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Year 3 - Preparation for Clinical Practise > Blood pressure > Flashcards

Blood pressure Flashcards

1
Q

Define blood pressure

A

Blood pressure is defined as the pressure exerted by blood on the wall of a blood vessel

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2
Q

What is blood pressure determined by

A
  • The volume of blood pumped by the heart in a particular unit of time. This is also known as the cardiac output
  • The level of resistance encountered by the blood as it passes through the vessels. This is also known as the peripheral resistance
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3
Q

How do you work out blood pressure

A

Blood pressure = cardiac output x peripheral resistance

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4
Q

What is the systolic measurement

A

The systolic measurement occurs during contraction of the left ventricle, also known as systole. It is defined as the maximal intra-arterial pressure

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5
Q

What is the diastolic measurement

A

The diastolic measurement occurs during relaxation of the ventricles, also known as diastole. It is defined as the minimal intra-arterial pressure

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6
Q

How is arterial blood pressure measured

A
  • using a sphygmomanometer
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7
Q

What is hypertension a risk factor for

A
  • development of cardiovascular disease
  • stroke
  • MI
  • vascular dementia
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8
Q

What can end organ damage be detected by in hypertension

A

By the presence of

  • Retinopathy on fundoscopy
  • Protein in the urine
  • Left ventricular hypertrophy on an electrocardiograph (ECG).
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9
Q

What can cause normal variation in blood pressure

A
  • The time of day
  • Nutritional factors
  • Position
  • Exercise
  • Psychological stress
  • Drugs
  • Disease.
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10
Q

What is the downside of measuring blood pressure via an aneroid sphygmomanometer

A
  • dial gauges are easily damaged especially if they are portable and this can cause errors in calibration
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11
Q

Describe the korotkoff method

A
  • Phase 1. This is the first appearance of sounds. It is used to determine the systolic blood pressure
  • Phase 2. A brief period may follow when the sounds soften or “swish”. Auscultatory gap: in some patients the sounds may disappear altogether
  • Phase 3. The return of sharper sounds becoming crisper for a short time
  • Phase 4. This is the muffling of sounds. In the past it has been used to measure diastolic blood pressure. It is still used for certain patient groups in whom Phase 5 is difficult to perceive. This includes pregnant women, and children under the age of 13
  • Phase 5. This is the final disappearance of sounds. It is used to determine diastolic blood pressure
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12
Q

What is the gold standard for measuring blood pressure

A

The Korotkoff method

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13
Q

List some automated measurement devices for measuring blood pressure

A
  • upper arm oscillatory device

- wrist mounted electronic oscillatory device

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14
Q

How do automated oscillatory measurement devices work

A

Oscillatory measurement of blood pressure involves measuring the oscillations, or vibrations, in an arterial wall as it is compressed and then release

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15
Q

What are oscillatory devices not suitable

A
  • inaccurate in patients with arrhythmias that are associated with a beat to beat variation in blood pressure such as artier fibrillation
  • only certain models are validated in pregnancy
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16
Q

What is the main source of error in a Wrist mounted electronic oscillatory device

A

-The main source of error with wrist devices is the position of the patient’s arm in relation to the heart. A wrist device may be accurate when the patient keeps their wrist at heart level, but patients may not always do this at home

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17
Q

what patient factors can reduce accuracy of blood pressure

A
  • Whether the patient is talking
  • Acute exposure to cold
  • Ingestion of alcohol or caffeine
  • When the patient sits with their legs crossed
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18
Q

How can you increase blood pressure accuracy

A
  • measuring blood pressure in a relaxed and temperature setting
  • ensuring that patient has not smoked or taken caffeine within the past 30 minutes
  • ensuring patient is seated
  • Allowing the patient to sit alone in a quiet room for five minutes before taking any measurements
  • Not talking to the patient while you take the measurement. Conversation has been shown to increase blood pressure
  • Leaving the room while the reading is being taken, or asking an allied health professional to take the reading
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19
Q

What are the technical factors that affect blood pressure accuracy

A
  • patient not sitting with their arm at the same height as their heart
  • differences in arms can also resulting error
  • wrong cuff size
  • ineffective positioning of the blood pressure cuff can also lead to inaccurate results
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20
Q

What can a too small and too big cuff size result in

A
  • Too small - leads to overestimation

- too large - leads to underestimation

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21
Q

How large should the cuff size be

A

The bladder of the cuff should fit around at least 80% of the patient’s arm, but not more than 100%

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22
Q

How accurate are blood pressure machines in clinical use

A
  • become less accurate after repeated use
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23
Q

how to you calibrate a blood pressure machine

A

To do this properly requires an expensive calibration device

24
Q

according to NICE guidelines how do you confirm the diagnosis of hypertension

A
  • use ambulatory blood pressure monitoring to confirm the diagnosis of hypertension if the clinic measurement is between 140/90 and 180/120
25
Q

what do you do if you ABPM is unstable

A
  • should offer home blood pressure monitoring
26
Q

what is the difference between blood pressures measured by ambulatory techniques and at home versus those in the clinic

A

Blood pressures measured by ambulatory techniques, and those measured at home, are lower on average than those taken in clinic

27
Q

What are the advantages of out of clinic measurement

A
  • predict a patients true blood pressure more accurately than those taken in the clinic
  • give a more accurate prediction of cardiovascular prognosis
  • The patient’s mean daytime pressure on ambulatory monitoring correlates to their extent of end organ damage
28
Q

what is the order of the best predictor of patients blood pressure

A
  • ambulatory blood pressure monitoring
  • home techniques
  • clinic measurement
29
Q

What is the benefits of a more accurate diagnosis of blood pressure

A
  • improved outcomes for patients

- lowered costs to the NHS through reduced anti-hypertensive prescribing and a reduction in cardiovascular events

30
Q

what is the disadvantages of measuring blood pressure out of clinic

A
  • ## Ambulatory and home measurement of blood pressure usually use an oscillatory method. This method may be inaccurate in patients with arrhythmias such as atrial fibrillation
31
Q

what are the routine investigations for newly diagnosed hypertensive patients in primary care

A
  • Test for urinary proteinuria by sending off a urine sample to assess the albumin:creatinine ratio
  • Test for urinary haematuria using a reagent strip
  • Take a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), serum total cholesterol, and high density lipoprotein (HDL) cholesterol
  • Perform fundoscopy to look for evidence of hypertensive retinopathy
  • Request a 12 lead electrocardiograph (ECG) looking for evidence of left ventricular hypertrophy.
32
Q

what is the guidance for measuring blood pressure in the clinic that NICE gives

A
  • Measure blood pressure in both arms.
  • If the difference in readings between arms is more than 15 mmHg, repeat the measurements
  • If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading

If blood pressure measured in the clinic is 140/90 mmHg or higher:

  • Take a second measurement during the consultation
  • If the second measurement is substantially different from the first, take a third measurement
  • Record the lower of the last two measurements as the blood pressure in clinic
  • If the clinic blood pressure measurements taken during a consultation is between 140/90 mmHg and 180/120 mmHg you should offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. You should request this if either systolic blood pressure, or diastolic blood pressure, or both, are raised.
33
Q

How should the patient sit when taking blood pressure

A
  • Avoid caffeine and smoking for 30 minutes before measurement
  • Rest for five minutes before measurement
  • Remain quiet but seated, with their back well supported and their legs uncrossed
  • Sit with their arm outstretched and supported, in line with the mid sternum.
34
Q

How much difference blood pressure between the arms is considered normal

A

A difference in blood pressure of less than 10 mmHg between arms is common, and is considered a normal variant

35
Q

Why are inter-arm differences in blood pressure important

A

Inter-arm differences in blood pressure are important, as they may be associated with increased 10 year cardiovascular mortality.

36
Q

What is postural hypotension

A
  • defined as a fall in blood pressure as 20mmHg systolic and or 10mmHg diastolic within 3 minutes after standing
37
Q

Who is postural hypotension likely to affect

A
  • elderly patients
  • patients with diabetes
  • patients taking some medications including alpha blockers
38
Q

how many times does the ambulatory measurement take the blood pressure

A
  • At least twice an hour during waking hours, usually from 8:00 to 22:00
  • Once an hour overnight, usually from 22:00 to 8:00.
39
Q

What does the ambulatory measurement use to diagnose hypertension

A

You should use the average daytime blood pressure to diagnose hypertension. This is calculated using at least 14 daytime readings

40
Q

what usually happens to night time blood pressure

A

Night time blood pressure normally dips compared to daytime pressure

41
Q

what can cause night time hypertension

A
  • shift work
  • daytime napping
  • obstructive sleep apnoea
42
Q

What is night time hypertension associated with

A
  • poorer health outcomes including increased mortality
43
Q

What should you advise patients who is taking ambulatory blood pressure monitoring

A
  • Not to drive while wearing the monitor: an inflating cuff can be distracting, and motorists may not be covered by their insurance company if they have an accident
  • To remove the device while showering or bathing: they should time bathing to take place during the 30 minutes between readings
  • That most devices will give a five second warning sound before they inflate: they should sit or stand still when this happens, in preparation for measurement.
44
Q

How long does ambulatory blood pressure monitoring take

A

After 24 hours of monitoring the patient should return the device to the surgery or clinic

45
Q

What should you advice patients who are taking home blood pressure measurements

A
  • Avoid caffeine and smoking for 30 minutes before measurement, and rest for five minutes before measurement
  • Remain quiet and seated, with their back well supported, their legs uncrossed, and their arm outstretched and supported in line with the mid sternum
  • Take two consecutive readings at least one minute apart - both of these readings should be used when calculating the mean blood pressure
  • Take a measurement twice daily. Usually this should be between 6:00 and midday, and 22:00 and midnight.
  • Measure their blood pressure for a minimum of four consecutive days, and ideally for seven days
  • Discard the first day’s results, but keep the rest as these will be used to calculate a mean of their blood pressure
46
Q

What do you do if the patients taking antihypertensive medications with blood pressure

A

If the patient is already taking antihypertensive medication, then the readings should be taken before they take their tablets.

47
Q

How do you define stage 1 hypertension

A
  • In clinic = 140/90 to 159/99mmHg

- out of clinic = 135/85-149/94

48
Q

How do you define stage 2 hypertension

A
  • In clinic = 160/100 to 179/119

- out of clinic - 150/95 or higher

49
Q

How do you define stage 3 hypertension

A
  • 180 mmHg systolic blood pressure or 120mmHg diastolic blood pressure
50
Q

what should you do if a patient has stage 3 hypertension

A
  • If a patient has severe hypertension but no symptoms or signs indicating same day referral for specialist care you should investigate for target organ damage as soon as possible
  • If target organ damage is identified you should consider treatment immediately but if there is no damage identified you should repeat the clinic blood pressure measurement within seven days
51
Q

When should you admit patients with hypertension to hospital

A
  • accelerated or malignant hypertension defined as 180/120 mmhm or greater
  • papilloedmea
  • retinal haemorrhages
  • chest pain
  • dyspnoea
  • altered mental status
  • neurological deficit
  • oliguria
  • proteinuria
  • angiopathic haemolytic anaemia
  • pheochromocytoma
52
Q

what are the signs and symptoms of pheochromocytoma

A
  • Labile or postural
  • hypotension
  • Headache
  • Palpitations
  • Pallor
  • Abdominal pain
  • Excessive sweating.
53
Q

What is the white coat affect

A

Some patients have higher blood pressure when a doctor or nurse is present than they do outside of a medical environment

54
Q

what is masked hypertension

A

Patients with masked hypertension have a normal blood pressure reading in clinic, and higher readings outside of clinic.

55
Q

What should you do for patients with white coat hypertension

A

Given that these patients seem to have a greater risk of progressing to sustained hypertension, you should consider providing them with regular blood pressure follow up.
- consider an annual review

56
Q

Who should you consider masked hypertension in

A

You should consider the possibility of masked hypertension in patients with evidence of end organ damage, but a normal blood pressure in clinic.

Year 3 - Preparation for Clinical Practise (33 decks)

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