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Ankle-Brachial Pressure Index Measurement (1.46)

Ankle-Brachial Pressure Index Measurement (1.46) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.46

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
August 30, 2016
amended: Aug. 15, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.46A

Original
Revision

Page
1
of 3

Title: Ankle-Brachial Pressure Index
Measurement (Adult)


I. PURPOSE

To ensure appropriate measurement of Ankle-Brachial Index (ABI) when performed
at bedside by a Registered Nurse (RN). Systolic blood pressures are measured using a
portable ultrasound doppler. The brachial systolic blood pressure is compared to the
posterior tibial or dorsalis pedis systolic blood pressure in order to formulate the ABI.
The ABI is used to monitor the efficacy of therapeutic vascular interventions and
quality of arterial blood flow to the lower extremities.

II. POLICY

A. Registered nurses can perform the Ankle Brachial Index (ABI) procedure.
B. Contraindications to performing ABI’s
1. Obesity (patient is too large for appropriate cuff sizing)
2. Acute deep vein thrombosis
3. Acute trauma, ulcerations, or intravenous catheter placement in the areas
needed for testing
4. Extensive dressings or casts at the sites to be tested
5. PICC or Midline (use contralateral extremity)
6. AV fistula (use contralateral extremity)

III. EQUIPMENT

A. 5 or 10 mHz Doppler instrument
B. Blood pressure cuff (use a cuff with a bladder that is 20 percent wider than the
diameter of the patient’s limb being measured)
C. Sphygmomanometer
D. Ultrasound gel (CS #4013337, CS #2200080, CS #2201677)
E. Gauze or tissue

IV. PROCEDURE

A. Explain the procedure to the patient
1. Have the patient remove stockings and shoes, as well as any clothing from
upper arms to provide access for obtaining blood pressures.
2. The patient should rest in the supine position with their legs uncrossed for
10-20 minutes prior to obtaining blood pressure measurements.
3. Provide education to patient regarding the purpose of the procedure using
Health Facts For You 7062, Ankle Brachial Pressure Index.

Page 2 of 3

B. Perform hand hygiene according to UW Health Clinical Policy 4.1.13, Hand
Hygiene.
C. Measure brachial systolic blood pressures in both arms.
1. Apply the appropriately sized blood pressure cuff to the patient’s arm and
palpate for a brachial pulse. Do not place blood pressure cuff over a
vascular access device.
2. Apply at least a fingertip-sized amount of ultrasound gel over the artery.
3. Turn on Doppler instrument and place the tip of the Doppler probe into the
top of the ultrasound gel at a 45-60 degree angle, applying very light
pressure. Listen for the “whooshing” sound, which indicates the pulse.
4. Inflate the blood pressure cuff until you no longer hear the sound, then 20
to 30 mmHg beyond that point.
5. Deflate the cuff at a rate of 2 to 4 mmHg/second until the sound returns,
which indicates systolic blood pressure.
6. Immediately repeat the steps above to obtain the systolic pressure for the
other arm.
D. Measure dorsalis pedis and posterior tibial systolic blood pressures in both lower
extremities.
1. Apply the appropriately sized blood pressure cuff above the patient’s
ankle and locate the posterior tibial pulse at the patient’s inner ankle and
the dorsalis pedis pulse on the top of the foot.
2. Repeat the procedure, as listed in part C. steps 2-6, measuring the systolic
blood pressure for both pulse sites on the opposite foot.
a. Be suspicious of arterial pressures less than 40 mmHg; this may be
a venous signal, have a colleague measure to confirm.
b. Be suspicious of an ankle pressure greater than 300 mmHg;
calcific sclerosis (common in patients with diabetes, chronic renal
failure, and hyperparathyroidism) produces falsely elevated ankle
pressures.
c. If you are unable to compress the vessel (the “whooshing” sound
does not go away with cuff inflation) use 300 mmHg as your
value. This will indicate a non-compressible vessel.
d. Avoid prolonged cuff inflation. Release the cuff if the patient
reports pain and notify the provider that ABI’s could not be
performed.
E. Remove the cuff and clean ultrasound gel from the skin and probe using tissue or
gauze. Wipe all external surfaces and probes with hospital disinfectant wipes. Do
not use alcohol. Clean the end of the probe with soap and water.
F. Record the location and result of each blood pressure measurement in the
patient’s clinical record.
G. Calculate the ABI
ABI values will be automatically calculated in Health Link using the
following formula:
a. Right ABI = Higher right ankle (dorsalis pedis or posterior tibial)
systolic pressure/higher brachial artery pressure (of either arm)
b. Left ABI = Higher left ankle (dorsalis pedis or posterior tibial)
systolic pressure/higher brachial artery pressure (of either arm)



Page 3 of 3

H. Interpretation of ABI

Greater than 1.40 Non-compressible
1.00-1.40 Normal
0.91-0.99 Borderline
0.90 or less Abnormal

It is common for ABI values to vary by 0.10 or less between observers and
observations. A change greater than 0.15 should be evaluated for clinical
significance.

V. UWHC CROSS REFERENCES

A. Health Facts For You 7062, Ankle-Brachial Pressure Index (ABI)
B. UW Health Clinical Policy 4.1.13, Hand Hygiene

VI. REFERENCES

A. Lewis, P. A. (2014). Vascular diagnostic studies. In Rebik Christensen, C. &
Lewis, P. A. (Eds.), Core curriculum for vascular nursing. (2
nd
ed., pp 44-47).
Philadelphia, PA:Wolters Kluwer.
B. Rooke, T. W., Hirsch, A. T., Misra, S., Sidawy, A. N., Beckman, J. A., Findeiss,
L. K., Golzarian, J., & et al. (2011). 2011 ACCF/AHA focused update of the
guideline for the management of patients with peripheral artery disease (updating
the 2005 guideline): a report of the American College of Cardiology
Foundation/American Heart Association Task Force [trunc]. J Am Coll Cardiol,
58(19), 2020-45.
C. Sinhlangu, D. & Bliss, J. (2012) Resting doppler ankle brachial pressure index
measurement: a literature review. British Journal of Community Nursing, 17(7),
318-324.
D. Young, T. (2011). How to undertake a Doppler ultrasound for leg ulceration.
Practice Nursing, 22(11), 597-601.

VII. REVIEWED BY

Chief of Vascular Surgery, UW School of Medicine and Public Health
Clinical Nurse Specialist, Vascular
Nursing Education Specialist, Heart and Vascular
Nursing Patient Care Policy and Procedure Committee, August 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive