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Inquiry and general inspection of patients with cardiovascular system diseases

June 8, 2024

Inquiry and general inspection of patients with cardiovascular system diseases.

Examination of pulse and blood pressure

Inspection and palpation of precordial region. Percussion of borders of relative and absolute heart dullness.

Patient’s complaints typical for diseases of a heart

The most typical complaints are the pain in the heart area, dyspnea, palpitation etc.

Dyspnea is the subjective feeling of air hunger or shortness of breath or digressing feeling of air deficit. Dyspnoea is a sign of the developing circulatory insufficiency, the degree of dyspnoea being a measure of this insufficiency. When questioning the patient, it is therefore necessary to find the conditions under which dyspnoea develops. At the initial stages of heart failure, dyspnoea develops only during exercise, such as ascending the– stairs or a hill, or during fast walk. Further, it arises at mildly increased physical activity. During talkind, after meals or during normal walk. .In advanced heart failure, dyspnoea is observed even at rest. Cardiac dyspnoea is caused by some factors which stimulate the respiratory centre.

It is necessary to distinguish attacks of cardiac asthma. In the time of attack the patient complaints on acute air hunger, rising of gurgling rales during breathing, expectoration of foamy sputum with impurity of blood. The patients quite often complain on palpitation. Sometimes the feeling of heart intermissions can occur, caused by infringement of its rhythm.

Attacks of asphyxia, which are known as cardiac asthma, should be differentiated from dyspnoea. An attack of cardiac asthma usually arises suddenly, at rest, or soon after a physical or emotional stress, sometimes during night sleep. It may develop in the presence of dyspnoea. In paroxysmal attacks of cardiac asthma, the patient would usually complain of acute lack of air; respiration becomes stertorous, the sputum is foamy with traces of blood.

The important attribute of heart failure is the pain in the heart area which is an important and informative sign.

It is necessary to find out its exact localization, reasons and conditions of its occurrence (physical or emotional overload, its occurrence at rest, during motion or in dream), character (acute, dull pain, feeling of weight or compression behind sternum, slight dull pain in the top of the heart), duration, irradiation.

The character of pain is different in various diseases of the heart. The physician should determine (by questioning) the location of the pain, the cause or condition under which it develops (exercise, emotional stress, walking, attack Of pain at rest, during night sleep), the character of pain (acute, boring, piercing, a feeling of heaviness or retrosternal pressure, small boring pain in the region of the apex), duration and radiation of pain, conditions under which the pain abates. Pain often develops due to acute insufficiency of the coronary circulation, which results in myocardial ischaemia. This pain syndrome is called stenocardia or angina pectoris. In angina pectoris pain is retrosternal or slightly to the left of the sternum; it most commonly radiates to the region under the left scapula, the neck, and the left arm. The pain is usually associated with exercise, emotional stress, and is abated by nitroglycerin. Angina pectoris pain occurs mostly in patients with coronary atherosclerosis but it may arise in inflammatory diseases of the vessels, e.g. rheumatic vasculitis, syphilitic mesaortitis, periarteritis nodosa, and also in aortal heart diseases and grave anaemia.

Pain is especially intense in myocardial infarction and, unlike in angina pectoris, it persists for a few hours, and sometimes for several days, it does not abate after vasodilatory preparations are given. Pain in dissecting aneurysm of the aorta is piercing (like in myocardial infarction). Unlike in myocardial infarction, pain radiates usually .to the spinal column, and moves gradually along the course of the aorta. Myocarditis is characterized by intermittent and pressing pain; it is dull, mild, and is intensified during exercise. Pain in pericarditis is located at the middle of the sternum or throughout the entire cardiac region; the pain is stabbing or shooting, and is intensified during movements, cough, even under the pressure of a stethoscope; the pain may persist for several days or arise in attacks. Permanent pain behind the manubrium sterni that does not depend on exercise or emotional stress (the so-called aortalgia) occurs in aortitis. Stabbing pain at the heart apex that arises at emotional stress or fatigue is sharacteristics of cardioneurosis. It should be remembered that pain in the cardiac region may arise due to affection of intercostals muscles, nerves, pleura, or the asjanced organs (diaphragmatic hernia, cholecystitis, ulcer, gastric cancer).

Patients with heart diseases often complain of cough which is due to congestion in the lesser circulation. The caygh is usually dry; sometimes a small amouln of sputum is coughed up. Dry caugh is also observed in aortal aneurism because of the stimulation of the vagus nerve. Haemoptysis in grave heart diseases is mostly due to congestion in the lesser circulation and rupture of fine bronchial vessels (e.g. during coughing)/ Haemoptysis mostly occurs in patients with mitral heart disease. It may occur in embolism of the pulmonary artery.

Oedema Venous congestion in the greater circulation occurs in severe heart diseases. The patients would complain of oedema, which first develops only in the evening and resolves during the nigit sleep. Oedema occurs mostly in the malleolus region and on the dorsal side of the foot; shins are then affected. In graver cases when fluid is accumulated at the abdominal cavity (ascites) he patient would complain of heaviness in the abdomen and its enlargement. Heaviness most commonly develops in the right hypochondrium due to congestion and enlargement of the liver. In rapidly developing congestion, pain is felt in this region dueto distention of the liver capsule. Patients may complain also of poor appetite, nausea, vomiting, and swelling of the abdomen. These symptoms are associated with disordered blood circulation in the abdominal organs. The renal function is upset for the same reason and diuresis decreases.

. Patients often complain of palpitation. They feel accelerated and intensified heart contractions. Palpitation is determined by the increased excitability of the patient’s nerve apparatus that controls heart activity. Palpitation is a sign of affection of the heart muscle in cardiac diseases such as myocarditis, myocardial infarction, congenital heart diseases, etc. it may arise as a reflex in diseases of some other organs, in fever, anaemia, neurosis, hyperthyroidism, and after administration of some medicinal preparations (atropin sulphate, etc.). Palpitation may also occur in healthy persons under heavy physical load, during running, emotional stress, smoking or coffee abuse. Patients with serious heart diseases may feel palpitation constantly, or it may arise in attacks of paroxysmal tachycardia.

Some patients comptain of intermissions (escaped beats) which are due to disorders in the cardiac rrhythm. Intermissions are described by the patients as a feeling of sinking, stoppage of the heart. Questioning the patient is aimed at determining the circumstances under wich intermissions develop. They may arise at rest or during exerscise, they may be intensified in special postures of the patient, etc.

Temperature: Cool hands occur most commonly as a result of exposure to a cold environment. However, this can also reflect vascular insufficiency, vasospasm, or hypovolemia.

General complaints. Patients with cardiovascular pathology often have dysfunction of .the central nervous system, which is manifested by weakness, rapid fatigue, decreased work capacity, increased excitability, and deranged sleep. Compaints of headache, nausea, noise in the ears or the head are not infrequent n essential hypertension patients. The headache, feeling of the noise in ears, vertigo in persons with hypertension are frequently observed.

Some heart disease’s (myocarditis, endocarditis, etc.) are attended by fevered (usually Subfebrile) temperature; sometimes high fever may occur. The patient should be asked about the time of the day when the temperature usually rises, how long it persists and if this rise is accomopained by chills, profuse sweating, etc.

Review of systems

Does the patient feel pain in the heart region? If yes, you should define the following characteristics:

-location (behind the sternum, above the apex, over the whole heart area);

–when does it develop (on physical exertion, emotional overstrain, at rest);

–its irradiation (to the left arm, neck, left part of the neck, low jaw, intercapular space, left shoulder-blade);

-characteristics of pain (acute, dull, constricting, stabbing, burning, pressing, boring, arching, or a sense of heaviness);

–intensity (slight, of moderate intensity, strong, severe);

–timing (persistent, periodical), if periodical – the frequency of its appearance a day;

–duration (during some minutes, hours, days);

-associated manifestations ;

-provoking factors (physical or emotional overstrain);

–factors that relieve or remove pain;

-patient’s behavior during pain attack,body position that relieves pain.

Palpitation. If yes, what are its:

–frequency (constant, paroxismal);

-if periodical – duration of an attack, in what time and under what conditions does the attack develop: at physical overload, emotional overstrain, at rest, due to change in posture, without any reason;

-when does it disappear?

Is it followed by heart intermissions (a sense of heart arrest, heart disposition)? If yes- what is the reason of these unpleasant feelings on the patient’s own opinion?

Frequency of attacks a day, their duration, factors that relieve or remove the symptom.

Feeling of pulsations in different parts of patient’s body: its

-location, frequency, duration;

-relation to palpitation, heart intermissions, pain;

-provoking factors;

–factors that relieve or remove symptom.

Does the patient complain of dyspnea? If yes, what is

-the setting of its development (on exertion, during conversation, emotional overstrain, at rest)?

-Its type (expiratory, inspiratory or mixed);

-is it attack-like or constant?

-Is it more intensive in recumbent or upright position of the patient?

-Relation of dyspnea to body position (upright, recumbent), physical loading.

Suffocation: if present, define its

-time of appearance (in day-time, at night);

-frequency of attacks;

-duration;

-factors, that relieve the symptom;

-what time and under what conditions does it develop (on exertion, emotional exertion, at night)?

Cough: time and condition of its appearance (in the morning, in the evening, at night);

–timing (is it permanent or periodical), in the last case – duration and frequency of attacks;

-loudness and intensity of cough (inssiculation, slight, of moderate intensity, loud);

–character of cough (dry or with expectoration of sputum (moist);

-under the what conditions does cough develop or become more severe, its relations to respiration, physical loading, singing, conversation etc.);

-factors that relieve or remove cough.

If cough is moist, define amount of sputum discharged per day and in one split;

–peculiarities of discharging (is it heavy or easy, at what day time and in what body position sputum may be best discharged);

-colour of sputum (greish, reddish);

-smell of sputum;

-are there any admixtures of blood in sputum, if yes, what is the degree of bleeding (blood streaks in sputum, sputum mixed with blood, pure blood in several splits, pronounced bleeding). Colour of sputum should be clarified (light-red, dark), frequency of bleedings, duration, provoking factors, under the what conditions does bleeding become less intense or disappear.

Edema: if present, what is its location?

-time of appearance (in the morning, in the evening, all time);

-under the what conditiond does in develip or become more pronounced (physical loading etc.)?

-Factors, that relieve the symptom (due to usage of diuretics or on its own).

-Relation of edema to water and salt intake.

Claudicatio intermittens: the time of appearance, relieving factors.

The signs of spasm of perypheral arteries: pain in the limbs, feeling of “freezing”, “numbness” of fingers, feeling of “dead” finger, headache, flickering before eyes.

History of present disease

The time of the onset of the disease and its first symptoms should be determined such as pain, palpitation, dyspnoea, elevation of the arterial pressure, the characteitand intensity of these symptoms, connection with infections and other diseases of the past, cooling, and physical overloads. The character of development of the primary symptoms is important. It is also necessary to find out if any treatment was given and its effect, if any. If there were exacerbations of the disease, their course and causes should be established.

Anamnesis. Special attention should be paid to various possible causes of the present heart disease. Information should be carefully collected concerning diseases of the past, especially such diseases as rheumatism, frequent tonsillitis, diphtheria, syphilis, which would normally provoke cardiovascular pathology. It is important to know the unfavourable living and working conditions, chronic exposure to cold and high humidity, nervous and psychic overstrain, hypodynamia, overeating, occupational hazards, smoking and alcohol abuse and ether harmful habits. It is also imprtant to ask the patient about cardiovascular diseases that occurred in his relatives, because familial predisposition to some, heart diseases is possible. It is necessary to inquire women about past pregnancies and labour, the onset of menopause because sometimes symptoms of cardiovascular pathology develop in them during this period.

Anamnesis:

-A complete history is essential regardless of the type of heart defect. The major categories to investigate include a history of:

– Poor weight gain, poor feeding habits, and fatigue during feeding

– Frequent respiratory infections and difficulties

– Cyanosis with or without clubbing of fingers

– Evidence of exercise intolerance in addition,

– a history of previous defects in a sibling,

– -In rheumatic fever a history of a previous streptococcal infection is of primary importance.

Phycical examination

Examination of the heart involves the skills of inspection, palpation, percussion, and auscultation, although the latter is the most significant. Overall assessment of cardiac function involves a comprehensive evaluation of pulse, blood pressure, respiratory function, and general physical growth and development. The doctor must be familiar with the anatomy and physiology of the normal heart in order to properly evaluate the findings.

The apex is located at the left midclavicular line and fifth intercostal space or mitral area. The heart of the infant is more horizontally positioned; therefore, the apex is higher (third to fourth intercostal space) and to the left of the midclclvicular line. The apical impulse, or point of maximum impulse, is normally located at the apex.

Data of general inspection

During examination of a patient you should pay attention to his general condition, posture, motor acivity, gait, skin color, facial expressions. Labored breathing, wheezing, cough are typical for heart decompensation.

The general appearance of the patient, his posture in bed, colour of the skin and visible mucosa, the presence of abcense of edema, the shapes of the terminal finger phalanges (clubbing fingers) and the belly should be assessed.

You should notice the patient’s forced posture – for example, preference for sitting up in the left-sided heart failure. Patients with expressed dyspnea usually lay in bed with high head end, at heavy dyspnea the patient is sitting with the lowered downwards legs (opthopnea). At exudative pericarditis patients prefer to sit, a little having bent forward. At heart dilatation they more often lay on the right side, as in postion on the left side the unpleasant sensations can occur.

Observe facial expressions at rest, during conversation about specific topics, during the physical examination, and in interaction with others. For the heart diseases anxiety, depression, sweading expressions are typical.

In elevation of intrathoracic pressure swelling of neck veins is visible;

The colour of the skin is important for diagnosis of some heart diseases. A skin pallor, cyanosis or yellowness may often be revealed in the patients with heart diseases.

Cyanosis. In heart diseases cyanosis is expressed on distant from heart sites (fingers of hands and legs, tip of the nose, lips, ear bowls).

Acrocyanosis

In the case if decompensation the central cyanosis can occur. Mitral stenosis can be diagnosed by the violet-red colour of the patient’s cheeks, mildly cyanotic colour of the lips, nose, and extremities, rhe skin and visible mucosa of patients with aortal heart diseases are usually pale. Cyanosis in combination with pallor (pallid cyanosis) is characteristic of stenosis of the orifice of the pulmonary trunk or thrombosis of the pulmonary artery. Icteric colour of the sclera and skin is characteristic of grave circulatory insufficiency. The skin of patients with persisting septic endocarditis has a peculiar colour resembling that of coffee with milk.

Cyanosis in mitral stenosis

Central and peripheral cyanosis in heart diseases

Venous insufficiency is characterized by a dark bluish/purple discoloration. Over time, long standing stasis of blood leads to the deposition of hemosiderin, giving the skin a dark, speckled appearance. If the leg is placed in a dependent position, the bluish/purple discoloration may darken dramatically, further suggestive of venous insufficiency. This occurs as a result of gravity working against an already ineffective blood return system. Patients with severe arterial insufficiency, on the other hand, may have relatively pale skin as a result of under perfusion. When their legs are placed in a dependent position, gravity enhances arterial inflow and the skin may become more red as maximally dilated arterioles attempt to bring blood to otherwise starved tissues. In cases of severe ischemia, the affected areas (usually involving the most distal aspect of the foot), can appear whitish or mottled, giving the leg a marbleized appearance. Dead tissue turns black (a.k.a. gangrene)

In rheumatic fever patients sometimes develop rash (erytema annulare)

Oedema frequently attends heart diseases. In gross heart lesions venous congestion in pulmonay ciculation as well as overload of right ventricle develop. They result in venous congestion in systemic ciculation and occurence of edema. Cardiac edema appear only to the evening at first and resolve for night and placed in the area of condilus, crues and back party of feets. In heavier cases the fluid accumulates in abdominal cavity and the patients complain on feeling of weight in the abdomen. If the patient stays out of bed, oedema is localized mainly in the malleolus, the dorsal side of the feet, and the shins, where a pressure of fingers leaves slowly levelling impresions. If the patient lies in bed, oedema is localized in the sacrolumbal region.

Determination of edema

If congestion in portal system develops the pain in the right hypochondrium occurs. At a bed mode edema are located on the back side of patient’s trunk. At severe heart disease with decompensation of heart failure hydrotorax, ascites or hydropericardiunm develop.

Ascites

If oedema is significant, it may extend onto the entire body while the ascitic fluid accumulates in various cavities of the body, such as the pleural cavity (hydrothorax), abdominal cavity (ascites), or in the pericardium (hydropericardium). Generalized oedema is called anasarca. The oedematous skin, especially the skin of the extremities, is pallid, smooth, and tense. In persistent oedema, the skin becomes rigid, its elasticity is lost, and the skin acquires a brown tinge due to diapedesis of erythrocytes from the congested vessels. Linear rhexes may develop in the subcutaneous fat of i he abdomen in pronounced oedema, which resemble the scars of pregnancy. In order to assess objectively the degree of oedema, the patient should be weighed regularly and the amount of liquid taken and excreted should foe strictly recorded.

Local oedema sometimes develops in cardiovascular pathology. When the superior vena cava is compressed, for example in exudative pericarditis or aneurysm of the aortal arch, the face, neck, and the shoulder girdle can foe affected by oedema (the collar of Stokes). In thrombophlebitis of the shin or thigh oedema of the affected extremity forms; ascites develops during thrombosis of the portal vein or the hepatic veins.

While edema is a relatively common finding in the lower extremity, it rarely occurs in the arms and hands. This is because the lower extremities are exposed to greater hydrostatic pressure due to their dependent position. Upper extremity edema, when present, usually occurs focally over an area of local inflammation (e.g. cellulitis). Diffuse arm edema can occur if drainage is compromised, as when the lymphatics are disrupted following axillary lymph node surgery for staging and treatment of breast cancer. Upper extremity venous obstruction can also cause edema, though blood clots in this region are much less common then in the lower extremity.

Edema is commonly associated with venous insufficiency, a blood return problem. This disorder tends to get worse when the legs are allowed to dangle for prolonged periods below the level of the heart (e.g. towards the end of the day if the patient has been standinag for long periods of time). The fluid builds up preferentially in the most distal aspects of the leg and progress up towards the knee as the process worsens. Arterial insufficiency, on the other hand, rarely causes edema, which makes perfect sense as the problem lies in the delivery of blood to the extremity, not the return from it. On occasion, the conditions may coexist.

It may be difficult to detect small amounts of fluid. Look around the malleoli, as fluid will cause a loss of the normally distinct appearing edges of the bone. Similarly, fluid will tend to “fill in” the spaces between the extensor tendons on the top of the foot, causing them to appear less defined. If you’re not sure whether fluid is present, push on the area for several seconds, release, and then gently rub your finger over that same spot, feeling for the presence of a “divot,” referred to as pitting. Much is said about pitting edema being associated with some disease states and non-pitting with others; however, the actual importance of this distinction is probably over stated. Also note the proximal extent of the edema and if it is present to the same degree in both legs. Edema may either be diffuse, involving all of the surrounding tissue symmetrically, as is frequently the case in disorders of low oncotic or elevated hydrostatic pressure. If, however, there is a local inflammatory process, as might occur with cellulitis, the area of edema can be quite focal. There is a very subjective scale for rating edema which ranges from “trace at the ankles” to “4+ to the level of the knees.” After examining many patients, you’ll develop a sense of what is a lot and what is not.

Edema: Fluid frequently collects in the feet and ankles due to the effects of gravity.

This is related to some perturbation in the Startling forces. Thinking in broad strokes, it’s usually the result of: Increased hydrostatic pressure: Transmitted back from the level of the heart (right heart failure), liver (portal hypertension), local venous insufficiency (e.g. venous valvular incomepetence with impaired flow of blood back to the heart from the legs), lymphatic obstruction (e.g. retroperitoneal adenopathy secondary to malignancy), or obesity (which may impair both venous and lymphatic drainage).

Realize that all “circulation” problems are not the same. Disorders of blood inflow (arterial) and outflow (venous) have different associated signs and symptoms based on their varying pathophysiology (see above).

For the control of edema of dynamics one should measure the patients’ body weigh systematically and keep up the volume of fluid patient had drunk per day as well as volume of excharged urina.

Take into account, that a healthy person in the absence of a body temperature elevation looses for about 0, 5-1 liter of fluid per day with urina, through respiratory ways leaves about 200 ml, and for about 100 ml of liquid is discharged with stool. For revealing of latent edema it is neccessary to measure a volume of day time and night urina. For this purpose collect two portions of urina: the first – from 8.00 a. m. up to 8.00 p. m. and the second – from 8.00 p. m. up to 8.00 a. m next day.

The shape of the nails and terminal phalanges of the fingers is informative. Drum-stick or clubbing (Hippocratic) fingers are characteristic of subacute septic endocarditis and some congenital heart diseases.Bulbous appearance of the distal phalanges of all fingers along with concurrent loss of the normal angle between the nail base and adjacent skin. This is most commonly associated with conditions that cause chronic hypoxemia (e.g. severe emphysema), though it is also associated with a number of other conditions. However, in general it is neither commoor particularly sensitive for hypoxia, as most hypoxic patients do not have clubbing. A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion. As with clubbing, it is not at all sensitive for either of these conditions.

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Hippocrate’s fingers

Nail growth: Nail thickening and deformity often occurs with arterial insufficicency; also with fungal infections

Ulceration of the skin can occur in the setting of either venous or arterial disease.

Capillary Refill: Push on the tip of the great toe or the nail bed until blanching occurs. Then release and note how long it takes for the red color to return, a reflection of blood inflow to the distal aspect of the lower extremity. Longer then 2-3 seconds is considered abnormal and consistent with arterial insufficiency. Refill may also be delayed in the setting of significant hypovolemia, as decreased blood volume available for perfusion is shunted away from the extremities to feed more vital organs.

Skin that is discolored from venous insufficiency blanches when pushed and it generally takes more then a few seconds for the bluish hue to return. Cellulitic areas, however, blanch and then very rapidly return to their bright red coloration. This can be helpful as it will occasionally be difficult to determine if infection and venous insufficiency are both present.

Tissue death (i.e. gangrene) of the fingers secondary to severe peripheral vascular disease

Inspection of heart region (precordium)

While examining the chest, any obvious bulging is noted, especially on the left side, which may indicate cardiac enlargement. This is best done by observing the patient sitting and looking at the anterior chest wall from an angle, comparing both sides of the rib cage to each other. Normally they should be symmetric. In patients with thin chest walls, the point of maximum impulse, or apical pulse, is sometimes apparent as a pulsation. Noting the location of the impulse may give some indication of the size and positioning of the heart, especially if it deviates from the expected apical site.

Since comprehensive evaluation of cardiac function is not limited to the heart, the doctor also considers other findings, such as presence of all pulses (especially the femoral pulses), distended neck veins, peripheral cyanosis, edema, blood pressure, and respiratory status.

You should inspect the precordium, assess the apical impulse, identify the jugular venous pulsations.

During the examination the patient should be lying with his upper body somewhat elevated. If you are examining the patient’s anterior chest, visualize the underlying cardiac chambers and great vessels: the right and left ventricles, the aorta, and the pulmonary artery. Try to detect any abnormal pulsations that they can produce.

You can see cardiovascular pulsations more easy when patients are thin. In contrast, a thick wall can obscure them, and lung tissue can intervene when age or emphysema increases the anteroposterior to detect pulsations. Observe for any pulsation on the aortic, pulmonary area or the right ventricular area (lower half of the sternum and the parasternal area, espesially on the left). Observe for diffuse lift or heave. You can revealed pulsation of aortic aneurism or pulsation of increased pressure or flow in the pulmonary artery; in patients with anemia, hyperthyroidism, fever, where cardiac output is increased, a brief right ventricular impulse may be revealed in epigastrium.

In at least half of adults the apical impulse may be revealed in the apical or left ventricular area (the 5^th intercostal space or just medial to the midclavicular line), especially in thin persons. Normally the apical impulse is just medial to the midclavicular line in either the 5^th or 4^th interspase.

The apical impulse may be displaced upward and to the left by pregnansy or a high left diafragm. It may also be displaced by deformities of the chest wall and by heart disease. When cardiac output is increased, as in anemia, hyperthyroidism, fever, or pregnansy, the apical impulse can have an increased amplitude.

Normally the apical impulse is a light tap, seen in an area about 1 cm to 2 cm in diameter or less.

Look and feel carefully for any extra impulses, such as those that can coincide with S₃ to S₄.

A rare patients has dextrocardia – a heart situated in the right chest. The cardiac impulses will then be found on the right side.

The pulsation of the abdominal aorta may often be seen in a normal person. In addition, the pulsation of the enlarged right ventricle can sometimes been seen.

At left ventricular enlargement the apical impulse may be displaced to the left and downward. It’s square occupies 3 cm or more, two or more inrterspases. When the ventricle is dilated as well as hypertrophied, the apical impulse is also both displaced and enlarged.

Inspection of precordial (heart) region

You should inspect the precordium, assess the apical impulse, identify the jugular venous pulsations.

You can see cardiovascular pulsations more easy when patients are thin. In contrast, a thick wall can obscure them, and lung tissue can intervene when age or emphysema increases the anteroposterior to detect pulsations. Observe for any pulsation on the aortic, pulmonary area or the right ventricular area (lower half of the sternum and the parasternal area, especially on the left). Observe for diffuse lift or heave. You can reveal pulsation of aortic aneurism or pulsation of increased pressure or flow in the pulmonary artery; in patients with anaemia, hyperthyroidism, fever, where cardiac output is increased, a brief right ventricular impulse may be revealed in epigastrium.

While examining the chest, any obvious bulging is noted, especially on the left side, which may indicate cardiac enlargement. This is best done by observing the patient sitting and looking at the anterior chest wall from an angle, comparing both sides of the rib edge to each other. Normally they should be symmetric. In patients with thin chest walls, the point of maximum impulse, or apical pulse, is sometimes apparent as a pulsation. Noting the location of the impulse may give some indication of the size and positioning of the heart, especially if it deviates from the expected apical site.

Cardiac hump-back can be seen during inspection of the precordium. This is bulging of the area over the heart. The degree of protrusion depending on the enlargement and hypertrophy of the heart (provided these defects develop in childhood when the chest is liable to changes). General protrusion of the cardiac region and levelling of the costal interspaces are observed in massive effusive pericarditis. The cardiac hump should be differentiated from deformation of the chest caused by changes in the bones, e.g. in rickets.

Apical and heart beat, their peculiarities

In patients with underdeveloped subcutaneous fat and asthenic body build, a limited rhythmic pulsation (the apex beat) can be seen in the fifth interspace, medially of the midclavicular line. This is caused by the thrust of the heart apex against the chest wall. In cardiac pathology, the apex beat may produce a stronger pulsation. If precordial depression is found instead of prominence, the apex beat is said to be negative. It occurs in adhesive pericarditis because of adhesion of the parietal and visceral layers of the pericardium.

Pulsation is sometimes observed to the left of the sternal line over a vast area extending to the epigastric region. This is the so-called cardiac beat. It is due to contractions of the enlarged right ventricle; a synchronous pulsation can also be seen in the upper epigastric region (below the xyphoid process).

Pulsation in the region of the heart base is sometimes observed. Pulsation of the aorta can be felt in the second costal interspace to the right of the sternum; it appears either during its strong dilation (aneurysm of the ascending part and of the arch of the aorta; aortic valve incompetence), or in sclerotic affection of the overlying right lung. In rare cases, the aneurysm of the ascending aorta can destroy the ribs and the sternum. Elastic throbbing tumour is then seen. Pulsation in the second and third costal interspace, that can be seen by an unaided eye, is caused by dilatation of the pulmonary trunk. It occurs in patients with mitral stenosis, marked hypertension in the lesser circulation, patent ductus arteriosus with massive discharge of the blood from the aorta to the pulmonary trunk, and in primary pulmonary hypertension. Pulsation occurring lower, in the third and fourth interspace to the left of the sternum, can be due to the aneurysm of the heart in post-infarction patients.

The apical impulse may be displaced upward and to the left by pregnancy or a high left diaphragm. It may also be displaced by deformities of the chest wall and by heart disease. When cardiac output is increased, as in anaemia, hyperthyroidism, fever, or pregnancy, the apical impulse can have an increased amplitude.

Normally the apical impulse is a light tap, seen in an area about 1 cm to 2 cm in diameter or less.

Look and feel carefully for any extra impulses, such as those that can coincide with S₃ to S₄.

A rare patients has dextrocardia – a heart situated in the right chest. The cardiac impulses will then be found on the right side.

At left ventricular enlargement the apical impulse may be displaced to the left and downward. It’s square occupies 3 cm or more, two or more interspaces. When the ventricle is dilated as well as hypertrophied, the apical impulse is also both displaced and enlarged.

Palpation

Palpation is used to assess the texture of a patient’s tissue (such as swelling or muscle tone), to locate the spatial coordinates of particular anatomical landmarks (e.g., to assess range and quality of joint motion), and assess tenderness through tissue deformation (e.g. provoking pain with pressure or stretching). In summary, palpation might be used either to determine painful areas and to qualify pain felt by patients, or to locate three-dimensional coordinates of anatomical landmarks to quantify some aspects of the palpated subject.

Palpation is typically used for thoracic and abdominal examinations, but can also be used to diagnose edema and to measure the pulse..

Quantitative palpation of anatomical landmarks for measurements must occur according strict protocols if one wishes to achieve reproducible measurements. Palpation protocols are usually based on well-described definitions for the location of anatomical, usually skeletal, landmarks.

Palpation of the heart helps reveal more accurately the apex beat, the presence of the cardiac beat, the visible pulsation, or detect cat’s purr symptom. Palpation is useful in determine the size of the heart by feeling for the point of maximum impulse, which ordinarily corresponds to the apex.

PRECORDIUM

Inspection and palpation of the precordium usually follows the assessment of jugular venous pressure. The process precedes auscultation of the precordium.

The precordium is the front of the chest wall over the heart. Of particular importance when inspecting and palpating the precordium is the apex/mitral area (left 5th intercostal space, mid-clavicular line), as this is where the apex beat can usually be felt (and where mitral valve sounds are best auscultated).

CHEST SCARS AND DEFORMITY

When inspecting the precordium it is important to look for scars suggesting cardiac surgery. A mid-line sternotomy suggests a coronary artery bypass graft (CABG) or valve replacement. A left sub-mammary thoracotomy scar suggests mitral valvotomy. It is also important to note if the patient has an implantable pacemaker or cardiovertor/defibrillator. There will be a scar just below the left (occasionally right) clavicle and a bulge in the skin may be visible.

Signs of chest deformity should be noted as this can affect examination of the heart. For example, pectus carinatum (‘pigeon chest’) or pectus excavatum (funnel chest) can displace the heart, affecting palpation and auscultation of the precordium.

THE APEX BEAT

The apex is the tip or summit of the heart and the apex beat is the impact of the organ against the chest wall during systole. It is primarily due to recoil of the heart’s apex as blood is expelled during systole. As it correlates with left ventricular contraction, apex beat assessment provides an indication of left ventrical functioning.

Sometimes the apex beat is not palpable. This is usually due to a thick chest wall, emphysema, pericardial infusion, shock or dextrocardia. Rolling the patient into the left lateral position may enable the apex beat to be palpated.

The location and the character of the apex beat should be noted. Its normal location is the 5th/6th intercostal space mid-clavicular line, with the patient lying in a supine position at approximately 45 degs. Causes of a displaced apex beat include:

– Cardiomegaly – a common cause of inferior or lateral displacement;

– Mediastinal shift – a large pleural effusion or tension pneumothorax can push the apex beat (and sometimes the trachea) away from the affected side; a collapsed lung can draw the apex beat towards the affected side;

– Dextrocardia (Douglas et al, 2005; O’Neill et al, 1989).

ASSESSMENT OF THE APEX BEAT

Experienced practitioners can assess the character of the apex beat. A normal apex beat is short and sharp. Abnormal findings of the apex beat include: l Heaving – a sustained and forceful heave caused by an obstruction, for example aortic stenosis or systemic hypertension, to the flow of blood out of the heart;

– Thrusting – caused by volume overload;

– Tapping – felt in mitral stenosis;

– Diffuse – left ventricular failure and cardiomyopathy;

– Thrills – transmitted heart murmurs – similar to a purring cat.

THE PROCEDURE

Explain the procedure to the patient.

– Ensure the patient is in a supine position at an angle of 45 degs.

– Wile ensuring privacy and maintaining dignity, expose the patient’s chest.

– Ask the patient to breathe normally.

– Inspect the precordium for cardiac surgery-related scars. In a female patient, it may be necessary to lift up the left breast to allow full inspection of the precordium. Note any chest shape deformity and unusual pulsations.

– Locate and palpate the apex beat. This is usually the 5th/6th intercostal space mid-clavicular line. To locate, place the right hand with the fingers outstretched against the left side of the patient’s chest wall.

– If locating the apex beat is difficult, roll the patient into the left lateral position. Although this may make it easier to locate the apex beat, the lateral position will push the apex beat further outwards as the heart has a degree of mobility in the chest.

– Using the tip of your finger, assess the character of the apex beat.

– If the apex beat is displaced, check that the trachea is central – if the trachea is deviated, this indicates mediastinal shift.

– Palpate to the left of the sternum to ascertain whether the hand visibly lifts with each ventricular contraction. Place the heel of the right hand with the fingers pointing upwards over the precordium to the left of the sternum. Iormal circumstances the movement related to respirations will be felt. If the hand is lifted with each ventricular contraction then this is referred to as a left parasternal heave, usually due to right ventricular hypertrophy or volume overload.

– Proceed to auscultation of the precordium. This process is described iext week’s article in this series.

PROFESSIONAL RESPONSIBILITIES

This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

Apex beat palpation

Technique of palpation: In order to determine the apex beat, the palm of the right hand is placed on the patient’s chest. (The left mammary gland in women is first moved upward and to the right.) The base of the hand should be rested on the sternum, while the fingers should be directed toward the axillary region, between the 3rd and 4th ribs. The terminal phalanges of three fingers should be flexed to form a right angle to the surface of the chest, and moved slowly along the interspaces toward the sternum until the moderately pressing fingers feel the movement of the heart apex. If the apex beat is felt over a considerable area, its borders are outlined hy locating the extreme left and lower points of the protruding area, which is considered to be the point of the apex beat. The apex beat can be better detected if the patient slightly leans forward, or by palpation during a deep expiration: in this position the heart is pressed closer to the chest wall.

video:palpation_apex_beat

A normal apex beat is found in the fifth interspace, 1-1.5 cm toward the sternum from the left midclavicular line. When the patient lies on his left side, the beat is displaced 3-4 cm to the left, and 1-1.5 cm to the right when the patient lies on the right side.

Video:inspection_palpation_heart

Properties of the apex beat: Stable displacement of the apex beat may depend on the changes in the heart itself or the adjacent organs. For example, if the left ventricle is enlarged, the apex beat is displaced to the left to the axillary line, and downwards to the 6th and 7th interspace. If the right ventricle is dilated, the apex beat may be displaced to the left as well because the left ventricle is moved to the left by the distended right ventricle. In cases with abnormal congenital heart position, e.g. in dextrocardia, the apex beat is felt in the fifth costal interspace, 1-1.5 cm toward the sternum from the right midclavicular line The position of the apex beat depends also on the diaphragm. Increased pressure in the abdominal cavity (in pregnancy, ascites, meteorism, tumours) displaces the apex beat upward and to the left because the heart is not only lifted but also turned to the left to assume a horizontal position. If the diaphragm is low (after childbirth, wasting, visceroptosis), the apex beat is displaced downward and slightly to the right to assume the more vertical position.

In the presence of effusion or gas in the right pleural cavity, the apex beat is displaced to the left accordingly. Pleuropericardial adhesions and sclerotic affection of the lungs due to growth of connective tissue in them displace the heart to the involved side. In patients with left-sided pleurisy with effusion and in accumulation of the fluid in the pericardial region, the apex beat disappears. In about one third of cases the apex is impalpable (covered by the rib).

Pathological changes:The apex is usually at a lower interspace and more lateral in a patient with cardiac enlargement. The apex is felt by placing the fingertips or the palmar aspect of the fingers and hand at the fifth intercostal space and left midclavicular line.

Stable displacement of the apex beat may depend on the changes in the heart itself or the adjacent organs. For example, if the left ventricle is enlarged, the apex beat is displaced to the left to the axillary line, and downwards to the 6th and 7th interspace. If the right ventricle is dilated, the apex beat may be displaced to the left as well because the left ventricle is moved to the left by the distended right ventricle. In cases with abnormal congenital heart position, e.g. in dextrocardia, the apex beat is felt in the fifth costal interspace, 1-1.5 cm toward the sternum from the right midclavicular line The position of the apex beat depends also on the diaphragm. Increased pressure in the abdominal cavity (in pregnancy, ascites, meteorism, tumours) displaces the apex beat upward and to the left because the heart is not only lifted but also turned to the left to assume a horizontal position. If the diaphragm is low (after childbirth, wasting, visceroptosis), the apex beat is displaced downward and slightly to the right to assume the more vertical position.

While feeling for the point of maximum impulse, the doctor notes the presence of vibratory thrills and pericardial friction rubs. Thrills are palpable vibrations most commonly produced by the flow of blood from one chamber of the heart to another through a narrowed or abnormal opening, such as a stenotic valve or a septal defect. They are best felt with the ball of the hand (palmar surface at the base of the fingers) and during expiration. Thrills feel similar to the placing of one’s hand on a purring cat.

Pericardial friction rubs are scratchy, high-pitched grating sounds, similar to pleural friction rubs, except that they are not affected by changes in respiration. This is a useful clue in differentiating the two rubs, because the pleural rub will cease if the child holds his breath, but the pericardial rub will not. Both thrills and rubs are abnormal and must be reported for further evaluation.

CARDIAC ASSESSMENT

Percussion.

Percussion is used mainly to determine the size, position and shape of the heart by outlining its borders and to check the vascular bundle width. Dullness is normally heard over the left area of the heart and partially over the right.

The relative and absolute heart dullness, the sequence of percussion of heart dullness borders, their normal indicies

The right contour of dullness of the heart and the vascular bundle is formed (from top to bottom) by the superior vena cava to the upper edge of the 3rd rib and by the right atrium at the bottom. The left contour is formed by the left part of the aortic arch at the top, then by the pulmonary trunk, by the auricle of the left atrium at the level of the 3rd rib and downward by a narrow strip of the left ventricle. The anterior surface of the heart is formed by the right ventricle. Being an airless organ, the heart gives a dull percussion sound. But since it is partly covered on its sides by the lungs, dullness is dual in its character, i.e. it is relative (deep) and absolute (superficial). The relative cardiac dullness is the projection of its anterior surface onto the chest. It corresponds to the true borders of the heart, while the absolute dullness corresponds to the anterior surface of the heart that is not covered by the lungs. Percussion can be done with the patient in both erect and lying position. It should, however, be remembered that the area of cardiac dullness in the vertical position is smaller than in the horizontal. This is due to mobility of the heart and the displacement of the diaphragm as the patient changes his posture.

Determining relative cardiac dullness. When determining the borders of relative cardiac dullness, interspaces should be percussed in order to avoid lateral distribution of vibrations along the ribs. The percussion stroke should be of medium strength. The pleximeter-inger should be tightly pressed against the chest so that the percussion vibration might penetrate deeper regions.

When determining the border of relative dullness, the remotest points of the cardiac contour are first found on the right, then on the left, and finally at the top. Since the border of cardiac dullness depends on the position of the diaphragm, the lower border of the right lung is first determined in the midclavicular line; its normal position is at the level of the 6th rib. The position of the lower border of the lung indicates the level of the diaphragm. The pleximeter-finger is then moved one interspace above the lower border of the right lung and placed parallel to the right border of the heart being determined (normally, in the 4th costal interspace). Percussion is continued by moving the pleximeter-finger gradually along the interspace toward the heart until the percussion sound dulls. The right border of the heart is marked by the outer edge of the finger directed toward a clear resonant sound. Its normal position is 1 cm laterally of the right edge of the sternum.

The left border of the relative cardiac dullness is determined in the interspace, where the apex beat is present. The apex beat is therefore first determined by palpation, and the pleximeter-fmger is then placed laterally of this point, parallel to the sought border, and the interspace is percussed toward the sternum. If the apex beat cannot be determined, the heart should be percussed in the 5th interspace from the anterior axillary line toward the sternum. The left border of relative cardiac dullness is located 1-2 cm medially of left midclavicular line; it coincides with the apex beat.

The upper border of the relative cardiac dullness is determined 1 cm to the left of the left sternal line. To that end, the pleximeter-fmger is placed perpendicularly to the sternum, near its left margin, and then moved downward until dullness appears. The normal upper border of the relative cardiac dullness is in the 3rd interspace.

video:relative_cardiac_dullness

Once the area of relative cardiac dullness of the heart has been established, its transverse length is measured by a measuring tape, from the extreme points of the relative dullness to the anterior median line. The normal distance from the right border of relative cardiac dullness (usually in the 4th interspace) to the anterior median line is 3 or 4 cm, while the distance from the left border of relative cardiac dullness (usually in the 5th interspace) to the same line is 8 or 9 cm. The sum of these lengths is the transverse length of relative cardiac dullness (normally 11-13 cm).

video:heart_diameter

Video:percussion_heart2

video:vacular_bundle

The shape of the heart can be determined by percussion of the borders of the vascular bundle in the 2nd intercostal space on the right and left, and of relative cardiac dullness in the 4th or 3rd interspace on the right, and in the 5th, 4th, or 3rd interspace on the left. The pleximeter-finger is moved parallel to the borders of expected dullness and the elicited points of dullness are marked on the patient’s skin. The points are then connected by a line to mark the contours of the relative cardiac dullness. Normally, an obtuse angle is formed by the lines of the left heart contour between the vascular bundle and the left ventricle. The heart is of normal configuration in such cases. In pathological conditions, when the chambers of the heart are dilated, mitral and aortal configurations are distinguished.

Displacement of the left border of relative heart dullness proved by X-ray examination.

Determining absolute (superficial) cardiac dullness. The anterior wall of the heart is not covered by the lungs and the area of absolute cardiac dullness corresponds to the area of the heart. Percussion of this area gives dullness. To determine absolute dullness of the heart, light percussion strokes are needed. The right border uf absolute cardiac dullness is first elicited. The pleximeter-finger is placed on the right border of relative (deep) cardiac dullness, parallel to the sternum, and then moved medially, to the left, to dullness. The border is marked by the outer edge of the finger directed toward resonance. Iormal subjects this border parses along the left edge of the sternum.

To outline the left border of absolute cardiac dullness, the pleximeter-finger is placed slightly outside the border of relative cardiac dullness, and then moved medially to dullness. The left border of absolute cardiac dullness is normally 1-2 cm medially of the border of relative cardiac dullness. To elicit the upper border of absolute cardiac dullness, the pleximeter-finger is placed on the upper border of relative cardiac dullness and then moved downward to dullness. The superior border of absolute cardiac dullness is normally at the level of the 4th rib. It is sometimes difficult to differentiate between absolute and relative cardiac dullness, if percussion is done from the lungs to the heart. The pleximeter-finger should in such cases be placed at the centre of absolute dullness and then moved to its borders (from dullness to diminished dullness). The first sign of the admixed pulmonary resonance indicates the transition from the area of absolute dullness to the area of relative dullness.

video:absolute_cardiac_dullness

Border’s of cardiac dullness

Border s of relative cardiac dullness	Location
Right	1 cm laterally of the right edge of the sternum (4^th intercostal space)
upper	The upper edge of the IV rib (at the left parasternal line)
Left	1-2 cm medialy of left midclavicular line (5^th intercostal space)

Border s of absolute cardiac dullness	Location
Right	left sternal line (4^th intercostal space)
upper	The upper edge of the III rib (at the left parasternal line)
Left	1-2 cm medialy of left border of relative heart dullness (5^th intercostal space)

In pathological conditions borders of absolure heart dullness can change:

The width of vessel bundle, normal indicies and pathologiocal changes

The borders of the vascular bundle are determined by light percussion in the second intercostal space, to the right and left from the midclavicular line, toward the sternum. When the percussion sound dulls, a mark should be made by the outer edge of the finger. The right and left borders of vascular dullness are normally found along the edges of the sternum; the transverse length of dullness is 5—6 cm.

The square of heart dullness, normal indicies and pathologiocal changes

The heart transverse diameter is the sum of shortest distances between the left and right borders of the relative heart dullness to the medial line. It is about 11-13 cm in a healthy person.

The area of cardiac dullness can be modified by extracardiac factors. At high position of the diaphragm, the heart assumes a horizontal position and its transverse dimensions thus increase. When the diaphragm is low, the heart assumes the vertical position and its transverse diameter is thus diminished. Accumulation of liquid or air in one pleural cavity displaces cardiac dullness toward the healthy side; in atelectasis and pneumosclerosis, or in the presence of pleuropericardial adhesion the borders of cardiac dullness are displaced to the affected side. The area of absolute cardiac dullness markedly diminishes or disappears in pulmonary emphysema, while it increases in pneumosclerosis. The area of absolute dullness is also enlarged in the anterior displacement of the heart (e.g. by a mediastinal tumour, due to accumulation of fluid in the pericardium, or in dilatation of the right ventricle). The borders of relative dullness are displaced in the presence of enlarged heart chambers. Displacement to the right is due to dilatation of the right atrium and the right ventricle. If the left atrium or the conus of the pulmonary trunk is enlarged, the area of relative dullness is displaced upwards. Dilatation of the left ventricle displaces the area of relative dullness to the left. It should be remembered that a markedly enlarged and hypertrophied right ventricle displaces the left ventricle and can also displace the border of relative dullness to the left. Aortic dilatation increases the dullness area in the second interspace.

Inspection and palpation of area of heart and big vessels:

-heart hump;

-apex beat (location, area, height, strength, resistance, is it positive or negative);

-heart beat (if present);

-pulsations in the region of heart and big vessels (carotic arteries, jugular veins), in epigastrium. Pulsation and winding of temporal, subclavial, brachial arteries. Musse’s symptom.

-pulsation of the liver;

-vibration murmur (thrill or cat’s purr): its relation to the phase of heart cycle (systolic, diastolic), location. Positive venous pulsation. Presence of varicose widening veins on the legs.

Percussion (percussio cordis): define heart limits (right, left, upper borders) and compare the revealed data with indicies of a healthy individual.

Examination of a pulse

A pulse is a rhythmic fluctuations of arteries walls, caused by emission of blood into arterial bed and changes of blood pressure in it during systole and diastole. With each contraction the left ventricle ejects a volume of blood (a stroke volume) into the aorta and then into the arterial tree. A pressure wave moves rapidly through the arterial system where it can be felt as the arterial pulse. The spreading of a pulse wave depends on the ability of arteries walls to elastic extension and contraction.

Perypheric arterial pulse nay be assessed at carotic, axillary, cubital, radial, femoral, popliteal arteries, arteries of the foot and abdominal aorta.

A doctor checks a patient’s pulse at the bilateral radial artery. (Photograph by Dagmar Ehling. Science Source/Photo Researchers. Reproduced by permission.)

Popliteal arteries. Move down to the level of the knee allowing it to remain slightly bent. Place your hands around the knee and push the tips of your fingers into the popliteal fossa in an effort to feel the popliteal pulse. Note whether it feels simply pulsatile (normal) or enlarged and aneurysmal (uncommon). This artery is covered by a lot of tissue and can be difficult to identify, so you may need to push pretty hard. Even then, it may not be palpable, which is not clinically important if you can still identify the more distal pulses (see below).

video:Pulse_assessment

Pulse assessment. Purpose

Pulse assessment is performed to establish a baseline on a patient’s admission (from which to compare any significant changes), and to detect any abnormalities from the healthy state.

Precautions

As there may be no prior knowledge of the patient’s previous pulse recordings for comparison, it is important for the nurse or other health professional to know the range of normal values that apply to patients of different ages. Any known medical and surgical history or abnormal readings of any of the vital signs, as well as details

Pulses are assessed to identify the presence of arterial vascular disease. In general, the less prominent the pulses, the greater the chance that there is occlusive arterial disease. This is not a perfect correlation, however, as pulses may be palpable even when significant disease is present (e.g. may be affecting predominantly smaller, more distal blood vessels). A history of pain/cramps with activity suggestive of arterial insufficiency is also of great importance. The location of the blockage(s) will dictate the symptoms and findings. Aorto-iliac disease, for example, will cause symptoms in the hips/buttocks and a loss of the femoral pulse while disease affecting the more distal vessels will cause symptoms in the calves and feet of any current medication the patient is taking, should be obtained. Exertion, such as climbing stairs, may affect the results. Therefore the patient should have rested prior to having their pulse taken, and refrained from consuming tobacco, caffeinated drinks, and alcohol 30 minutes prior to the procedure. Of course, these precautions cannot be taken in an emergency situation.

Description

The pulse is checked as one indicator of abnormalities of the heart by observing the rate, rhythm, and the strength and tension of the beat against the arterial wall. The pulse may be recorded hourly to every four hours, or p.r.n. (when required), based on the patient’s condition. For example, the pulse may be recorded postoperatively every 15 minutes in the recovery room.

Preparation

The equipment required for pulse assessment is a watch with a sweep second hand or a digital readout. The pulse may be read where a surface artery runs over a bone, e.g. the radial artery (in the forearm), carotid artery (in the neck), temporal artery (at the temple), popliteal artery (at the back of the knee), or dorsalis pedal artery (at the instep). The radial artery in the wrist is the option used most often. The physician may choose such sites as the carotid artery pulse if atrial or ventricular problems are suspected.

To take the radial pulse, the patient should be sitting or lying comfortably, so that the readings are taken in similar positions each time and that there is little excitement to affect the results. The patient’s forearm should not be raised to a level higher than the heart, as this position will change the reading. The nurse should place the index, middle, and ring fingers over the radial artery, which is located above the wrist on the anterior surface of the thumb side of the wrist. Apply gentle pressure to avoid obstructing the patient’s blood flow. The rate, rhythm, strength and tension of the pulse should be noted. Using a watch, the pulsations that are felt where the artery rests against the bone are counted for half a minute, and the result doubled to give the beats per minute. However, any irregularities noted within the 30-second count means that the pulse should be recorded for one full minute to avoid any discrepancies.

Aftercare

The nurse should make the patient comfortable and reassure him or her that recording the pulse is part of normal health checks and that it is necessary to ensure the patient’s health is being correctly monitored. Any abnormalities in the pulse must be reported in the nurse’s notes and relayed to the attending physician.

Results

The average heart rate for older children and adults can range from 50 to 90 beats per minute (bpm). This is an average; rates vary between males and females, with age, and with the patient’s health and level of fitness. It is not abnormal for athletes to display a low pulse rate.

The pulse is an indicator of the health of the heart and the arterial circulation. Such factors as anxiety, medication, or pulmonary disease may also cause the heart rate to be faster or slower.

A low-volume, or weak, pulse may be caused by a number of factors, including myocardial infarction, shock, intracranial pressure, or the use of vasoconstrictor drugs.

Pulse pressure may become raised due to arteriosclerosis, as the heart has to pump harder to promote the flow of blood around the body. This high-pressure pulse is called a bounding pulse, and may also be caused by such conditions as fever, pregnancy, or thyrotoxicosis. It may also be an indicator that pulmonary disease is present.

Other conditions that can be detected in part by pulse assessment include tachycardia (a heartbeat that is too fast) and bradycardia (a heartbeat that is too slow). The nurse would also be able to detect missed heart beats and pulsus alternans (alternating strong and weak beats).

The pulse is recorded and compared with normal ranges for the patient’s age, gender, and medical condition, and a decision is made regarding the interpretation of the results as to whether any further action should be taken.

Properties of the pulse are assessed at the radial artery.

First the examiner should determine if the pulse can be equally felt on both arms. To that end both radial arteries should be palpated simultaneously he magnitude of pulse waves on both hands compared (normally it is the same). The pulse on one arm may happen to be lower (in unilateral structural abnormalities in peripheral course of the artery, its constriction, compression by a tumor etc.). Pulse may also be different when similar changes occur in in the brachial or subclavial artery, or due to compression of large arterial trunk by the aortic aneurism, mediastinal tumor, retrosternal goiter, or markedly enlarged left atrium.

Rrhythm. In healthy individuals cardiac contractions and pulse waves follow one another at regular intervals: the pulse is said to be rrhythmic or regular. Some pulse waves nat be missed or they may appear prematurely (in extrasystole) or pulse waves follow one another at irregular intervals ( fibrillation).

Pulse rate iormal conditions corresponds to the rate of cardiac contractions and is 60-80 per min.

If the pulse is arrhythmic the heart bets should be counted and compared with the pulse rate. During the frequent and irregular contractions of the heart, some systoles of the left ventricle can be so weak that the blood is not ejected into the aorta or the amount of blood is very small and the pulse wave does not reach the peripheral arteries. The difference between heart and pulse rate is called the pulse difficit while the pulse itself is called pulsus defcicens.

Pulse pressure is determined by the force that should be applied to the pulsating artery to compress it completely. This property depends on the magnitude of the systolic arterial pressure. If arterial pulse is normal, the artery can be compressed bya moderate pressure. A normal pulse is therefore of moderat tension. The higher the pressure, the more difficult is it to compress the artery (dull pulse or pulsus durus). If the arterial pressure is small, the artery is easy to compress and the pulse is called soft (pulsus mollis).

Volume of pulse. Pulse volume shows the artery filling with blood, which is turn depends on the amount of blood that is ejected during systole into the arterial system and which produses variations in the artery volume. Pulse volume depends on the stroke volume, on the total amount of circulating blood, and its diatribution in the body. If the stroke volume is normal and the artery is sufficiently filled with blood, the pulse is said to be full (pulsus plenus). In abnormal circulation and blood loss, pulse volume decreases (pulsus vacuus).

Pulse size – implies filling and tension.

If the pulse pressure and filling are high the pulse is called large-volume pulse or pulsus magnus or pulsus altus. (characteristic for aortic valse incompetence). Decreased pulse pressure and filling are typical for amall pulse (pulsus parvus)/ It occurs in aortic asenosis.

The pulse wave my be quite insignificant in shock, acute cardiac failure and massive loss of blood. This pulse is called thready (pulsus filiformis).

Properties of pulse on radial artery: symmetry (synchronous or asynchronous), frequency (accelerated, slowed, the pulse rate), rhythm (rhythmic, arhythmic), tension (of moderate tension, dull, soft), feeling (full, empty), size (high, small, thready), character (quick, slow), pulse deficiency (indicate the number of missing waves per min).

Presence of pulse on carotic, temporal, subclavial, femoral arteries, a.poplitea, a.dorsalis pedis, abdominal part of aorta, jugular veins.Quincke’s (capillary) pulse.

Assessment of blood pressure

Blood pressure (BP), sometimes referred to as arterial blood pressure, is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, “blood pressure” usually refers to the arterial pressure of the systemic circulation. During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure The blood pressure in the circulation is principally due to the pumping action of the heart Differences in mean blood pressure are responsible for blood flow from one location to another in the circulation. The rate of mean blood flow depends on the resistance to flow presented by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the heart through arteries and capillaries due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles Gravity affects blood pressure via hedrostatic forces (e.g., during standing) and valves in veins, breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins

The measurement blood pressure without further specification usually refers to the systemic arterial pressure measured at a person’s upper arm and is a measure of the pressure in the brachial artery, the major artery in the upper arm. A person’s blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure and is measured in millimetres of mercury (mmHg), for example 120/80.

Classification

Classification of blood pressure for adults
Category	systolic, mmHg	diastolic, mmHg
Hypotension	< 90	< 60
Desired	90–119	60–79
Prehypertension	120–139	80–89
Stage 1 Hypertension	140–159	90–99
Stage 2 Hypertension	160–179	100–109
Hypertensive crisis	≥ 180	≥ 110

The table on the right shows the classification of blood pressure adopted by the American Heart Association for adults who are 18 years and older It assumes the values are a result of averaging blood pressure readings measured at two or more visits to the doctor.

Blood pressures are usually categorised into three groups: low (90/60 or lower), high (140/90 or higher), and normal (values above 90/60 and below 130/80).

Normal range of blood pressure

While average values for arterial pressure could be computed for any given population, there is often a large variation from person to person; arterial pressure also varies in individuals from moment to moment. Additionally, the average of any given population may have a questionable correlation with its general health; thus the relevance of such average values is equally questionable. However, in a study of 100 human subjects with no known history of hypertension, an average blood pressure of 112/64 mmHg was found,which are currently classified as desirable or “normal” values. Normal values fluctuate through the 24-hour cycle, with highest readings in the afternoons and lowest readings at night.

Various factors, such as age and sex influence average values, influence a person’s average blood pressure and variations. In children, the normal ranges are lower than for adults and depend on height. As adults age, systolic pressure tends to rise and diastolic tends to fall In the elderly, blood pressure tends to be above the normal adult range,largely because of reduced flexibility of the arteries. Also, an individual’s blood pressure varies with exercise, emotional reactions, sleep, digestion and time of day.

Differences between left and right arm blood pressure measurements tend to be random and average to nearly zero if enough measurements are taken. However, in a small percentage of cases there is a consistent difference greater than 10 mmHg which may need further investigation, e.g. for obstructive arterial disease.

The risk of cardiovascular disease increases progressively above 115/75 mmHg. In the past, hypertension was only diagnosed if secondary signs of high arterial pressure were present, along with a prolonged high systolic pressure reading over several visits. Regarding hypotension, in practice blood pressure is considered too low only if noticeable symptoms are present

Clinical trials demonstrate that people who maintain arterial pressures at the low end of these pressure ranges have much better long term cardiovascular health. The principal medical debate concerns the aggressiveness and relative value of methods used to lower pressures into this range for those who do not maintain such pressure on their own. Elevations, more commonly seen in older people, though often considered normal, are associated with increased morbidity and mortality.

Physiology

There are many physical factors that influence arterial pressure. Each of these may in turn be influenced by physiological factors, such as: diet, exercise, disease, drugs or alcohol, stress, and obesity.

Some physical factors are:

· Volume of fluid or blood volume, the amount of blood that is present in the body. The more blood present in the body, the higher the rate of blood return to the heart and the resulting cardiac output. There is some relationship between dietary salt intake and increased blood volume, potentially resulting in higher arterial pressure, though this varies with the individual and is highly dependent on autonomic nervous system response and the renin-angiotensin system.

· Resistance. In the circulatory system, this is the resistance of the blood vessels. The higher the resistance, the higher the arterial pressure upstream from the resistance to blood flow. Resistance is related to vessel radius (the larger the radius, the lower the resistance), vessel length (the longer the vessel, the higher the resistance), blood viscosity, as well as the smoothness of the blood vessel walls. Smoothness is reduced by the build up of fatty deposits on the arterial walls. Substances called vasoconstrictors can reduce the size of blood vessels, thereby increasing blood pressure. Vasodilators (such as nitroglycerin) increase the size of blood vessels, thereby decreasing arterial pressure. Resistance, and its relation to volumetric flow rate (Q) and pressure difference between the two ends of a vessel are described by Poiseuille’s Law.

· Viscosity, or thickness of the fluid. If the blood gets thicker, the result is an increase in arterial pressure. Certain medical conditions can change the viscosity of the blood. For instance, anemia (low red blood cell concentration), reduces viscosity, whereas increased red blood cell concentration increases viscosity. It had been thought that aspirin and related “blood thinner” drugs decreased the viscosity of blood, but instead studies found that they act by reducing the tendency of the blood to clot.

In practice, each individual’s autonomic nervous system responds to and regulates all these interacting factors so that, although the above issues are important, the actual arterial pressure response of a given individual varies widely because of both split-second and slow-moving responses of the nervous system and end organs. These responses are very effective in changing the variables and resulting blood pressure from moment to moment.

Moreover, blood pressure is the result of cardiac output increased by peripheral resistance: blood pressure = cardiac output X peripheral resistance. As a result, an abnormal change in blood pressure is often an indication of a problem affecting the heart’s output, the blood vessels’ resistance, or both. Thus, knowing the patient’s blood pressure is critical to assess any pathology related to output and resistance.

Regulation

The endogenous regulation of arterial pressure is not completely understood, but the following mechanisms of regulating arterial pressure have been well-characterized:

• Baroreceptor reflex: Baroreceptors in the high pressure receptor zones detect changes in arterial pressure. These baroreceptors send signals ultimately to the medulla of the brain stem, specifically to the Rostral ventrolateral medulla (RVLM). The medulla, by way of the autonomic nervous system, adjusts the mean arterial pressure by altering both the force and speed of the heart’s contractions, as well as the total peripheral resistance. The most important arterial baroreceptors are located in the left and right carotid sinuses and in the aortic arch.

• Renin-angiotensin system (RAS): This system is generally known for its long-term adjustment of arterial pressure. This system allows the kidney to compensate for loss in blood volume or drops in arterial pressure by activating an endogenous vasoconstrictor known as angiotensin II.

• Aldosterone release: This steroid hormone is released from the adrenal cortex in response to angiotensin II or high serum potassium levels. Aldosterone stimulates sodium retention and potassium excretion by the kidneys. Since sodium is the main ion that determines the amount of fluid in the blood vessels by osmosis, aldosterone will increase fluid retention, and indirectly, arterial pressure.

• Baroreceptors in low pressure receptor zones (mainly in the venae cavae and the pulmonary veins, and in the atria) result in feedback by regulating the secretion of antidiuretic hormone (ADH/Vasopressin), renin and aldosterone. The resultant increase in blood volume results an increased cardiac output by the Frank–Starling law of the heart, in turn increasing arterial blood pressure.

These different mechanisms are not necessarily independent of each other, as indicated by the link between the RAS and aldosterone release. Currently, the RAS is targeted pharmacologically by ACE inhibitors and angiotensin II receptor antagonists. The aldosterone system is directly targeted by spironolactone, an aldosterone antagonist. The fluid retention may be targeted by diuretics; the antihypertensive effect of diuretics is due to its effect on blood volume. Generally, the baroreceptor reflex is not targeted in hypertension because if blocked, individuals may suffer from orthostatic hypotension and fainting.

Measurement

A medical student checking blood pressure using a sphygmomanometer and stethoscope.

Arterial pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure Blood pressure values are generally reported in millimetres of mercury (mmHg), though aneroid and electronic devices do not use mercury.

For each heartbeat, blood pressure varies between systolic and diastolic pressures. Systolic pressure is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the ventricles are contracting. Diastolic pressure is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood. An example of normal measured values for a resting, healthy adult human is 120 mmHg systolic and 80 mmHg diastolic (written as 120/80 mmHg, and spoken [in the US and UK] as “one-twenty over eighty”).

Systolic and diastolic arterial blood pressures are not static but undergo natural variations from one heartbeat to another and throughout the day (in a circadian rhythm). They also change in response to stress, nutritional factors, drugs, disease, exercise, and momentarily from standing up. Sometimes the variations are large. Hypertension refers to arterial pressure being abnormally high, as opposed to hypotension, when it is abnormally low. Along with body temperature, respiratory rate, and pulse rate, blood pressure is one of the four main vital signs routinely monitored by medical professionals and healthcare providers

Measuring pressure invasively, by penetrating the arterial wall to take the measurement, is much less common and usually restricted to a hospital setting.

Noninvasive

The noninvasive auscultatory and oscillometric measurements are simpler and quicker than invasive measurements, require less expertise, have virtually no complications, are less unpleasant and less painful for the patient. However, noninvasive methods may yield somewhat lower accuracy and small systematic differences iumerical results. Noninvasive measurement methods are more commonly used for routine examinations and monitoring.

Palpation

A minimum systolic value can be roughly estimated by palpation, most often used in emergency situations, but should be used with caution. It has been estimated that, using 50% percentiles, carotid, femoral and radial pulses are present in patients with a systolic blood pressure > 70 mmHg, carotid and femoral pulses alone in patients with systolic blood pressure of > 50 mmHg, and only a carotid pulse in patients with a systolic blood pressure of > 40 mmHg.

A more accurate value of systolic blood pressure can be obtained with a sphygmomanometer and palpating the radial pulse. The diastolic blood pressure cannot be estimated by this method. The American Heart Association recommends that palpation be used to get an estimate before using the auscultatory method.

Auscultatory

Auscultatory method aneroid sphygmomanometer with stethoscope

Mercury manometer

The auscultatory method (from the Latin word for “listening”) uses a stethoscope and a sphygmomanometer. This comprises an inflatable (Riva-Rocci) cuff placed around the upper arm at roughly the same vertical height as the heart, attached to a mercury or aneroid manometer. The mercury manometer, considered the gold standard, measures the height of a column of mercury, giving an absolute result without need for calibration and, consequently, not subject to the errors and drift of calibration which affect other methods. The use of mercury manometers is often required in clinical trials and for the clinical measurement of hypertension in high-risk patients, such as pregnant women.

A cuff of appropriate size is fitted smoothly and snugly, then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. Listening with the stethoscope to the brachial artery at the elbow, the examiner slowly releases the pressure in the cuff. When blood just starts to flow in the artery, the turbulent flow creates a “whooshing” or pounding (first Korotkoff sound). The pressure at which this sound is first heard is the systolic blood pressure. The cuff pressure is further released until no sound can be heard (fifth Korotkoff sound), at the diastolic arterial pressure.

The auscultatory method is the predominant method of clinical measurement.

Oscillometric

The oscillometric method was first demonstrated in 1876 and involves the observation of oscillations in the sphygmomanometer cuff pressure which are caused by the oscillations of blood flow, i.e., the pulse. The electronic version of this method is sometimes used in long-term measurements and general practice. It uses a sphygmomanometer cuff, like the auscultatory method, but with an electronic pressure sensor (transducer) to observe cuff pressure oscillations, electronics to automatically interpret them, and automatic inflation and deflation of the cuff. The pressure sensor should be calibrated periodically to maintain accuracy.

Oscillometric measurement requires less skill than the auscultatory technique and may be suitable for use by untrained staff and for automated patient home monitoring.

The cuff is inflated to a pressure initially in excess of the systolic arterial pressure and then reduced to below diastolic pressure over a period of about 30 seconds. When blood flow is nil (cuff pressure exceeding systolic pressure) or unimpeded (cuff pressure below diastolic pressure), cuff pressure will be essentially constant. It is essential that the cuff size is correct: undersized cuffs may yield too high a pressure; oversized cuffs yield too low a pressure. When blood flow is present, but restricted, the cuff pressure, which is monitored by the pressure sensor, will vary periodically in synchrony with the cyclic expansion and contraction of the brachial artery, i.e., it will oscillate. The values of systolic and diastolic pressure are computed, not actually measured from the raw data, using an algorithm; the computed results are displayed.

Oscillometric monitors may produce inaccurate readings in patients with heart and circulation problems, which include arterial sclerosis, arrhythmia, preeclampsia, pulsus alternans, and pulsus paradoxus.

In practice the different methods do not give identical results; an algorithm and experimentally obtained coefficients are used to adjust the oscillometric results to give readings which match the auscultatory results as well as possible. Some equipment uses computer-aided analysis of the instantaneous arterial pressure waveform to determine the systolic, mean, and diastolic points. Since many oscillometric devices have not been validated, caution must be given as most are not suitable in clinical and acute care settings.

The term NIBP, for non-invasive blood pressure, is often used to describe oscillometric monitoring equipment.

Continuous noninvasive techniques (CNAP)

Continuous Noninvasive Arterial Pressure (CNAP) is the method of measuring arterial blood pressure in real-time without any interruptions and without cannulating the human body. CNAP combines the advantages of the following two clinical “gold standards”: it measures blood pressure continuously in real-time like the invasive arterial catheter system and it is noninvasive like the standard upper arm sphygmomanometer . Latest developments in this field show promising results in terms of accuracy, ease of use and clinical acceptance.

Non-occlusive techniques: the Pulse Wave Velocity (PWV) principle

Since the 90s a novel family of techniques based on the so-called Pulse wave velocity (PWV) principle have been developed. These techniques rely on the fact that the velocity at which an arterial pressure pulse travels along the arterial tree depends, among others, on the underlying blood pressure. Accordingly, after a calibration maneuver, these techniques provide indirect estimates of blood pressure by translating PWV values into blood pressure values

The main advantage of these techniques is that it is possible to measure PWV values of a subject continuously (beat-by-beat), without medical supervision, and without the need of inflating brachial cuffs. PWV-based techniques are still in the research domain and are not adapted to clinical settings.

White-coat hypertension

For some patients, blood pressure measurements taken in a doctor’s office may not correctly characterize their typical blood pressure. In up to 25% of patients, the office measurement is higher than their typical blood pressure. This type of error is called white-coat hypertension (WCH) and can result from anxiety related to an examination by a health care professional The misdiagnosis of hypertension for these patients can result ieedless and possibly harmful medication. WCH can be reduced (but not eliminated) with automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic.

Debate continues regarding the significance of this effect.^] Some reactive patients will react to many other stimuli throughout their daily lives and require treatment. In some cases a lower blood pressure reading occurs at the doctor’s office

Home monitoring

Ambulatory blood pressure devices that take readings every half hour throughout the day and night have been used for identifying and mitigating measurement problems like white-coat hypertension. Except for sleep, home monitoring could be used for these purposes instead of ambulatory blood pressure monitoring.^[ Home monitoring may be used to improve hypertension management and to monitor the effects of lifestyle changes and medication related to blood pressure. Compared to ambulatory blood pressure measurements, home monitoring has been found to be an effective and lower cost alternative,^[but ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs.

Aside from the white-coat effect, blood pressure readings outside of a clinical setting are usually slightly lower in the majority of people. The studies that looked into the risks from hypertension and the benefits of lowering blood pressure in affected patients were based on readings in a clinical environment.

When measuring blood pressure, an accurate reading requires that one not drink coffee, smoke cigarettes, or engage in strenuous exercise for 30 minutes before taking the reading. A full bladder may have a small effect on blood pressure readings; if the urge to urinate arises, one should do so before the reading. For 5 minutes before the reading, one should sit upright in a chair with one’s feet flat on the floor and with limbs uncrossed. The blood pressure cuff should always be against bare skin, as readings taken over a shirt sleeve are less accurate. During the reading, the arm that is used should be relaxed and kept at heart level, for example by resting it on a table

Since blood pressure varies throughout the day, measurements intended to monitor changes over longer time frames should be taken at the same time of day to ensure that the readings are comparable. Suitable times are:

· immediately after awakening (before washing/dressing and taking breakfast/drink), while the body is still resting,

· immediately after finishing work.

Automatic self-contained blood pressure monitors are available at reasonable prices, some of which are capable of Korotkoff’s measurement in addition to oscillometric methods, enabling irregular heartbeat patients to accurately measure their blood pressure at home.

Invasive

Arterial blood pressure (BP) is most accurately measured invasively through an arterial line. Invasive arterial pressure measurement with intravascular cannule involves direct measurement of arterial pressure by placing a cannula needle in an artery (usually radial, femoral, dorsalis pedis or brachial).

The cannula must be connected to a sterile, fluid-filled system, which is connected to an electronic pressure transducer. The advantage of this system is that pressure is constantly monitored beat-by-beat, and a waveform (a graph of pressure against time) can be displayed. This invasive technique is regularly employed in human and veterinary intensive care medicine, anesthesiology, and for research purposes.

Cannulation for invasive vascular pressure monitoring is infrequently associated with complications such as thrombosis, infection, and bleeding. Patients with invasive arterial monitoring require very close supervision, as there is a danger of severe bleeding if the line becomes disconnected. It is generally reserved for patients where rapid variations in arterial pressure are anticipated.

Invasive vascular pressure monitors are pressure monitoring systems designed to acquire pressure information for display and processing. There are a variety of invasive vascular pressure monitors for trauma, critical care, and operating room applications. These include single pressure, dual pressure, and multi-parameter (i.e. pressure / temperature). The monitors can be used for measurement and follow-up of arterial, central venous, pulmonary arterial, left atrial, right atrial, femoral arterial, umbilical venous, umbilical arterial, and intracranial pressures.

Methods of blood pressure measuring; principles of definition of blood pressure by N.S.Korotkov:

Blood pressure in the arterial system varies with the cardiac cycle, reaching a systolic peak and diastolic trough, the levels of which are measured by sphygmomanometer. The difference between systolic and diastolic pressures is known as the pulse pressure.

The technique. The patient should be as comfortable and relaxed as possible, his arm free of clothing. Center the inflatable bagover the brachial artery on the inside of the arm. The lower border shoud be about 2.5 cm above the antecubital crease. Position of the patient’s arm so that it is slightly flexed at the elbow. Support it yourself or rest it on a pillow, table, or other steady surface, making sure that the cuff lies at heart level. Find the brachial artery-usually just medial to the biceps tendion.

With the thumb or fingers of one hand resting on the brachial artery, rapidly inflate the cuff to about 30 mm Hg above the level at which the pulsations disappear. Deflate the cuff slowly until you again feel the pulse. This is the palpatory systolic pressure and helps you avoid being misled by an auscultatory gap. Deflate the cuff completely.

Now place the bell of a stethoscope lightly over the brachial artery. Inflate the cuff again, to about 30 mm Hg above the palpatory systolic pressure. Then deflate the cuff slowly, allowing the pressure to drop at a rate of about 3 mm Hg per second. Note the level at which you hear the sounds of at least two consecutive beats. This is the systolic pressure.

Continue to lower the pressure slowly until the sounds become muffled and then disappear. Then deflate the cuff rapidly to zero. The disappearance point, which is usually only a few mm Hg below the muffling point, marks the diastolic pressure.

Blood pressure should be taken in both arms at least once. Normally there may be a difference in pressure of 5 mm Hg ,sometimes up to 10 mm Hg. Subsequent reading should be made on the arm with the higher pressure.

The normal and changed indicies of blood pressure:

Upper limit of normal blood pressure in adults have traditionaly been set on 140\90 mm of Hg. Even the lower of these two criteria would be suspiciously high, however, in a young adult. The indices of blood pressure above this limit should be interpreted as an arterial hypertension. But blood pressure readings on at least three separate visits should usually taken before making a diagnosis of hypertension.

Lower limits of normal blood pressure, sometimes estimated at 90\60 in adults, should always be interpreted in the light of past reading and the patient’s present clinical state.

Ambulatory blood pressure monitoring (ABPM) is a method of taking regular blood pressure readings, usually over a 24-hour period, as patients conduct their normal activities. A special, automatic blood pressure monitor is used, and patients are asked to keep a diary or log of their activities during the day.

Ambulatory blood pressure monitoring is usually used when a physician suspects that a patient is suffering from “white coat hypertension.” This is a condition in which high blood pressure occurs only in the physician’s office as a result of stress and anxiety.

However, there are a number of other situations that might cause a physician to recommend ambulatory blood pressure monitoring. These include patients who do not respond to medication and patients with symptoms such as fainting (syncope). In addition, ABPM has been found to be a more accurate predictor of patients at high risk of a cardiac event than then other blood pressure monitoring methods.

Ambulatory blood pressure monitoring is distinguished from home blood pressure testing. Home monitoring systems are gaining in popularity. Relatively inexpensive, they allow people to take their own blood pressure at various times throughout the day. Though this can yield valuable information, there are several drawbacks when compared to ambulatory blood pressure monitoring.

ABPM uses specialized equipment to measure blood pressure at regular intervals, 24 hours a day. This information is combined with a written log to aid in the diagnosis and/or treatment of conditions related to blood pressure.

Ambulatory blood pressure monitoring (ABPM) is a method of taking regular blood pressure readings over a 24- or 48-hour period. This is accomplished with a special device that is worn at all times and measures blood pressure automatically, recording the readings.

Studies have shown that ABPM is a valuable tool in the diagnosis of several conditions. It is also beneficial for adjusting doses of medication for high blood pressure and even predicting cardiac events in certain patients.

Blood pressure is a measure of the force, or tension, of the blood against the walls of the arteries. High blood pressure puts an added workload and strain on the heart, whereas low blood pressure (hypotension) can lead to fainting (syncope). High blood pressure (hypertension) is a very common disease in America. It is considered a major risk factor for heart attacks and strokes.

Blood pressure is measured with the use of an arm cuff (sphygmomanometer) and expressed as systolic pressure over diastolic pressure. Systolic pressure is the highest level of the blood’s pressure within the artery walls and corresponds to the contraction of the ventricle. Diastolic pressure is the lowest pressure at which blood stays within the aorta. Both are measured in millimeters of mercury (mmHg).

In most cases, blood pressure is measured in a physician’s office. In recent years, blood pressure measuring equipment has become available that allows people to measure their blood pressure easily and affordably at home. In addition, monitoring equipment is often found in public places, such as grocery stores and pharmacies. However, all of these approaches have certain disadvantages that make ABPM an attractive option for some individuals. For example, in the case of blood pressure measurements at a physician’s office, many people suffer from “white coat hypertension,” or high blood pressure as a result of anxiety connected to the blood pressure test itself. Similarly, the at-home tests and those completed out of a medical setting may be inconsistent and unreliable.

By contrast, the ABPM measures blood pressure at regular intervals throughout the monitoring period, including at night when the patient is asleep. It then records these measurements. Coupled with an activity diary, the ABPM can give a physician a very accurate picture of factors that may be affecting a patient’s blood pressure, such as exercise, eating, medications and certain forms of heart disease.

This information is useful for a variety of reasons. For example, it may help the physician adjust the dosages of antihypertensive medication. Many studies have shown that blood pressure spikes in the morning, right around the time that 24–hour antihypertensives are at their weakest. Thus, heart attacks and strokes may be more likely to occur in the morning. An ABPM could help identify this situation, and the physician could adjust the patient’s medication accordingly. Studies have also shown that ABPM may be a better predictor for certain cardiac events than other methods of measuring blood pressure.

The special ABPM blood pressure monitor is automatic, lightweight (about 1 pound or less) and quiet. It consists of an arm cuff, a tiny computer and a small compressor to inflate the arm cuff. The compressor and computer are generally worn on a belt around the waist with a tube leading up to a cuff placed on the upper arm. The monitor is programmed to automatically inflate the cuff at specific intervals during the ABPM period, usually every 15 to 30 minutes. In cases of recurring fainting, measurements may be taken as frequently as every seven to eight minutes.

The frequency of measurements may be programmed differently during the night to minimize the disturbance to a patient’s sleep. The schedule also adjusts for the fact that changes in blood pressure are less dramatic when the patient is at rest. There are two basic techniques that can be used with the monitor cuff to read a patient’s blood pressure. Some monitors use one or both of the following techniques: