuff on the patient
10 Why selecting the correct cuff size is so important in obtaining accurate readings
11 Obtain a single blood pressure reading and describe what is happening
12 Stop a blood pressure determination
13 Set a 15-minute automatic blood pressure cycle
14 Apply the Sp02 sensor and describe what is displayed on the monitor
15 Silence Sp02 alarm when sensor is removed
16.Correctly respond to alarms/ error codes
Registered
Non-Registered
Circle below
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
N/A
Yes / No
Yes / No
Yes / No
Yes / No
N/A
N/A
17.Access alarm menu and alter alarm values
Yes / No
N/A
18.Review previous readings if required
Yes / No
19.Cleaning and infection control procedures
Yes / No
Yes / No
20.Who to report to if the device is faulty
Yes / No
Yes / No
Registered Staff:
Statement: Having answered “yes” to all the questions above and taken into account my personal assessment of my
competence with the device, as required by my grade I declare that: I am competent to use this device without further
training
Print Name: …………………………………………. Signature: ………………………………….. No: …………………….
Designation: ………………………………… Band: ……… Clinical Area: ……………… Date: ……………
Non-Registered Staff:
Statement: Having answered “yes” to all the questions above and taken into account my personal assessment of my
competence with the device, as required by my grade I declare that: I am competent to use this device without further
training
Print Name: …………………………………………. Signature: ………………………………….. No: ……………………
Designation: ………………………………… Band: ……… Clinical Area: ……………… Date: …………..
Counter signed by: Print Name: …………………………….. Signature: …………………………….
Designation: ………………………………… Band: ……… Clinical Area: ……………… Date: ……………
If competence not achieved:
If you are in any doubt regarding your competence to use the device, you should seek education to bring about
improvement and then repeat assessment. Seek education from either self-directed learning, coaching & formal training
with medical devices core trainer/link nurse, colleagues or the Medical Devices Trainers.
Plan for meeting learning needs: …………………………………………………………………………………
……………………………………………………………………………………………………………………………
Date to be achieved by: ………………….
Print Name: …………………………………………. Signature: …………………………………..
Designation: ………………………………… Band: ……… Clinical Area: ……………… Date: ……………
Once completed return to your Clinical Core Trainer
Clinical Guidelines for taking a non-invasive blood pressure (BP) measurement V1 Page 23 of 23