Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 86: Improving Accuracy with Blood Pressure Measurement
Want some tips to improve the accuracy of your blood pressure technique? I’ve got you covered. It all starts with a manual cuff, the obliteration technique and a few simple setup tips.
Join me in this episode as we break down the step-by-step technique of improving accuracy with blood pressure measurements.
In this episode:
- Set up considerations prior to taking BP
- Importance of cuff size
- Positioning with BP measurements
- How to perform the obliteration technique
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Welcome to Talking All Things Cardiopulm. I am your host, r Rachele Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is brought to you by Jane, a clinic management software and EMR. As a clinic owner, your main priority should be caring for your patients, not worrying about rising EMR costs. That's why Jane has come up with a new balance plan which includes essential features. You need to run your clinic without any of the extra stuff you don't. With the balance plan, you'll get really helpful features like one-on-one telehealth, email, appointment reminders and unlimited customer support. It's a great fit for new or growing practitioners who are booking up to about 20 appointments a month, and the best part is that Jane pays for itself with the cost of just one appointment. So head over to janeapp backslash pricing to check out their plan, starting at just $39 a month. And if you're ready to get started, don't forget to use CARDIOPULM1MO code at the time of signup for a one-month grace period applied to your new account. Thanks again, jane. All right, welcome back.
Rachele Burriesci:This is Thanksgiving week, had a super busy weekend and before I get into I don't know life updates I guess it is a life update I want to send a shout out to my sister and anyone who lives in the New York, new Jersey, area heads up. My sister just opened Toastique in Ridgewood, new Jersey. I am super proud of her. So if you're out in that area it's right across from the railroad station go check out Toastique, give her a big hello and congrats and support her business. I am so, so proud of my sister. You know, starting a new business, starting a new venture, changing gears in your career, is such a huge endeavor and I think it can't be overlooked. And if anyone could do something like this, it's definitely her. So I just want to put all the good energy, all the good juju and abundance her way. And again, if you're in the area, go check it out. It is an awesome place, healthy options and plenty to choose from. So Tostique Ridgewood, new Jersey just opened this past weekend. Go support it, give a shout out, say hello to my sister Laura and send good juju her way. All right, what else?
Rachele Burriesci:I feel like holidays are always these like crazy times in the sense of like trying to get things done. And it's all of a sudden here and I know I've been saying it all year but this year is just like everything feels fast this year and I'm not really sure why. I don't know if it's a me thing, I don't know if it's just. You know, people say as you get older, things feel like they move faster. So it might be a little bit of both or just trying to do you know too many different things in a short period of time. So patio's done. We're almost complete with the area around it. I am hoping maybe today I can get it covered in and in a safe position. And the reason why I say that is because I bid it so hard this week.
Rachele Burriesci:How I did not hurt myself is complete luck and how I stepped off the curb is also completely mind blowing. So Nikki and I were home. We were trying to get yard work done. This week we kind of split tasks front and back of the yard and I was pushing the mower like I have a million times and literally stepped off the whole sidewalk. And because we're building a trench to kind of trench the lines. I literally slid down a two-foot hole, didn't drop the mower, just FYI. I did not let go of the mower and my first thought after I hit the ground was did I crack the cement? I don't know. I think it's something that has been instilled in me since I was younger. I remember like falling off my bike and ripping my jeans and thinking, oh God, I have to go home with my ripped jeans and instead of being worried about actually being injured, I was worried about the clothing that I had to now explain. Explain what happened here. Anyway, all's good. All's good in the world.
Rachele Burriesci:Christmas. Christmas lights are starting to go up, piece by piece, trying to get it done before the weather gets too cold. Prepping for Thanksgiving this week we typically host, so super excited for that, thanksgiving holds a very special place in my heart. It reminds me of my grandmother. I feel her cooking with me every Thanksgiving. So I 100% enjoy this holiday and everything that is kind of built around it in the world of being with your family and giving thanks and being grateful for that day. So it's one of my favorite holidays. I like to enjoy the food, enjoy the people and not have to worry so much about the gift aspect of it.
Rachele Burriesci:All right, let's jump into today's episode. I've been kind of sitting with this one for a while. I actually thought I've already done this podcast but looking back I had not. So I wanted to jump in and kind of just talk about some things that we can do to help improve accuracy with blood pressure, and one of the things that kind of brought this back up for me was a new client that I have. I always check blood pressure prior to our session and on eval, especially if I'm in person, I'm doing a manual blood pressure. So I think a lot of people are sometimes surprised by that. I feel like automatic cuffs are becoming more and more common, even in your primary care setting, although I feel like that is the one place that people still take a manual cuff or a manual blood pressure, I should say. So I think it's interesting when people are surprised by it, and I also feel sometimes I have to kind of preface what I'm doing when I'm taking the blood pressure.
Rachele Burriesci:So I use something called an obliteration technique, and the obliteration technique is one of those ways to help improve accuracy with your blood pressure measurement and essentially what you're doing is finding out the point of radial obliteration to help determine how high you should pump up the blood pressure cuff to take a more accurate reading. And what this does is it helps prevent over-inflating the cuff when taking the blood pressure, which is more comfortable for the patient and also can help prevent error in measurement. So let's talk about the obliteration technique first, and then I'll jump into some other things that can help improve accuracy in general. So we're going to talk specifically about manual blood pressure today and I think I'm going to do a follow-up podcast on automatic cuffs, because I would be lying to you to say I never use it and that is absolutely false. I 100% use automatic blood pressure machines in the hospital setting. It is more easily available, it is common practice and I feel like we have to discuss both and there are pros and cons to both, and I can argue both sides like I typically do.
Rachele Burriesci:So let's talk about the manual blood pressure technique and, specifically, we'll talk a little bit about the obliteration technique. So, first of all, sometimes people ask like should you take it on your left or should you take it on the right arm? So, right off the bat, you're supposed to take it on both arms, especially if it's the first time you're meeting a patient and what you want to do is assess, side to side, how close are your measurements, and essentially you're going to take the higher of the two measurements and then you're going to stick to that arm. So, for example purposes, if my left arm was 10 millimeters of mercury higher than my right, I'm going to take the measurement of my left side and I'm going to stick to the left side for accuracy over time. The other thing, before even getting started, is prepping the person's position, and even starting with something as simple as choosing the appropriate blood pressure cuff size is so important. I made such a big deal about this when I was teaching in academia because I feel like if we don't instill the basics early, we can lose them later on.
Rachele Burriesci:Using the right blood pressure cuff is very important to accuracy in blood pressure measurements. So before you're even getting your patient into a position using an obliteration technique, choosing a manual versus automatic machine, it starts with choosing the right size cuff. If your cuff is too small and it doesn't fit around the patient's arm appropriately, you're going to have an erroneously high measurement due to the tightness of the actual cuff. If your cuff is too large and doesn't fit appropriately, you are likely going to have an erroneously low blood pressure measurement. So blood pressure measurement or blood pressure cuff size, is so important and I think it's one of the simplest things you can do.
Rachele Burriesci:The way that you assess arm cuff size is by using a tape measure and basically measuring the circumference around mid bicep, so the midpoint between the acromion and the olecranon, and that measurement, either in inches or centimeters, is going to correlate to your cuff size and most blood, most blood pressure cuffs will have the size on the actual cuff itself, the bladder, and if not, there is typically a chart that gives the range between child size, small, adult, standard, large, adult and then adult thigh size and it's super important to be close in that measurement. Too big of a cuff you're going to get a low measurement. Too small of a cuff you're going to get a high measurement. So it starts with simply choosing the right cuff and you can get good at eyeballing the correct cuff size. But if you're having someone who's having some really odd measurements and you're not really sure you're kind of in between cuff sizes, go ahead and take a measurement, reflect back to that chart and pick a size that's going to be appropriate for that patient because it's going to give you better accuracy long-term. Something super simple that can make a big difference. The other piece to cuff size is the length of the cuff on the arm as well. So knowing that it's not covering the antecubital fossa is going to be a big part of it, that it's not up in the armpit, making sure that it's an appropriate fit on length as well.
Rachele Burriesci:Cuff inflation how much you're pumping up that cuff can also create erroneous measurements, and so this is where the obliteration technique comes in. If we're over-inflating that cuff we can cause false high, very similar to the tight blood pressure cuff, and if you're under inflating you're just going to miss that top car cough number anyway and just get a completely erroneous number. So super important that we are pumping up high enough, but not pumping up so high that we're causing vasospasm and all kinds of things to basically increase that blood pressure and then you get an erroneously high blood pressure. So cuff inflation can be a very easy technique to help create accuracy, which brings us to the obliteration technique. So when you're performing the obliteration technique, it's a two-step process so it does take a little bit longer but it's going to give better accuracy overall, especially if you're doing something like research and blood pressure measurement is an important piece of that. I would definitely use the obliteration technique. If you have someone who has severe peripheral arterial disease, maybe someone who has AFib with RVR, or maybe someone who's throwing a lot of PVCs or just some weird arrhythmias, a manual cuff is going to be a little bit more accurate for these patients, including ones that are even just very bradycardic less than 60. So this is going to give you a little more accuracy across the board.
Rachele Burriesci:When you're performing the obliteration technique, the first thing that you're going to do is assess the brachial artery. You want to assess the brachial artery, know where you're going to palpate that, place the cuff appropriately not too tight, not too loose. On the cuff there is typically a marker for where the brachial artery line should be, so line that up. If you did not measure the cuff when you place it on, there should be a line to show what's an appropriate fit. If it doesn't close all the way, it's not the appropriate size. That arm should then be placed elevated so that it is equal in height to the height of the right atrium.
Rachele Burriesci:So if the person's in a sitting position. An easy way to do this is to place their arm on a table next to them. In the acute care setting I like to use the tray to do that, just because it gives you, you know, a little bit more freedom with another hand. You can also hold the arm to keep it at that level. In the acute care setting that can be a little more tricky, depending on how much assist the person needs, and I'll talk about that a little bit more when we talk about the automatic cuffs next time. So you have your person in the sitting position. Their feet should be flat on the floor, legs should not be crossed. They should have been sitting for about five minutes resting prior to taking. When you're assessing the blood pressure, the patient is not talking and you are not talking to the patient.
Rachele Burriesci:When you're assessing the obliteration technique, the first thing that you're going to do, after placing the cuff and putting them in the appropriate position, is to palpate the radial artery. So this is a dual task sort of thing. It's a little bit of a coordination and it takes a little practice when you're performing it. So when the person's in the appropriate position, you're going to palpate the radial artery, let's say with your non-dominant hand, and then with your dominant hand you have the pump to inflate the bulb, and so you're going to pump up the cuff while paying attention to the radial artery. You're going to pump until you no longer feel the radial artery and you're going to mark that number. So there's three things that you're doing You're palpating the radial artery, you're pumping up the cuff and you're watching the manometer.
Rachele Burriesci:When you lose palpation of the radial artery, that's your obliteration point. So let's just say, for a reference value, you pump up your palpating and you lose radial artery at 110 millimeters of mercury. What you're going to do with that number A, mark it down. And secondly, you're then going to, when you take the blood pressure, pump up 30 above that number. So if you obliterate it at 110, you're going to pump up to 140 millimeters of mercury. Now that's much less than what you may have done to you in clinic and a primary care type office or if you've ever done it, you know in your practice as well. A lot of people just pump up to 200 and then go down from there. The problem with that is that you can get an erroneously high measurement, and another problem could be that it's not high enough. So the obliteration technique really gives you a little more accuracy as to where that first car cough sound is going to come in.
Rachele Burriesci:Then you follow the typical techniques for taking a blood pressure measurement. So you're going to now on the second go, after taking about a minute rest, place your stethoscope over the brachial artery. Manometer should be at eye level. I teach my students to have the patient hold it up. If not, you can hook it on the cuff and just be at eye level with it. You're then going to pump up to 140. And when you release the valve you're going to be dropping two millimeters of mercury. As you're dropping down, that first sound is your first car cough sound. That's your systolic blood pressure. When you hear that first boom coming in, then you're going to hear a change in sound, a swishing, a pretty loud bang, bang, bang, and then it's going to go away Right when that last sound comes in. That's your diastolic blood pressure. So the point of the obliteration technique is to create a more accurate measurement by not over or under inflating that cuff. Having your feet flat on the ground improves accuracy. Having your legs crossed can increase your blood pressure for about five millimeters of mercury.
Rachele Burriesci:Having your arm supported is very important. I haven't talked about this yet. Your arm should be at the level of the right atrium, whether they're in supine, sitting or standing. This can create a little more difficulty, especially in the acute care setting, if a person needs physical assistance, but you want that arm to be supported and at the appropriate level because, again, you can get an erroneous measurement. If the arm is low, then you can have an erroneously high measurement, and if the arm is high, you can get an erroneously low measurement. It's very similar to a transducer positioning.
Rachele Burriesci:One of the things I see in clinic often, and I have to also remind myself, is a supine measurement. If the person is laying in supine and you place the cuff around their arm, that arm is going to be below the level of the right atrium. So if it's below the level of the atrium, you're going to get an erroneously high measurement. You want to place a pillow under that arm, just a simple little adjustment. That might take a few seconds longer, but it's going to give you a more accurate measurement anyway.
Rachele Burriesci:When your person's in the sitting position, one of two things that you can do is one cradle the arm and then that allows. I usually use my left arm to cradle and then my my left hand is holding the stethoscope over the brachial artery and my right hand is using the valve. Because my dexterity on the right side is much more accurate, I can really drop that two millimeters of mercury a little bit more appropriately In standing. Same is true. Cradling usually is the easiest unless you have a table that can raise and lower, that can adjust to the level of the person. You don't want the person to hold the arm themselves, because that isometric positioning can again create an erroneously false high. So just these little bits of adjustments can make a difference.
Rachele Burriesci:Cuff size very important. Not too big, not too small. Placing the cuff appropriately, not too tight, not too loose. Placing the arm at the level of the right atrium. Again, if you're below heart level you're going to get a false high. If you're above heart level you're going to get a false low. Over or under inflating is going to cause erroneous measurements. This is why we use the obliteration technique so that we don't over or under inflate.
Rachele Burriesci:And then also releasing the valve. You want to release at that steady two millimeters of mercury. If you release too fast you might miss the car cough sounds altogether. If you release too slow you're going to get a false high reading, typically more diastolic than systolic. But it's kind of equivalent to the too tight cuff or the overinflated cuff. So, correct cuff size, correct inflation technique, making sure that your arm is at a good position at right atrium, no over or under inflating the cuff, and then really practicing your release on the valve.
Rachele Burriesci:What I find with people who are students, who are new to taking blood pressure, it's letting go of that valve is probably the biggest things to practice. If you first of all lock it too tight, when you release it it's going to be a little bit of a bear to undo, which then usually leads to releasing really fast and that manometer just plummeting down and then typically you just lose all sound. Making sure that when you tighten that valve it's tight but you can undo it. I usually check it before I go. Another tip I typically give students is to check the valve beforehand. When I did checkoffs one of the biggest things especially with nerves that happen is that the valve isn't closed and the student starts pumping the cuff and the manometer is just kind of fluttering around. It's not actually inflating.
Rachele Burriesci:Check your valve, righty-tighty. Lucy, make sure you understand how you're holding that inflation tube. A lot of people like to hold it upside down and I can't. I don't like that technique because that's going to switch your valve. I always keep the valve on the north side of the pump, of the I'm not using my word right of the inflation bulb Bulb is the word I wanted and I keep the valve on top of it because that's going to keep the valve righty-tighty, lefty-loosey. Some people flip it. I've seen a lot of students do it. I usually encourage against it because that's also going to change the position of your valve and that can throw off your technique if you're not paying attention or you change it up last minute.
Rachele Burriesci:Some other things to consider making sure that we are resting before taking the blood pressure. I didn't mention smoking, eating or exercise. So there should be no smoking, no eating or exercise greater than 30 minutes prior to taking a measurement. Same deal in the acute care setting. You may have come in just after breakfast or lunch. That's a hard one to time In the outpatient clinic you can't really adjust to what patients have done unless you've given them these instructions ahead of time, knowing that you might have some variability in blood pressure. This is also why it's so important to take it more than once, especially if someone's new to you. I typically also ask patients after taking a blood pressure what do you normally run? Do you take your blood pressure at home? Because what they take at, what their blood pressure is at home versus what they're going to be in a clinic might be wildly different. Could be based on time of day, could be based on the level of activity performed before taking that measurement, could be white coat syndrome, could be their machine, right, and so that's another thing that can be discussed, as well, as if your patient does have an automatic machine at home to take it into clinic and do a side-by-side comparison between the two.
Rachele Burriesci:Not talking, I find to be one of the most difficult things in all settings, and sometimes you have to tell the patient you know, don't talk during the measurement, don't talk before the measurement. But from a productivity perspective, right, you're trying to do so many different things at once. This is one of those times where you want to try to encourage just a quiet few minutes prior to taking blood pressure. I have to say, in the acute care setting I don't think I ever get a true five minute break before taking the actual measurement, without any talking or anything like that. I find it nearly impossible to be absolutely honest like that. I find it nearly impossible to be absolutely honest. When I ran cardiac rehab and pulmonary rehab and we would do six minute walk test testing prior to admission to the programs, this was a much easier process, um skill to to hone in on, and it was also a more streamlined process where you could have the patient sitting in the chair at the start of the six minute walk test, where they're not able to talk to anybody else and they're sitting resting and you can put a timer on and really gauge how long they've been resting before taking that first measurement In other settings.
Rachele Burriesci:I think this is the one where likely there has been some form of talking, you know, during before that measurement. The other piece of the talking is what they're talking about. If someone is really amped up about something this actually just happened to me the other day and I had to give the cue all right, let's sit and like, take a few breaths before taking this measurement. That piece had already been done right. The stress was already increased, the sympathetic system's firing, you're going to get a higher measurement. So you have to kind of gauge that along with what you're expecting and I think that's kind of part of all of it. Right, it's one number in time doesn't tell the whole story, it's just a part of the picture and so I think you have to keep that perspective whenever you're taking vitals, whenever you're looking at a lab value.
Rachele Burriesci:One number isn't the whole picture and when we are even thinking about the diagnosis for hypertension, it has to be two separate blood pressures on two separate occasions at the level above stage one or two to be considered true hypertension. So again, one number is not a make or break in any situation. But I do think the more frequently you as a clinician practice the skill, you become more accurate, and also the more frequent you take blood pressure on your clients, the more consistency you can see whether it's time of day, because you're going to see variability in the morning versus afternoon, versus closer to dinner time, versus their own blood pressure measurements, which might be first thing in the morning or right before bed, right, so those variations can have a lot of differences. What their day looked like before coming to you, that's going to play a role. But that five minute rest break should try to be attained. But again, I think the talking and the true five minutes without any sort of interruption is probably where myself have the hardest time sticking to the accuracy perspective. So just something to keep in mind.
Rachele Burriesci:The flat feet, I think is really easy, although I can't tell you how many times. Patients just cross their legs, whether they're in supine or sitting position, like all right, uncross those legs again and it can increase blood pressure. I believe they said about five to eight millimeters of mercury. They did a repeat study on the American Heart Association guidelines for blood pressure taking and I think that was the gauge in change. If legs were crossed Up three to five, five to eight millimeters of mercury for systolic and three to five for diastolic for legs crossed. So those little bits can add up across the board. So those little bits can add up across the board Even having your back not supported. I find this one interesting too. Systolic and diastolic might be increased by 5 to 15 and 6 millimeters mercury respectively. So 5 to 15 to systolic and 6 for diastolic. In the acute care setting your patient is sitting edge of bed. Typically when you're going from supine to sit they're going to have lack of back support. So just another piece to kind of keep in mind, not that it changes much, but that you know that that could create a difference in blood pressure measurement. The last thing is and I've already mentioned it but I want to say it again is make sure that cuff is fitting appropriately.
Rachele Burriesci:One of my I have like a. You have memories of things that like really stick. I was working at my first job at the orthopedic hospital and we had a older, older female patient who just had spine surgery. I want to say she was like 80s and I believe it was something like a two level fusion. It was a smaller surgery. It wasn't like a multi level fusion with multiple hemobacs or anything. It was a relatively small surgery, so to speak. And she was older I want to say 82, something like that but she was like 90 pounds, soaking wet, didn't have a tremendous loss of blood on post-op, but she was trending very low for her blood pressure.
Rachele Burriesci:And I remember going to see this person for evaluation on post-op day one. I want to even say it was like late morning. This person like very much sticks out in my mind. I can even see the room she was in. She's on the 12th floor. She was at the window, the window wall of the two room room because everything had two beds at that time and the nurse was really concerned about me going to evaluate her because her blood pressure was so low, her MAP was low and you know, I'm aware of the situation and I said, well, let me at least just start the conversation. Maybe we can do some bed thorax and assess her blood pressure, maybe try orthostatics of see if she's symptomatic. The whole, you know the whole conversation of that.
Rachele Burriesci:And when I went in the room she had a standard adult cuff on her bedside and I just took one look at her and I was like this cuff is so big for her. So I put it on because that's what they had been using. And I took it and we were using automatic cuffs and it was low it was probably something like eighties, over sixties, something in that ballpark not so low that I was like, oh, she's, she's not going to be able to tolerate anything. So low that I was like, oh, she's not going to be able to tolerate anything. Woman's completely asymptomatic. And I said, you know what, I'll be right back.
Rachele Burriesci:And I went and got a small and a child size cuff, I don't remember which one ended up being in the right size, retook it and she was something like 102 over 70s or something a little bit more manageable, or 98 over 68. And she's asymptomatic. So you know we kept going. She ended up ambulating that day and was fine. So when I gave report to the nurse she was very surprised by the whole situation. It was like her cuff was too big. It was probably an erroneous measurement. I put a child size or a small cuff in the room and she's getting much more appropriate maps, asymptomatic throughout. She was actually very encouraged to get going and we moved on right.
Rachele Burriesci:But this is one of those situations where something so simple size of a blood pressure cuff, something so foundational, something that second nature of like just picking a cuff and going can lead to now this older patient staying in bed for more hours in the day than she needed. So if something is not feeling right, something's not lining up, go back to the foundational pieces. Check the size of the cuff, measure the arm, make sure your blood pressure cuff is calibrated. Do all the techniques where you rest, where you support the arm in the right position, get the feet flat on the ground. Go back to the basics, because sometimes when we get into the groove of things, we start to forget the foundation and we kind of just start skipping steps and then you can end up with some erroneous measurements. But we are all human here. I am not saying that I do step by step, 100% every time, but when you are paying attention to what you're doing, you start correcting the little things and you might get a little more accuracy in your measurements, especially if you need more accuracy Whether you're doing research or you're just.
Rachele Burriesci:You have someone who's like writing the low levels of safety. Do the little things. Make sure that you're paying attention to your person, pay attention to their symptoms and practice your techniques. All right, I hope I hope that was helpful for you. Let me know if you have any questions. Let me know if you use the obliteration technique in practice, and next time we'll be talking a little bit more about automatic blood pressure cuffs and a little bit about the pros and cons of that. All right, I hope you all have a wonderful day. If I don't speak to you before Thanksgiving, have a happy Thanksgiving and whatever you have to do, I get after it, thank you.
