The nurse is unable to palpate the right radial pulse on a patient. the best action would be to:

ALERT

If unable to palpate an artery because of a weakened pulse, use an ultrasonic stethoscope (Figure 1).

OVERVIEW

Blood pressure (BP) is the force exerted by blood against the vessel walls. During a normal cardiac cycle, BP reaches a peak, followed by a trough. The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta. When the ventricles relax, the blood remaining in the arteries exerts a trough, or diastolic, pressure against the arterial wall. Diastolic pressure is the minimum pressure exerted against the arterial wall.

Patients at risk for alterations in BP measurement include those who have:

• Circulatory shock (hypovolemic, septic, cardiogenic, or neurogenic)
• Acute or chronic pain
• Rapid IV infusion of fluids or blood products
• Increased intracranial pressure
• Postoperative status
• Preeclampsia of pregnancy

The standard unit for measuring BP is millimeters of mercury (mm Hg). The measurement indicates the height to which the BP can sustain the column of mercury.

The most common methods for measuring BP are auscultation using a sphygmomanometer and a stethoscope and measurement using an electronic BP monitor. Palpation may be used to obtain an estimate of systolic BP before using the auscultation method.

During auscultation, as the sphygmomanometer cuff is deflated, five different sounds, called Korotkoff sounds, are heard over the artery. Each sound has a distinct characteristic (Figure 2). BP is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound). The difference between systolic pressure and diastolic pressure is the pulse pressure. For a BP of 120/80 mm Hg, the pulse pressure is 40 mm Hg, the difference between 120 mm Hg and 80 mm Hg.

Cuff size should be proportionate to the limb circumference. Most adults require a large adult cuff. An improper-size cuff produces an inaccurate BP measurement. Studies show that using a cuff that is too narrow results in an overestimation of BP, whereas using a cuff that is too wide results in an underestimation of BP.undefined#ref1">1

When measuring BP in the upper arm is not possible—for example, when the available BP cuffs do not fit the upper arm properly—BP may be measured in the forearm. To obtain the most accurate reading, the nurse must use the proper size BP cuff for the forearm, which typically has a smaller circumference than the upper arm. BP measurements in the forearm and upper arm are not interchangeable. Systolic blood pressure readings tend to be higher in more distal arteries, such as those in the forearm, whereas diastolic blood pressure readings tend to be lower in more distal arteries.6,8 The thigh or calf can be used if measurement of the upper arms and forearms is not possible.1

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the equipment and the procedure to the patient and family.
• Instruct the patient and family about ambulatory BP threshold guidelines. In adults, normal BP is less than 120/803,4 mm Hg for daytime monitoring (Table 1).
• Educate the patient and family about the risk factors for hypertension.
• Family history of hypertension, premature heart disease, lipidemia, or renal disease
• Obesity
• Cigarette smoking
• Heavy alcohol consumption
• High blood cholesterol and triglyceride levels
• Prolonged stress from psychosocial and environmental factors
• Sedentary lifestyle
• Educate the patient and family regarding the primary strategies for preventing hypertension.2
• Managing weight
• Engaging in daily exercise
• Limiting sodium and saturated fat in the diet
• Maintaining adequate intake of dietary potassium and calcium
• Taking medication as prescribed
• Limiting alcohol intake
• Avoiding tobacco products
• Instruct the patient and family to ensure that the patient has adequate rest before BP measurements and that BP measurements are performed at the same time each day using the same limb with the patient in the same position, either sitting or lying down.
• Explain that the patient must remain still and quiet during the procedure.
• Explain that Korotkoff sounds may be difficult to hear for one of the following reasons (Table 2).
• Cuff is too loose, not big enough, or too narrow.
• Stethoscope is not over the arterial pulse.
• Cuff is deflated too quickly or too slowly.
• Cuff is not pumped high enough for systolic readings.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Review the patient’s medical record for a history of cardiovascular disease, renal disease, diabetes, and other factors that may influence BP (e.g., weight, smoking, medications).
5. Assess the patient for risk factors for BP alterations.
1. Circulatory shock (hypovolemic, septic, cardiogenic, or neurogenic)
2. Acute or chronic pain
3. Rapid IV infusion of fluids or blood products
4. Increased intracranial pressure
5. Postoperative status
6. Preeclampsia of pregnancy
6. Assess the patient for signs and symptoms of BP alterations.
1. Assess a patient at risk for high BP for the following signs and symptoms.
1. Headache (usually occipital)
2. Facial flushing
3. Nosebleed
4. Fatigue
2. Assess a patient at risk for low BP for the following signs and symptoms.
1. Dizziness
2. Mental confusion
3. Restlessness
4. Pale, dusky, or cyanotic skin and mucous membranes
5. Cool, mottled skin over the extremities
7. Determine the best site for BP assessment. Consider using the lower extremity if the brachial arteries are inaccessible (Figure 3). Avoid applying the cuff to an extremity when:
1. IV fluids are infusing.
2. An arteriovenous shunt or fistula is present.
3. Ipsilateral breast or axillary surgery has been performed.
4. The extremity has been traumatized.
5. The extremity has known infections or medical conditions (e.g., those causing vasoconstriction or a tumor pressing on the vascular supply).
6. The extremity has a cast or bulky bandage.
8. Determine the previous baseline BP and site, if available, from the patient's record.

Preparation

1. Make sure the patient has not exercised, ingested caffeine, or smoked immediately before BP assessment.4 Make sure the patient does not have to void.

Rationale: The urge to void can significantly increase BP.5

2. Make sure the room is warm.

Rationale: Exposure to cold can significantly increase systolic BP.5

3. Measure the extremity circumference and select the appropriate-size cuff (Figure 4).

Rationale: Proper cuff size is necessary for an accurate reading. The cuff must be wide and long enough to allow for the size of the arm or thigh. Narrow cuffs can cause an artificially high reading.

4. Tell the patient that BP will be taken and that the cuff will squeeze the arm or leg.

PROCEDURE

1. Perform hand hygiene. Don additional appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Have the patient sit or lie down. Record the patient’s position when performing orthostatic vital signs. If sitting, ensure the patient’s back is supported.5

   Rationale: BP is generally higher in the supine position than the sitting position.5

5. If using the upper arm or forearm:
1. Position the patient's arm, supported, at heart level with the palm facing up (Figure 5).
2. If sitting, instruct the patient to keep the feet flat on the floor with the legs uncrossed.

Rationale: If the patient's arm is not supported at the heart level, a lower BP will be recorded when the arm is above heart level, and a higher BP will be recorded when the arm is below heart level.1 Leg crossing can increase systolic and diastolic BP.

3. If supine, ensure that the patient’s legs are not crossed.

Rationale: Leg crossing can falsely increase systolic and diastolic BP.

6. If using the leg:
1. Assist the patient to a prone position.
2. If unable to assume a prone position, assist the patient to a supine position with the knee slightly flexed.

Rationale: The prone position provides the best access to the popliteal artery. Leg crossing can falsely increase systolic and diastolic BP.

3. Ask the patient not to cross the legs.

Rationale: Leg crossing can result in an increased systolic and diastolic BP.

7. Expose the patient's arm or leg fully by removing any constricting clothing. Do not place the BP cuff over clothing.

Rationale: Placing the cuff over clothing may affect the BP measurement.

8. Apply the BP cuff to the patient's arm or leg.
1. Upper arm
1. Palpate the brachial artery for a pulse (Figure 6).
2. Position the cuff above the antecubital fossa.
3. Apply the cuff by centering the arrows marked on the cuff over the brachial artery so that the end of the cuff is 2 to 3 cm (about 1 inch) above the antecubital fossa to allow room for placement of the stethoscope (Figure 7).1 If the cuff has no center arrows, estimate the center of the bladder and place it over the artery.

Rationale: Positioning the cuff bladder directly over the brachial artery ensures that proper pressure is applied during inflation.

4. Wrap the fully deflated cuff evenly and snugly around the patient's upper arm (Figure 7).

Rationale: A loose-fitting cuff can cause an artificially high reading.

2. Forearm
1. Palpate the radial artery for a pulse.
2. Position the cuff below the antecubital fossa.
3. Apply the cuff by centering arrows marked on the cuff over the radial artery with the top edge of the cuff positioned 2 to 3 cm (about 1 inch) below the antecubital fossa.6,8 If the cuff has no center arrows, estimate the center of the bladder and place it over the artery.

Rationale: Positioning the cuff bladder directly over the radial artery ensures that proper pressure is applied during inflation.

4. Wrap the fully deflated cuff evenly and snugly around the patient's forearm.

Rationale: A loose-fitting cuff can cause an artificially high reading.

3. Thigh
1. Palpate the popliteal artery for a pulse.
2. Position the cuff over the lower third of the patient's thigh.1
3. Apply the cuff by centering the arrows marked on the cuff over the popliteal artery so that the lower edge of the cuff is 2 to 3 cm (about 1 inch) above the popliteal fossa to allow room for placement of the stethoscope.1 If the cuff has no center arrows, estimate the center of the bladder and place it over the artery (Figure 3).

Rationale: Positioning the cuff bladder directly over the popliteal artery ensures that proper pressure is applied during inflation.

4. Wrap the fully deflated cuff evenly and snugly around the patient's thigh.

Rationale: A loose-fitting cuff causes false-high readings.

4. Calf
1. Palpate the dorsalis pedis or posterior tibial artery for a pulse.
2. Position the cuff over the lower half of the patient's calf.1
3. Apply the cuff so that the lower edge of the cuff is 2 to 3 cm (about 1 inch) above the malleoli.1
4. Wrap the fully deflated cuff evenly and snugly around the patient's calf.

Rationale: A loose-fitting cuff can cause an artificially high reading.

9. Position the manometer vertically at eye level.

Rationale: Looking up or down at the scale can result in a distorted, incorrect reading.

10. Ask the patient not to speak while BP is being measured.
11. Locate and continually palpate the brachial artery (upper arm BP), radial artery (forearm BP), popliteal artery (thigh BP), or dorsalis pedis or posterior tibial artery (calf BP) with the fingertips of one hand (Figure 6).
12. Palpate the artery distal to the cuff with the fingertips of the nondominant hand while inflating the cuff rapidly to a pressure above the point at which the pulse disappears.
13. Slowly release the pressure bulb valve, allowing the manometer needle to fall slowly and continuously at a rate of 2 to 3 mm Hg per second.5
14. Note the point on the manometer at which the pulse reappears. This point is the palpated estimate of systolic BP.

Rationale: Too rapid or slow a decline in the mercury level causes inaccurate readings.

15. Deflate the cuff fully and wait a short amount of time.

Rationale: The estimate of systolic BP determines the maximum inflation point for an accurate reading by palpation. Completely deflating the cuff prevents venous congestion and false-high measurements.

If unable to palpate the artery because of a weakened pulse, use an ultrasonic stethoscope.

16. Remove the cuff from the patient's arm or leg unless a repeat measurement is needed.

Rationale: Continuous cuff inflation can cause arterial occlusion, resulting in numbness and tingling of the arm or leg.

17. If this is the patient's first BP assessment, repeat the procedure on the other arm or leg. If there is a consistent difference between the BP in the patient's arms, use the arm or leg with the higher pressure.1

Rationale: Comparison of BP in both arms or legs helps detect cardiovascular, neurologic, and musculoskeletal abnormalities. A normal difference of up to 10 mm Hg may exist between arms.1

18. Help the patient resume a comfortable position and return any removed clothing. Inform the patient of the blood pressure reading, as appropriate.
19. Report abnormal values to the practitioner (Table 1).
20. Clean the BP cuff per the manufacturer’s instructions and the organization’s practice. Return the equipment to its assigned storage space.
21. Discard supplies, remove any PPE, and perform hand hygiene.
22. Document the procedure in the patient's record.

MONITORING AND CARE

1. If assessing BP for the first time, establish the BP reading as the baseline if it is within the acceptable range.
2. Compare the BP reading with the patient's previous baseline and the usual BP for the patient's age.
3. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

• BP is within acceptable range for patient's age and body size.
• Patient tolerates procedure.

UNEXPECTED OUTCOMES

• BP is above acceptable range.
• BP is below acceptable range or insufficient for adequate perfusion and oxygenation of tissues.
• BP reading cannot be obtained.
• Patient experiences orthostatic hypotension.
• A significant difference exists between left arm and right arm BP readings or between left leg and right leg BP readings.

DOCUMENTATION

• BP measurement
• Method
• Site assessed and patient's position
• Pain assessment and management
• Abnormal findings
• BP measurement after administration of specific therapies
• Signs and symptoms of BP alterations
• Unexpected outcomes and related interventions
• Education

PEDIATRIC CONSIDERATIONS

• BP measurement is not a routine part of assessment in children younger than 3 years of age.7
• The right arm is preferred for BP measurements in children for consistency and comparison with standardized BP measurement tables for age and weight.9 If coarctation of the aorta is suspected, a BP measurement obtained in the left arm may be low.9 Thigh BP measurement is uncomfortable for children.9
• BP measurement may frighten children. Prepare a child for the squeezing feeling of an inflated BP cuff by comparing the sensation to an elastic band on a finger or a tight hug on the arm.
• Measure the child's BP before performing anxiety-producing tests or procedures.
• Assess the BP level of a child or adolescent with respect to body size and age.
  • Heavier and taller children have a higher BP than smaller children of the same age.
  • During adolescence, BP continues to vary according to body size.
  • The normal range for 10- to 17-year-old patients at the 90th percentile for weight is systolic 124 to 136 mm Hg and diastolic 77 to 84 mm Hg for males and systolic 124 to 127 mm Hg and diastolic 63 to 74 mm Hg for females.9
• Korotkoff sounds are difficult to hear in children because of the low frequency and amplitude. A pediatric stethoscope bell is often helpful.
• Though the beginning of the fifth Korotkoff sound indicates diastolic pressure in adults, the fourth Korotkoff (distinct muffling) indicates diastolic pressure in children.

OLDER ADULT CONSIDERATIONS

• Older adults, especially frail older adults, typically have lost upper arm mass, requiring special attention to BP cuff size.
• The skin of older adults is more fragile and susceptible to damage from cuff pressure when BP measurements are frequent. More frequent assessment of the skin under the cuff or rotation of BP sites is recommended.
• Older adults have increased systolic pressure because of decreased vessel elasticity.
• Older adults often experience a fall in BP after eating.
• Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries.

HOME CARE CONSIDERATIONS

• Assess the home noise level to determine the room that provides the quietest environment for BP measurement.
• Teach the patient the importance of using an appropriate-size BP cuff for home BP measurement.
• Assess the family's ability to afford a sphygmomanometer for performing BP evaluations on a regular basis. Recommend electronic devices or aneroid sphygmomanometers that have proven to be accurate according to standard testing as well as appropriate-size cuffs.

REFERENCES

1. American Association of Critical-Care Nurses (AACN). (2016). AACN practice alert: Obtaining accurate noninvasive blood pressure measurements in adults. Critical Care Nurse, 36(3), e12-e16. doi:10.4037/ccn2016590 (Level VII)
2. American Heart Association (AHA). (2017). Changes you can make to manage high blood pressure. Retrieved April 15, 2021, from https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure
3. American Heart Association (AHA). (2017). Monitoring your blood pressure at home. Retrieved April 15, 2021, from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home#.Wuct7ExFwy9
4. American Heart Association (AHA). (2021). Understanding blood pressure readings. Retrieved April 15, 2021, from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings#.Wucr9UxFwy9
5. Kallioinen, N. and others. (2017). Sources of inaccuracy in the measurement of adult patient’s resting blood pressure in clinical settings: A systematic review. Journal of Hypertension, 35(3), 421-441. doi:10.1097/HJH.0000000000001197 (Level I)
6. Muntner, P. and others. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. doi:10.1161/HYP.0000000000000087 (Level VII)
7. National Heart, Lung, and Blood Institute (NHLBI). (2012). Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Retrieved April 15, 2021, from https://www.nhlbi.nih.gov/files/docs/peds_guidelines_sum.pdf (classic reference)* (Level VII)
8. Pickering, T. and others. (2004). Recommendations for blood pressure measurement in humans and experimental animals. Part 1: Blood pressure measurement in humans: A statement for professionals from the subcommittee of professional and public education of the American Heart Association Council on high blood pressure research. (classic reference)* Retrieved on April 8, 2021 from https://www.ahajournals.org/doi/full/10.1161/01.HYP.0000150859.47929.8e (Level VII)
9. Schroeder, M.L., Delaney, A., Baker A. (2019). Chapter 27: The child with cardiovascular dysfunction. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s nursing care of infants and children (11th ed., pp. 958-1018). St. Louis: Elsevier.

ADDITIONAL READINGS

American Heart Association (AHA). (2017). What is high blood pressure? Retrieved April 15, 2021, from https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about- high-blood-pressure/what-is-high-blood-pressure (Level VII)

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Adapted from Perry, A.G. and others (Eds.). (2022). Clinical nursing skills & techniques (10th ed.). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

What should the nurse do if unable to palpate a peripheral pulse?

Which action should the nurse perform after identifying a pulse deficit?

When assessing the force of a radial pulse the nurse documents a weak?

How do you palpate a radial pulse?