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Blood Pressure + Pulses

From Mediwikis
  1. Wash Hands
  2. Introduce self, intended purpose - I've been asked to assess your pulse and blood pressure today. Is that alright?
  3. Confirm Age, Date of birth
  4. Do you have any questions?
  5. Would you mind lifting your sleeve for me please? Make sure it doesnt compress the arm at all.

Pulse

Palpate radial pulse for 15 seconds, comment on:

  • Rate (BPM)
  • Regularity (Regular/Irregular)
  • Character(strong, weak, thready)

Carotid Pulse:

Im just going to press on your neck briefly. Let me know if it's uncomfortable

  • Palpate carotid pulse = decribe character (waveform)
  • Aortic valve stenosis - slow rise
  • Aortic regurgitation/incompetence = collapse

Assess both radial pulses simultaneouly, assessing synchrony.

  • Delay = coarctation
  • Right radial and left carotid dysynchrony = coarctation between braciocephalic and left carotid
  • Right radial and left radial dysynchrony = coarctation between left carotid and left subclavian
  • Right radial and femoral dysynchrony = coarctation after left subclavian

Auscultate carotid pulse checking for bruits. Expect to hear nothing if flow is normal = laminar flow

  • Narrowing = bruits = turbulent flow

Systolic BP estimate via palpation

  • Check to ensure sphygmomanometer is properly calibrated, working properly
  • At this point I would allow the patient to relax for 2 minutes
  • I'm now going to assess your blood pressure quickly. Just relax and breathe normally.
  • Apply cuff, midpoint of cuff over brachial artery
  • Estimate systolic bp by palpation (to detect auscultatory gap - venous congestion, arterial stiffness)
    • Take pulse with tip of distal and middle fingers at radial point
    • Inflate cuff until pulse vanishes
    • Inflate cuff for an additional 20mmhg
    • Release pressure slowly until pulse is felt again
    • This is estimated systolic bp

Auscultatory Systolic and Diastolic Pressure

  • Place stethoscope head over brachial artery
  • Close valve and inflate rapidly, 20mmhg after pulse ceases to be heard
  • Slowly release pressure, watching mercury column
  • Record the value of systolic, diastolic and patient position


Summary

We have John, a x year old patient. Heart Rate is x beats per minute, regular and strong. Patient is normo/hypo/hypertensive with a bp of xx/xx seated. If bp was high, I would reassess bp in the left arm, and proceed with a full cardiovascular examination.

Theory

Korotkoff actually described five types of sounds:

  1. The first Korotkoff sound is the snapping sound first heard at the systolic pressure. Clear tapping, repetitive sounds for at least two consecutive beats is considered the systolic pressure.
  2. The second sounds are the murmurs heard for most of the area between the systolic and diastolic pressures.
  3. The third = A loud, crisp tapping sound.
  4. The fourth sound, at pressures within 10 mmHg above the diastolic blood pressure, were described as "thumping" and "muting".
  5. The fifth Korotkoff sound is silence as the cuff pressure drops below the diastolic blood pressure. The disappearance of sound is considered diastolic blood pressure -- two mm Hg above the last sound heard.

The second and third Korotkoff sounds have no known clinical significance.

Questions

If blood pressure is high in both arms and there is a radio femoral delay, what would you suspect?
Coarctation of the aorta after the left subclavian artery. Secondary hypertension.
Name major arterial pulse points of the limbs when assesing peripheral aterial circulation
Temporal, facial, carotid, brachial, radial, femoral, polpliteal, posterior tibial, dorsalis pedis
What is a pulse deficit?
Difference between the HR and pulse rate. Occurs in atrial fibrillation, with fast irregular beats, some of which aren't strong enough to open the aortic valve.
What is sinus arrhythmia?
Regular variation in hr occuring during breathing cycle (increases during inspiration, decreases in expiration) due to stimulation of nucleus ambiguus
What is sinus tachycardia?
HR over 100 bpm originating from SA node, fever, anxiety, exercise, anxiety, hypovolemia
What is sinus bradycardia? What might cause it?
HR under 60 from Sa node. Sleep, hypothermia, hypothyroidism
What can cause an Irregularly Irregular Heart rate
Heart block, conduction block, normal breathing.
What is pulse pressure? What condition can cause a decrease?
The difference between systolic and diastolic, reflects stroke volume, inversely proportional to aortic compliance. Usually under 40 mmHg. Can drop with blood loss, aortic stenosis,
What is Pulsus paradoxus? What can cause it?
Exxageration of the normal variation in pulse during inspiration. The paradox is the associated pulse deficit, due to accentuated decrease in blood pressure. Cardiac tamponade, pericarditis, apnea, COPD
What can cause systolic hypertension?
Raised systemic resistance
What can cause wide pulse pressure?
Athersclerosis, thyrotoxicosis, anaemia, pregnancy. Increases normally with exercise (systolic increases, diastolic remains the same)