Blood Pressure Article part 2

Question 1

Step 4.

Cuff Placement

Locate the patient’s ____________artery at the midpoint of the upper arm by palpating btwn the biceps and triceps muscles on its inner surface. Wrap the cuff smoothly and snugly around the arm with its bladder center directly over the palpated artery and lower edge of the cuff 2.5cm above the antecubital fossa.

Avoids false high readings that occur when cuff pressure is not equally distributed over the artery. Avoids errors that result from extra sounds when the stethoscope comes in contact with cuff or tubing.

Answer 1

brachial

Question 2

Step 5.

Determine the maximum inflation level

Before listening for the BP, determine the inflation level necessary to obtain an accurate systolic reading, the maximum inflation level (MIL)

Locate the_______pulse and note the heart rate and rhythm.

Rationale. When the heart rate is irregular, systolic BP may vary beat to beat. Then additional readings are needed to get the best estimate of the systolic BP.

Continue feeling the pulse and rapidly inflate the cuff to 60mm Hg and then by 10mm increments until the pulse is no longer palpable. This is the first estimate of the ______________pressure. Stop inflating the cuff.

Begin deflation at 2mm Hg/s. Note the pressure at which the pulse reappears. This is the palpated systolic pressure and will usually be within 10mm Hg of the level at which the pulse disappeared. Additional readings are needed for accurate estimation of the palpated systolic BP when the pulse is irregular.

Immediately release all pressure. Add 30mg hg to the palpated systolic reading to determine the MIL

Rationale. Determines the minimum pressure needed to get an accurate systolic BP on a patient and decreases patient discomfort. Avoids errors that result from failure to inflate above systolic BP reading, including an inaccurately low systolic BP reading, which occurs when the observer begins listening during an auscultatory gap.

Answer 2

radial

palpated

Question 3

Step 6. Stethoscope Placement

Position the stethoscope earpieces pointing forward in your ears.

Rationale.Sound is not transmitted well when the eartips fail to point into the ear canal.

Find the point at which the ___________artery pulse is the strongest, usually just above the antecubital fossa on the inner aspect of the arm. Usling light pressure, position the chespiece over this point with all edges gently touching the skin surface. The stethoscope bell or a low frequency detecor is recommended.

Rationale. The loudest sounds will be heard over this pulse.Avoids errors due to difficulty hearing and interpreting Korotkoff sounds. Errors result when too much stethoscope pressure causes additional artery occlusion and distorts BP sounds. Korotkoff sounds are of low frequency.

Do not allow the stethoscope head to touch the cuff or tubing.
Rationale. Extraneous sounds mask and confuse Korotkoff sounds.

Answer 3

brachial

Question 4

Step 7. Inflation/Deflation

Rapidly inflate the cuff to the MIL. If sounds are heard immediately, completely release all pressure and repeat step 5 to repeat the palpated pressure.

Rationale Rapid inflation to correct level ensures listening above systolic BP. Slow inflation traps venous blood in the arm and may result in pain and diminished or distorted sounds.

Release the air from the cuff so that the mercury falls at a rate of 2mm Hg/s until Korotkoff sounds are heard. Continue deflation at the rate of 2mm Hg per beat.If unable to hear sounds clearly, quickly release all pressure, and check position of eartips and stethoscope. Repeat the procedure

Question 5

Slow deflation is necessary to allow the observer to hear the systolic and diastolic pressures at the point of onset. A reading can be no more accurate than the rate of deflation, ie, a deflation of 10 mm Hg/S will result in a pressure accurate to only 10mm Hg, and if one beat is missed, to only 20mm Hg.

Question 6

Step 8. Systolic BP

Reading to the nearest 2mm Hg mark, remember the systolic pressure at the onset of Korotkoff phase 1, the first of at least two regular “tapping” sounds. When the reading falls between two 2mm Hg marks, round to the higher of the two.Concentrate and remember the reading by silently repeating the systolic number with every heart beat until you confirm disapperance. Immediately record both systolic and diastolic BPs.

Question 7

Observers must learn to rule out sound artifacts. Single sounds inconsistent with heart rate are insignificant artifacts unless the pulse was irregular during palpation. In the case of arrhythmia, additional readings are needed to get the best estimate of the systolic BP.

Forgetting the reading is a common source of errors of 8 to 10mm Hg, especially in the presence of a wide pulse pressure (difference between the systolic and diastolic pressures)

Question 8

Step 9 Diastolic BP

Remember the pint at which the last regular Korotkoff sound is heard. When the sounds continue to very low diastolic levels or 0, remember the reading at the onset of KIV, the point at which sounds begin to muffle, as well as the last sound heard. This is best determined on a second reading if the pressure is heard to _________

Answer 8

zero

Question 9

The onset of KV (disappearance) is more reliably interpreted when observers listen for the last sound heard. The absence of KV occurs often in children, during pregnancy, and in other high-cardiac-output states. In these cases, the onset of KIV is the most accurate diastolic indicator.

Question 10

If the diastolic BP is heard above 90mm Hg, listen for an additional 40mm Hg. Otherwise, listen for 10 to 20mm Hg below the last sound to confirm disappearance.

Rationale. Avoids inaccurately high diastolic BP due to failure to listen until sounds reappear after a period of silence when an auscultatory gap is present.

Question 11

Step 10.

Record the reading, the arm used, the position of the patient, and the cuff size used. Immediately record the reading as KI/KV. If KIV is recorded, write the three numbers as KI/KIV/KV. If sounds do not cease,record KV as 0.

Question 12

Standardized recording methods are necessary to correctly interpret and compare readings by different observers. When phase V is absent, Korotkoff phase IV is the best indication of diastolic pressure.

Question 13

Step 11. Repeat the Reading

Make certain that all air is out of cuff. Wait 1 to 2 minutes and repeat steps 6 through 10.

BP normally changes from minute to minute,especially during clinical measurements. The average of two or more BP readings in a single arm is more reliable and a better indicator of usual readings than is a single reading or one reading in each arm

Question 14

Step 12. Repeat the process

Repeat the measurements in the other arm during initial workup and standing or supine as dictated by the patient’s situation. Postural changes in BP are measured after 1 and 3 minutes of standing. Note the arm with the higher reading for future comparisons.

BP can differ by more than 10mm Hg between arms. The higher pressure more accurately reflects intra-arterial pressure.

Question 15

Special Techniques and Populations

Absence of Korotkoff Phase V

When cardiac output is high, as in some children, in thyrotoxicosis, during fever, and in pregnant women, KV is often ___________.

Answer 15

absent

Question 16

In this event, Korotkoff sounds are heard until the mercury column falls to zero. BP should be recorded as three numbers (KV/KIV/0)

Question 17

BP measurement in children

The principles of measurement are the same in newborns, infants, and children. A most important consideration is the selection of a cuff that is appropriate for the arm circumference, as described above.

Question 18

BP Measurement in the Elderly

In the elderly, the brachial arteries, occasionally become very thickened and stiff. When this happens, the indirect cuff pressure may overestimate intra-arterial pressure, because higher cuff pressure is required to compress such a rigid vessel. The presence of a radial artery is still palpable after the cuff is inflated above the systolic BP should be a warning of this error.

Question 19

If the artery feels excessively thick when rolled back and forth under the finger, the BP reading measured with indirect techniques may be falsely high. Recheck the pressure by palpation in the forearm. If the palpated systolic pressure differ by >15mm Hg, then a direct arterial puncture may be needed to be certain of the true pressure.

Question 20

The patient should be informed and the problem noted on the patient’s record to alert others who measured BP in that individual.

Question 21

Very Large, Cone-Shaped, and Muscular Arms

If the patient is greater than 41cm in circumference or it is shaped so that a cuff will not fit on it well, then accurate pressure measurement may be impossible. In this case, palpated and auscultated readings should be attempted, with a cuff the appropriate size, in both the upper arm and forearm. If these differ by greater than 15mm Hg, then a better estimate of true pressure will be palpated systolic pressure with the cuff on the forearm.