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Injuries and Exercise Contraindictations. > Clinical assesment. > Flashcards

Clinical assesment. Flashcards

1
Q

What are the vital signs?

A

pulse, temperature, respirations, and blood pressure.

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2
Q

what are they called vital signs?

A

they are called vital because they are signs of human life and their presence confirms life and their absence confirms death, and more importantly any amount of deviation from normal is correlated for each parameter and especially in combination with the magnitude of the threat to life.

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3
Q

Can vital signs alone diagnose someone?

A
  • while they are not enough alone for diagnosing they are sensitive indicators of the presence of disease and useful in the presence of disease and useful in the generation of pathophysiological hypotheses and differential diagnosis can be correlated with the severity of illness and outcome.
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4
Q

What is blood pressure?

A
  • the pressure within the major arterial system of the body and is measured in millimetres of mercury.
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5
Q

who was the first person to measure blood pressure?

A
  • Stephen hales was the first person to measure direct blood pressure in 1708 by connecting the left crural artery of a horse to a 9-foot tall glass manometer using brass tubes and a trachea of a goose.
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6
Q

who introduced indirect blood pressure?

A
  • by Vierodt of Germany in 1855 by introducing the principle that blood pressure was equal to the amount of external pressure necessary to obliterate the distal pulse. The blood pressure cuff was invented in 1896 by Riva-Rocci.
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7
Q

What is systolic blood pressure?

A
  • the maximum pressure within the arteries during the contraction of the ventricles. (ventricular systole).
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8
Q

What is diastolic pressure?

A
  • lowest pressure in the artery just prior to the next contraction (systole).
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9
Q

What is pulse pressure?

A
  • it is the difference between systolic and diastolic pressure and depends on stroke volume.
  • it may be normal in healthy patients and even those with severe aortic stenosis.
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10
Q

where might we see abnormal pulse pressure?

A
  • may be abnormally small or narrow in patients with left ventricular dysfunction or abnormally large in those with a murmur or aortic insufficiency.
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11
Q

What does a pulse pressure of 80+ mmHg indicate?

A
  • it increases the probability that the regurgitation is moderate or severe with a positive LR= 10.9.
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12
Q

How do we estimate the mean arterial pressure?

A

= (systolic + 2x diastolic)/3.

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13
Q

How do we measure intraarterial pressure directly?

A
  • it can be measured directly by inserting a needle into the lumen of the artery and using sophisticated and expensive equipment. Necessary in some settings but impractical for primary care clinical settings.
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14
Q

How do we measure blood pressure directly?

A
  • we use a sphygmomanometer which is an easy, safe and accurate measurement of blood pressure for the most clinical situation. It involves applying external pressure to the overlying tissues, and the compression necessary to occlude the artery is assumed equal to the intraarterial pressure.
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15
Q

What is a sphygmomanometer?

A
  • it consists of a flat rubber bag enclosed in a cuff of in-distensible fabric or plastic.
  • a rubber pump inflates the bag with air and tubing connects the pump to the bad and also to a manometer (either mercury or aneroid). to measure the applied air pressure in millimetres of mercury.
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16
Q

what is the first step out of eight for indirectly taking blood pressure?

A
  1. The patient should sit comfortably in a chair with his or her back supported with feet on the floor, or in the supine position and should rest for at least 5 minutes before the blood pressure is measured.
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17
Q

what is important element 2/8 for blood pressure?

A
  1. Screen the patient to identify if the patient has avoided caffeine and smoking 30 minutes prior to measurement. Also be aware that anxiety, “white coat syndrome”, rushing to make the appointment on time, bladder distension, chronic alcoholism, recent cigarette smoking and caffeine consumption can contribute to temporarily raised blood pressure in the absence of disease.
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18
Q

what is important element 3/8 for indirect BP?

A
  1. The patient’s arm should be bare, free of clothing, and have no scarring, lymphedema, or arteriovenous (AV) fistulas. Keep the patient’s arm at the level of the heart.
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19
Q

what is important element 4/8 for BP measurement?

A
  1. Use a blood pressure cuff that is of the proper size to minimize errors in blood pressure determinations. The arm cuff should be at least 10cm wide, and for a thigh width of 18cm is preferable. The length of the blood pressure cuff’s bladder should encircle at least 80% of the arm’s circumference.
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20
Q

what happens if a blood pressure cuff is to small?

A
  • it gives erroneously high results.
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21
Q

What happens if the blood pressure cuff is too large?

A
  • it gives erroneously low results.
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22
Q

what is important element 5/8 for indirect BP?

A
  1. The clinician should obtain at least two readings separated by at least 30 seconds and average them; if these differ by more than 5 mm Hg, additional readings are necessary.-
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23
Q

what is important element 6/8 for indirect BP?

A
  1. The readings should be rounded off to the nearest 2 mm Hg.
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24
Q

what is the important element 7/8 for indirect BP?

A
  1. In some clinical scenarios additional measurements are necessary, including those of the legs or opposite arm, or measurements are taken with the patient in different positions.
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25
Q

what is the important element 8/8 for indirect BP?

A
  1. BP should be taken in both arms at the first office visit and again in both arms when the patient has new cardiovascular or neurologic complaints.
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26
Q

What is the first step of the blood pressure palpatory technique?

A
  1. Palpate for the exact location of the brachial arterial pulse – it is usually medial but occasionally lateral to the insertion of the biceps brachii tendon
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27
Q

what is step 2/11 for palpatory BP?

A
  1. Place the deflated cuff snugly and smoothly on the patient’s bare arm, so the distal margin of the cuff is at least 2.5-3cm proximal to the antecubital fossa, and with the bladder centred over the brachial artery

It should be high enough on the arm to allow the stethoscope to be placed in the antecubital fossa without touching the cuff.

28
Q

what is step 3/11 of the palpatory BP technique?

A
    1. Rest the supinated arm on the table or by supporting the arm with the antecubital fossa approximately at the level of the heart (at the level of the 4th intercostal space at the sternum)
29
Q

what is step 4/11 of the palpatory BP technique?

A
  1. First estimate the systolic pressure by palpation: Palpate the radial artery on the same arm, inflate the cuff slowly and note when the radial pulse disappears.
30
Q

what is step 5 of the palpatory BP technique?

A
  1. Rapidly deflate the cuff. To take blood pressure either wait for 1-2 minutes OR instruct your patient to raise their arm in the air and pump their fist ten times. This eliminates venous congestion which may produce artificially low systolic and high diastolic pressures.
31
Q

what is step 6 of the palpatory BP technique?

A
  1. Place the bell of your stethoscope (ideal for listening to low-pitch Korotkoff sounds) over the brachial artery in the antecubital fossa and make an air seal. (Note studies have demonstrated that measurements with the bell and the diaphragm are the same).
32
Q

what is step 7 of the palpatory BP technique?

A
  1. Inflate the cuff to pressure about 20-30 mm Hg higher than that which eliminated the radial pulse.
33
Q

what is step 8 of the palpatory BP technique?

A
  1. Open the valve slightly and release the pressure in the cuff slowly at a rate of 2 mm Hg per second.
34
Q

what is step 9/11 of the palpatory BP technique?

A
  1. Listen for Korotkoff sounds which are vibrations from the artery under pressure and are used as pressure indicators.

Note the pressure at which sounds first become audible, which is the systolic pressure
As deflation proceeds, the sounds become louder and maintain a maximum for a considerate range before becoming muffled
Note the pressure at the point of muffling
Finally, note the point where the sounds disappear
Record these three readings – for example, 120/80/75, where the first pressure is where sound appeared, the second pressure is where muffling occurs, and the third is where the sounds disappear completely

35
Q

what is step 10 of the palpatory BP technique?

A
  1. The highest value is systolic pressure, but disagreement exists as to whether the second or third value represents the closest approximation to the intra-arterial diastolic pressure
36
Q

what does the American heart association recommend as the point of disappearance for diastolic pressure in most instances?

A

In most studies, phase 5 sounds correlate better with intra-arterial measurements of diastolic blood pressure.
Many persons lack phase 4 sounds.
The inter-observer agreement is better for phase 5 sounds than phase 4 sounds
In some circumstances as in hyperthyroidism and aortic regurgitation, the sound persists to zero pressure which is impossible therefore accept the second value
Most importantly, long-term studies showing that hypertension increases the risk of cardiovascular events have used phase 5 sounds as the definition of diastolic blood pressure, and shown that treatment reduces this risk

37
Q

What is step 11/11 of the palpatory BP technique?

A
  1. Perform blood pressure on both arms, and always repeat on the higher arm in future visits.

All patients should have their blood pressure checked in the left and right arm at least once to detect anatomical abnormalities.
Blood pressure should not differ by more than 10mmHg between arms with the right arm usually greater than the left
Pressure differences greater than 15 mm Hg may indicate obstruction of flow to one of the brachial arteries, such as occurs in the coarctation of the aorta.

38
Q

What is femoral artery blood pressure?

A

Femoral Artery Blood Pressure:

Taking arterial pressure in the femoral artery – have the patient lying prone on a table
Wrap a wide cuff (18 cm or more) around the thigh so that the lower margin of the cuff is several centimetres proximal to the popliteal fossa
Inflate the cuff and auscultate the popliteal artery in its fossa
May have difficulty in holding the cuff on the conical thigh to get even compression

39
Q

What are Korotkoff sounds?

A

Korotkoff sounds are produced underneath the distal half of the blood pressure cuff. The sounds occur with cuff pressures between the systolic and diastolic blood pressure because the underlying artery collapses completely when the cuff pressure exceeds diastolic pressure, and then reopens with each heartbeat because cuff pressure is less than systolic pressure.

40
Q

What do Korotkoff sounds represent?

A

The sound represents the sudden deceleration of the rapidly opening arterial walls, which causes a snapping or tapping sound. Once cuff pressure falls below the diastolic blood pressure, the sound disappears because the vessel wall is held open by diastolic pressure and gently contracts and expands with each beat.

41
Q

what is phase one of the sequence of korotkoff sounds?

A
  • Phase 1: the sudden appearance of sharp tapping sounds.
    – Systolic blood pressure is best estimated using phase I Korotkoff sounds (i.e., the first sounds auscultated).
42
Q

outline phase 2 of korotkoff sounds

A

swishing sounds.

43
Q

outline phase 3 of korotkoff sounds

A
  • regular, louder sounds.
44
Q

outline phase 4 of the korotkoff sounds;

A
  • abrupt muffling of sounds.
45
Q

outline phase 5 of korotkoff sounds;

A
  • loss of all sounds. estimation of diastolic pressure.
46
Q

what to note about phase 4 and 5?

A
  • Usually, phase IV and phase V sounds occur very near each other. If, however, they are widely separated, the blood pressure may be written to signify both (e.g., 128/80/30). Under these circumstances, phase IV sounds more accurately predict diastolic pressures.
  • Kirkendall et al. (1981) recommend using phase V sounds in adults and phase IV in children as the diastolic measure.
47
Q

outline the first step of postural vital signs.

A

Blood pressure is usually taken with the patient seated. Additional information may be obtained with postural vital signs by comparing measurements when the patient is supine with those when the patient is upright – this is checking for orthostatic blood pressure.

  1. Have the patient lying for at least 2 minutes
48
Q

what is step 2 of postural vital signs?

A
  1. Measure the pulse rate and blood pressure with the patient lying supine.
49
Q

what is step 3 of postural vital signs?

A
  1. Then ask the patient to stand and measure the pulse rate and blood pressure at least 1 minute after standing
    - Shorter periods of supine rest significantly reduce the sensitivity of postural vital signs in detecting blood loss.
50
Q

what is step 4 of postural vital signs?

A
  1. Normally, after a person stands, the pulse change stabilizes after 45 to 60 seconds, and the blood pressure stabilizes after 1 to 2 minutes. Counting the heart rate first, beginning at 1 minute, allows more time for the blood pressure to stabilize.
51
Q

what is step 5 of postural vital signs?

A
  1. Compare supine vital signs with standing vital signs, because sitting instead of standing significantly reduces the clinician’s ability to detect postural changes after blood loss
52
Q

what is step 6 of postural vital signs?

A
  1. Normally, systolic blood pressure should not drop more than 10 mm Hg, and diastolic pressure should remain unchanged or rise slightly.
53
Q

what is the significance of extreme orthostatic changes?

A

Significant orthostatic changes in blood pressure may indicate dehydration or an adverse drug reaction. When correlated with an inadequate rise in pulse, it may indicate autonomic nervous system dysfunction.

54
Q

How much blood shifts when a person stands up?

A

350 to 600 mL of blood shifts to the lower body.

55
Q

what results because of this change from sitting to standing?

A

Normally, compensatory increases in cardiac output, heart rate, and systemic vascular resistance, and transfer of blood from the pulmonary circulation to the systemic side allows the blood pressure to remain relatively stable during this shift.

56
Q

What is orthostatic hypotension?

A

Orthostatic hypotension, defined as a drop in systolic blood pressure of > 20 mm Hg or diastolic blood pressure of > 10 mm Hg, may occur if:

(1) compensatory mechanisms fail (i.e., autonomic insufficiency) or

(2) the patient has lost excessive amounts of fluid from blood vessels (e.g., acute blood loss).

57
Q

What is the response when a normovolemic person stands up?

A

The pulse increases on average by 10.9 beats/min, systolic blood pressure decreases by 3.5 mm Hg, and diastolic blood pressure increases by 5.2 mm Hg.

58
Q

what is the most valuable observation in postural vital signs?

A

postural pulse increase of > 30 beats/min or the inability of the patient to stand long enough for vital signs because of severe dizziness.

59
Q

in patients with suspected blood loss what are the 2 specific indicators of significant blood loss?

A

both supine tachycardia and supine hypotension are specific indicators of significant blood loss, although both are infrequent.

60
Q

What factors cause variation in blood pressure?

A
  • the biological variation, with physical activity, smoking, caffeine ingestion, emotional state, the temperature of the room, and season.
  • they may also vary due to inappropriate technique, improper equipment or other biases related to the observer.
61
Q

what is an example of improper equipment?

A
  1. Wrong Cuff Size
  • both the bladder width and length affect the measurement, although if the bladder encircles at least 80% of the arm’s circumference, the effect of width is minimized.
62
Q

why do cuffs that are to short overestimate blood pressure?

A

because they transmit cuff pressure inefficiently to the underlying soft tissues. This requires the clinician to apply much higher cuff pressures to collapse the artery, leading to a misdiagnosis of hypertension when it is not present. This error is greater the farther the center of the bladder is positioned from the brachial artery.

63
Q

Why do much larger cuffs underestimate blood pressure?

A

although this is controversial and most studies show the error is small. Underestimation means that the blood pressure reading may be normal in someone who actually has high blood pressure.

64
Q

What is an auscultatory gap?

A
  • an auscultatory gap is when phase 1 knockoff sounds normally appear but then they disappear slightly before they arise again above the diastolic pressure.
65
Q

What percentage of elderly patients have an auscultatory gap?

A

20.

Injuries and Exercise Contraindictations. (1 decks)

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