ViTal Signs

Question 1

Define Pulse Pressure
Normal Value
Describe abnormalities

Answer 1

The difference between systolic and diastolic blood pressure measurements, in mmHg

Normal is ~ 40 mmHg

Widened pulse pressure (>40mmHg)
Often due to atherosclerosis, hyperthyroidism, anemia
(increased SV)
Narrow pulse pressure (<30mmHg)
Trauma (hypovolemia), aortic stenosis, cardiac tamponade
(decreased SV)

Question 2

Blood Pressure Formula

Answer 2

BP = CO x PVR
Cardiac output (CO) = amount of blood pumped by
the heart (L/min)
A product of stroke volume and heart rate
(CO = SV x HR)
Stroke volume (SV) = Volume of blood ejected from
the LV with each cardiac contraction
Arterial elasticity
Volume of blood in the system
Blood viscosity
Heart rate (HR)
Peripheral vascular resistance (PVR)

Question 3

Direct measurement of BP

Answer 3

Arterial line
Swan-Ganz catheter
 Pulmonary artery catheter
 Measures heart function, blood flow, pressures in/around heart
Central venous pressure line
 Direct measurement of pressure in right
atrium, vena cava
 Measurement of right ventricular preload

Question 4

Indirect measurement of BP

Answer 4

Mercury, Aneroid, Electronic/ Automated

Question 5

Mercury

Answer 5

Mercury column, hand bulb, bladder, stethoscope
No need to calibrate
Most accurate but most difficult
More costly initially
Contains mercury!!
Gold standard

Question 6

Aneroid

Answer 6

Needle gauge, hand bulb, bladder, stethoscope
Less expensive but less accurate
Requires calibration

Question 7

Electronic/ Automated

Answer 7

Digital
Less accurate
Easy
Wide price range
Calibrate the home device in the office
It has become more common

Question 8

What is the Palpatory Method?

Answer 8

A method to estimate systolic blood pressure
without a stethoscope
Uses the radial pulse

Question 9

Steps of the Palpatory Method

Answer 9

Place cuff as normal
Palpate the radial artery on the same side
Inflate the cuff until you lose the pulse
This is your estimated systolic pressure
ADD 30 to this number - this is the level you
will inflate the bladder for measurement

Question 10

Why use the palpatory method?

Answer 10

Allows you to avoid a falsely low SBP and falsely high DBP due to the auscultatory gap
Avoids unnecessary discomfort for the patient

Question 11

What is the Auscultatory gap?

Answer 11

A period of diminished or absent Korotkoffsounds between the systolic and diastolic pressures

Associated with arterial stiffness

Question 12

Steps of the Auscultatory Method

Answer 12

Inflate the cuff to the measurement determined by the
palpatory method
Deflate slowly (about 2-3 mm Hg per second)
With the bell of the stethoscope, note the level at which
you hear at least 2 consecutive beats= SYSTOLIC BP
Continue lowering the pressure in the cuff
Note the level when sounds disappear= DIASTOLIC BP

Question 13

Korotkoff Sounds – 5 sounds

Answer 13

1. 1st audible, clear sound= systolic pressure
2. Swishing sound or auscultatory gap
3. Loud, high-pitched sound (3rd)
4. Abrupt muffling (1st diastolic sound) Occasionally hear
   muffling to 0mmHg, if so use the onset of muffling as the
   diastolic reading
5. Absence of sound (2nd diastolic) = diastolic pressure

Question 14

Common Mistakes when taking BP

Answer 14

Table Of slide 44

Question 15

Hypertension Classification w/corresponding values

Answer 15

Normal <120mmHg and <80mmHg
Prehypertension 120-139 OR 80-89
Stage I Hypertension 140-159 OR >90-99
Stage II Hypertension > 160 OR >100

Question 16

Diagnosis of hypertension

Answer 16

Usually made after 2-3 readings on 2 or more occasions spread out over time
If extremely elevated (ie >180/110), or evidence of end-organ dysfunction, diagnose and treat sooner
Consider ambulatory monitoring to rule out white coat syndrome or masked hypertension

Question 17

Etiology of hypertension

Answer 17

Primary: 90%cases Essential hypertension Idiopathic
Secondary: Glomerulonephritis, hyperaldosteronism, pheochromocytoma, renal artery stenosis, drugs

Question 18

Hypotension

Answer 18

<90/60
(In adults), AND symptomatic
For some, normal variant i.e. athletes
Pathologic
 MI
 Sepsis
 Adrenal insufficiency
 Aortic dissection
 Iatrogenic
 Volume loss
Orthostatic

Question 19

Orthostatic hypotension

Answer 19

Measure heart rate and blood pressure in 2 positions
Supine, after resting 3-10 minutes
Then within 3 minutes after standing

Question 20

How to diagnose orthostatic hypotension?

Answer 20

• Drop in systolic pressure of 20 mm Hg or more
• Drop in diastolic of 10 mm Hg or more
• INCREASE of HR more than 15 bpm

Question 21

What is an arterial pulse?

Answer 21

A bounding wave of blood with varying force exerted by the blood against the
arterial wall as the ventricles of the heart contract & relax.
Diminishes with increasing distance from the heart
Takes 0.2 sec. for the impact of this wave to be felt in the pulses of the foot

Question 22

Technique of doing pulse

Answer 22

Use the distal pads of 2ND & 3RD fingers
Apply light pressure; do not occlude a vessel
Palpate 60 seconds to fully evaluate
May count for 30 seconds & double it if a pulse is
regular

Question 23

Locations to check Pulse

Answer 23

Carotid artery
Brachial artery
Radial artery
Femoral artery
Popliteal artery
Dorsalis pedis artery
Posterior tibial artery

Question 24

Bruit

Answer 24

unexpected audible swishing sound or
murmur over an artery or vascular organ; usually
blowing or rushing in nature

Question 25

Clinicasignificance of Bruit?

Answer 25

underlying arterial occlusive

Question 26

Pulse rate

Answer 26

Number of times your heart beats

*radial artery best for calculating heart rate

Question 27

Normal Pulse rate

Answer 27

Newborns up to 1 month old: 70 to 190 bpm
Infants 1 to 11 months old: 80 to 160 bpm
Children 1 to 2 years old: 80 to 130 bpm
Children 3 to 4 years old: 80 to 120 bpm
Children 5 to 6 years old: 75 to 115 bpm
Children 7 to 9 years old: 70 to 110 bpm
Children 10 years and older, and adults (including seniors): 60 to 100 bpm
Well-trained athletes: 40 to 60 bpm

Question 28

Rythm

Answer 28

Regular (no skips aur pauses)

Question 29

Contour

Answer 29

(shape, wave form): Smooth, rounded, swift upstroke, peaks then gradually
descends, towards end get second, smaller upstroke (the dicrotic wave, but usually not
palpable)

*carotid artery best to assess contour

Question 30

Amplitude (strength)

Answer 30

4=bounding
3=full, increase, 2=expected
1=dimished
0=absent

Question 31

Coarctation

Answer 31

*usuallly the femoral pulse strong=radial pulse

If the radial pulse is stronger than femoral or if femoral is absent abnormality is called Coarctation of the aorta

Question 32

History
questions for
the pt with
circulatory
complaints/
pathology

Answer 32

Present history: pain, cramping
or burning in arms, legs, toes;
skin changes (thin, cold, pallor,
shiny, hair loss); palpitations;
SOB, chest pain; use of
stimulants
PMH: Diabetes mellitus, HTN,
CAD, heart murmurs,
arrhythmias, hyperlipidemia
Meds: β-blockers, stimulants
SH: Tobacco, ETOH, Exercise,
Illicit Drugs
FH: MI, CAD, Hx of sudden
death, arrhythmias