Medically Fit For Exams
Medically Fit For Exams

Blood pressure and pulse

Blood pressure using sphygmomanometer

  • Ensure the patient has had time to rest since activity, 5 minutes
  • Explain the procedure and gain consent
  • Choose arm, ideally you would do both and take the highest. Avoid arms that have pain, paralysis, oedema, mastectomy side, stroke etc
  • Remove clothing tight enough to restrict arm, but can measure over thin clothing
  • Put cuff on, ensure you have the right size (check the boundaries on the cuff), and right orientation (line up with the brachial artery), should be about 1 inch about the elbow
  • Have their arm (elbow) at about heart level, can use a cushion, or your arm to support
  • Feel for the brachial pulse (medial to biceps tendon, in crook of arm), and inflate the cuff until the pulse is cut off (valve is closed), this is an estimate value of systolic
  • Deflate the cuff to about 30mmHg, and simultaneously place diaphragm of stethoscope on the brachial artery, and identify pulse
  • Pump the bladder up to 30mmHg above the estimated systolic pressure, this prevents auscultatory gap (up to 20% of elderly hypertensives)
  • Deflate slowly, about 2mmHg per second, until you hear the pulse (Phase 1 Korotkoff sound). This is the systolic pressure
  • Continue deflating at the same speed until the pulse is silent (phase 5 Korotkoff sound). This is the diastolic pressure. If the sound remains muffled rather than silent, use the point at which it becomes muffled as diastolic pressure
  • Remove the cuff, and ensure the patient is comfortable
  • Allow the patient to re-dress

 

Blood pressure using machine

  • Take the same steps as above until cuff is secured
  • Press the inflate button and wait for reading
  • Read off reading of systolic and diastolic, and HR if using the finger probe
  • If it doesn’t get a reading, try again
  • If still no reading, the patient may have a very high or low blood pressure, or an irregular pulse, such as in atrial fibrillation

 

Radial pulse

  • Ensure the patient has been resting sufficiently to get an appropriate reading
  • Place the pads of first and second finger over the radial artery (lateral to the tendon – flexor carpi radialis)
  • Ideally count the beats for a full minute, but can do 30 seconds or even 15 if part of a wider examination
  • Palpate both pulses simultaneously to detect differences between the two
  • To detect collapsing pulse
    • Check has no movement restriction or pain
    • Feel radial pulse, then raise arm above the patient’s head
    • If it is collapsing, the peak of the pulse will arrive early and followed by a rapid descent

 

Brachial pulse

  • Ensure appropriate rest time
  • Place pads of fingers over the brachial artery, just above the elbow, and medial of the biceps tendon

 

 

Carotid pulse

  • Some clinicians consider this inappropriate because may cause events such as TIA or bradycardia, but is the pulse of choice if patient has had cardiac arrest
  • Explain the procedure and ensure rest time
  • Position patient semi-lying down in case you cause reflex tachycardia
  • Gently place finger tips between larynx and anterior border of sternocleidomastoid muscle and feel for pulse
  • Can also listen for bruits with diaphragm of stethoscope

 

 

Character

Cause/associated condition

Hypertension

Grade 1: >140 mmHg systolic and/or >90mmHg diastolic

Grade 2: >160 mmHg systolic and/or >100 mmHg diastolic

Grade 3: >180 mmHg systolic and/or >110 mmHg diastolic

Primary (essential) hypertension or secondary hypertension. Can be secondary to renal disease, phaeochromocytoma, Cushing’s syndrome, Conn’s syndrome (aldosterone secreting adrenal cortex tumour). ‘Malignant’ hypertension is rare.

Hypotension

Systolic below 90-100 mmHg

Hypovolemia, shock, infection

Collapsing pulse

Rapid rise and rapid fall in radial pulse when arm extended above head

Severe aortic regurgitation, associated with wide pulse pressure

Slow-rising pulse

Gradual up-stroke with reduced peak, late in systole

Severe aortic stenosis

Pulsus paradoxus

Exaggeration of normal variability of pulse volume with breathing. Pulse volume increases during expiration and decreases during inspiration.

Increased intrapericardial pressure, eg in cardiac tamponade and constrictive pericarditis

Large pulse volume

Strong beat, with high volume increase during systole

Can be physiological or pathological, reflects high pulse pressure. Arteriosclerosis is most common cause. Other causes include anaemia, thyrotoxicosis, aortic regurgitation, Paget’s disease, hypertension

Low pulse volume

Low volume increase during systole, weaker beat

Low stroke volume – in LV failure, hypovolemia or peripheral arterial disease (PAD)

Irregularly irregular pulse

No pattern to the heart beats

Atrial fibrillation is most common cause, often also have tachycardia

Tachycardia

Heart rate above 100 bpm

Many causes – including reflex tachycardia in hypotension. Primary tachycardia syndromes include sinus tachycardia.

Bradycardia

Heart rate below 50-60 bpm

Medication (beta blockers, CCB), athletic conditioning, SA or AV node dysfunction

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