Blood Pressure_2023.pdf

Blood Pressure, Pulse Rate and Carotid Auscultation Ariette Acevedo, O.D. PPO 1 Blood Pressure • Blood pressure is used to determine the pressure in the arteries at the height of the ventricular contraction (systolic) and ventricular relaxation (diastolic). • It is important to verify blood pressu...

Blood Pressure, Pulse Rate and Carotid Auscultation Ariette Acevedo, O.D. PPO 1 Blood Pressure • Blood pressure is used to determine the pressure in the arteries at the height of the ventricular contraction (systolic) and ventricular relaxation (diastolic). • It is important to verify blood pressure on every patient. • Especially before dilating a patient • Some drops are contraindicated in high blood pressure. • Blood pressure is also key in determining a possible health compromise that may affect the eyes. • • • • Hypertensive Retinopathy Malignant Hypertension Retinal Vein Occlusions Impending strokes or myocardial infarctions Blood Pressure • Blood pressure is performed in every patient • For our clinic: every patient 3 y/o and older. • Recording: • • • • Systolic/diastolic in mmHg Arm tested: left (LA) or right arm (RA) Position: sitting or supine Time • Example: 110/70 RAS @ 3:00pm Equipment • Aneroid sphygmomanometer • Dual head stethoscope • Bell and a Diaphragm • Alcohol swabs • Clean the ear plugs of the stethoscope with alcohol, especially if sharing. Blood Pressure Procedure • Set Up: • The patient must be seated in a quiet setting/room for at least 5 minutes • Should not have consumed any caffeine-containing products, exercised or smoked within 30-60 minutes prior to BP evaluation • The patient should be relaxed, with back support, feet resting on the ground and uncrossed. • Arm should be flexed and resting with the palm facing upward, supported on either a table or arm of a chair, at the level of the left atrium. • Preferably perform the procedure on bare skin, avoid rolled up sleeves, as it may excessively constrict the upper arm. Blood Pressure Procedure • Palpate the brachial artery just below the bend of the elbow (antecubital crease) • Center the bladder of the cuff (marked with an arrow) over the arm overlying the brachial artery • Lower edge of the cuff should be 1in. above the antecubital crease • Wrap the cuff snuggly, but not too tight around the upper arm. • Cuff should easily fit 1-2 fingers under the cuff. Blood Pressure Procedure • Attach the pressure gauge to the holding strap (if applies) or hold it where you can easily read it. • Determine the palpable systolic pressure: • Locate and palpate the patient's radial artery at the wrist • Using your index and middle finger palpate on the patient's wrist between the bone and the tendon of the thumb. • Close the valve and inflate the cuff quickly to 30mmHg above the level which the radial pulse disappears. • Take a mental note of this reading. • Deflate slowly (2-3mmHg/sec) until the radial pulse is felt again. • Take a mental note of this reading. Palpable Systolic Pressure • This reading is close to the systolic pressure and will aid in finding the auscultatory gap. • An auscultatory gap is a period of diminished or absent sounds during the manual BP measurement. • This is the silence between the true systolic and its reappearance at a pressure 1520mmHg lower, thus, giving you a false systolic finding. • This is believed to be a finding seen in arteriosclerosis. • https://youtu.be/EQQDEsG21Bw?si=HafL757dF3PBmL7F Blood Pressure Procedure • If not performing the palpable systolic pressure, inflate the cuff to 160-180mmHg. • If after inflating to 180mmHg, you still hear a sound, inflate more until not heard and then start the procedure. • A person with low BP and thin upper arms, inflating to 200-220mmHg will cause pain. Blood Pressure Procedure • Place the diaphragm of the stethoscope directly over the brachial artery. • Close the valve, inflate 20-30mmHg above the palpable systolic pressure found with radial artery pulse or inflate to 160-180mmHg • Deflate the cuff at a slow rate of 2-3mmHg/sec • Note the first and last Korotkoff sounds to be heard • Record the first KS: systolic • Record the last KS: diastolic Korotkoff Sound • Korotkoff Sounds I-V: These are arterial sounds heard through the stethoscope on the brachial artery distal to the sphygmomanometer cuff. • Sounds change with varying cuff pressure and are used to determine systolic and diastolic blood pressure. I. II. III. IV. V. Sudden appearance of regular tapping sounds • Corresponds with the systolic reading. A swishing, softening of sounds Crisper sounds, increasing in intensity An abrupt muffling of sounds The complete cessation of sounds • Corresponds to the diastolic reading Korotkoff Sounds https://www.youtube.com/watch?v=VJrLHePNDQ4 Practice • https://www.practicalclinicalskills.com/taking-blood-pressurepractice • https://www.practicalclinicalskills.com/case-blood-pressure/159 • https://www.youtube.com/watch?v=j-326lCJ7wY • https://www.youtube.com/watch?v=bHXvhOQ0hYc Findings • Diurnal variations are normal • Highest midmorning and lowest during sleep • 5-10mmHg discrepancies between the 2 arms are normal • Greater than 10-15mmHg are not • This could indicate narrowing of the subclavian or brachiocephalic arteries • Beware of false high or low readings: False Low False High Cuff too wide White coat syndrome Arm above heart level Cuff too loose Deflate too rapidly (affected systolic) Deflated too slowly (affect diastolic) Auscultatory gap Arm below arm level Rigid arteries (elderly) Pearls • The cuff should be about 80% of the arm circumference. • If the cuff is too wide for the patient, findings will be artificially low. • If the cuff is to narrow for the patient, findings will be artificially high. • Arm position • If the arm is too high, the measurement will be low. • If the arm is too low, the measurement will be high. Expected Findings Blood Pressure Category Systolic mmHg And/Or Diastolic mmHg Low Less than 80 Or Less than 60 Normal Less than 120 And Less than 80 Elevated (Prehypertension) 120-129 And Less than 80 Hypertension Stage 1 130-139 Or 80-90 Hypertension Stage 2 140 or higher Or 90 or higher Hypertensive Crisis Higher than 180 Or Higher than 120 What to do if while examining a patient you encounter the following: Arterial Blood Pressure Action Up to 140/100 • Continue with the exam. • Ask when was the last time they took their medication. ≤140/105-110 • Ask about last medication dosage • Repeat BP measurement in 15 minutes. • If still elevated stop the exam and recommend to visit PCP for treatment review. ≥160/110-120 • Ask about last medication dosage • Repeat BP measurement in 15 minutes. • If still elevated stop the exam and refer to MD for immediate evaluate and treatment. Pulse Rate Pulse Rate • Number of heartbeats per minute. • Gives information of the heart rate, pattern of beats and strength of the pulse. • Pulse should be regular, strong and easily palpated. • If not there could be a problem. • For children over 10y/o and adults, in a resting state, pulse ranges from 60100 bpm. • Younger children: 80-110 bpm • Newborns: 120bpm • Athletes: 40-60bpm • Tachycardia is a consistently high resting heart rate, over 100bpm. • Bradycardia is a consistently low resting heart rate, less than 60bpm. Pulse Rate • Count the number of pulses for 60 seconds. This will be the heart rate in beats per minute (bpm) • Can also count the number of pulses for 30sec and multiply by 2 for heart rate in bpm. Sites to Palpate Pulse • Most common is the wrist (radial pulse) • Others: • • • • • • • • Ulnar at the wrist in line with the small finger. Carotid: to the front of the neck Brachial: in the joint of the elbow Femoral: felt in the groin Popliteal: behind the knee Apical: a stethoscope is required to listen to heart rate Dorsal pedis: on the top part of the foot Posterior tibial: lower inner aspect of the ankle Carotid Artery Auscultation • This is performed in cases with signs or symptoms of vascular disease. • In patients with: • Transient Ischemic Attacks (TIA): a cerebral ischemia that can manifest with transient loss of vision or visual field loss that returns in approximately 5 minutes, but may last longer. • Amaurosis fugax: transient monocular blindness • Hollenhorst plaques seen in fundus evaluation: plaques of cholesterol lodged in retinal arteries, usually at a bifurcation and can cause vascular infarcts. Transient Ischemic Attack (TIA) • Characteristic symptoms of TIA if problems originate in the carotid artery: • Monocular transient loss of vision (amaurosis fugax) • Pathognomonic symptom • Language impairments • Aphasia: language dysfunction • Alexia: unable to read • Agraphia: unable to write • Hemiparesis and hemi-hypoesthesia Carotid Artery Auscultation • With a stethoscope listen for a rushing sound, known as Bruits. • Caused by turbulent blood flowing through a narrowed or partially obstructed artery. • Bruits are not commonly heard in asymptomatic patients. • https://youtu.be/ToL3vuvdZA0 Carotid Artery Auscultation • Procedure: • Patient seated with chin slightly elevated and turned to the side. • Palpate the common carotid artery. • Using the bell side of the stethoscope place it over the common carotid artery approximately 1 inch above the clavicle. • Have the patient hold their breath and listen for bruits for ~10sec. • Have the patient breath and reposition the bell further up the artery. • Repeat the procedure 3-4 times along the length of the common carotid artery. Carotid Artery Auscultation • The presence of a bruit is the sound of a whooshing murmur, blowing, or roaring each time the heart beats as the blood rushes through the narrowed artery. • There has to be at least 50% reduction before bruits are heard and are much easier heard at 70%. • Over 85% of stenosis no bruit will be heard • Middle aged or elder population are the most commonly affected. • Evaluate both sides and compare. • In young adults or children, bruits may be present due to vessel elasticity, but in this case they are benign. Why is BP evaluation important? • As Primary Cate Providers (PCP) blood pressure evaluation is part of our routine evaluation. • Ocular manifestations may present that need to be addressed: • • • • • Hypertensive Retinopathy (HTR) Malignant Hypertension with Papilledema Retinal Vascular Occlusions Loss of VF due to cerebral ischemia Subconjunctival hemorrhages (SCH) • Pupillary Dilation • Dilation is an important procedure to further evaluate the peripheral retina. • Systemic conditions, traumas, retinal lesions or degenerations. Pupillary Dilation • Before dilating the patient, BP measurements must be taken. • Ophthalmic drugs can have adverse reactions, in some cases increasing blood pressure. • Topical Phenylephrine 2.5% is used for routine pupillary dilation • May have hypertensive effects, but more frequent at 10% concentration. • 10% is used for breaking of posterior synechiae. • To minimize systemic side effects, perform punctal occlusion for a minute after instillation. Arterial Attenuation Arterial Attenuation and Increased light reflex Compare Healthy Fundus Hypertensive Fundus Hypertensive Retinopathy Stage 3 Silver Wire Cooper Wire Malignant Hypertension Hypercholesterolemia and Diabetes Mellitus Cholesterol Levels • Elevated cholesterol levels is one of the major risk factors for Coronary Artery Disease (CAD) • High density lipids (HDL) is known as the “Good” Cholesterol • Low density lipids (LDL) is known as the “Bad” Cholesterol • Triglyceride levels must also be evaluated • Lab work is performed under fasting conditions. Cholesterol Levels • Guidelines • Total Cholesterol: <200 mg/dL • Considered high if >240 mg/dL • Optimal levels: • HDL: >50 mg/dL • LDL: <100 mg/dL • High LDL >160 mg/dL • HDL Reference Ranges: • Males: 22-68 mg/dL • Females: 30-80 mg/dL • Triglycerides: Expected ≤150 mg/dL • Elevated: 200-499 mg/dL Ocular Manifestations • Arcus juvenilus & Arcus senilus • Arcus: lipid deposit within the peripheral corneal stroma. • Frequently occurs with hyperlipidemia, especially in elder patients. • In elders, might have had elevated lipid levels, now might be controlled. • In juvenile patients, blood work is indicated as it almost always indicates lipid discrepancies. • If unilateral in presentation, evaluate the carotid artery. • Carotid auscultation Hollenhorst Plaque Diabetes Mellitus • Signs/Symptoms: • Increase in normal daily thirst and urination patterns. • Complaints of constant or varying blurry vision. • Changes in refractive error • Depending on BSL could be hyperopic or myopic shifts • FBS over 200-300 mg/dL will produce refractive error changes • Retinal dot blot hemorrhages • Exudates • Venous beading Diabetes Mellitus • Glucose Levels: • Fasting Blood Sugar (FBS) • • • • • Low: ≤ 60 mg/dL Normal: 70-99 mg/dL Borderline: 100-125 mg/dL High: >140 mg/dL Coma risk: >700 mg/dL • Glycosylated Hemoglobin (HbA1c) • Evaluated blood glucose levels in red blood cells. • Provides a 3 month average. • 𝑒𝐴𝐺 = 28.7 𝑥 𝐴1𝑐 − 46.7 • Estimated Average Glucose (eAG) Diabetic Retinopathy Lymph Node Evaluation Lymph Node Evaluation • Important procedure to be able to identify the presence of lymphadenopathy • Provides important information regarding viral/bacterial/fungal infections • Especially for red eyes • Lymph nodes are bean shaped organs containing a large number of leukocytes and phagocytes that filter out infectious and toxic material. • In the presence of infections, lymph nodes become inflamed and tender. Preauricular Lymph Node Evaluation Procedure • Have the patient sit comfortably in a chair and tilt their chin up, facing the examiner. • The examiner sits/stands in front of the patient • Placing your hands on the patent's face that the middle and ring fingers are positioned in front of the patient’s external ear. • Evaluate both sides R/L at the same time • Locate the temporomandibular joint and move the skin over the underlying bony structure. • Search for a depression of the joint (normal) or an elevated nodular lesion (swollen lymph node) • A swollen preauricular node will feel like a pebble or a bean under the patient’s skin. Cervical, Submandibular and Submental Lymph Node Evaluation Procedure • Place the tips of your fingers on the patient’s neck • For the cervical nodes begin at the angle of the jaw • Gently rotate the patient's skin between your fingers and the underlaying sternocleidomastoid muscle. • Moving your fingers down continue to palpate following the sternocleidomastoid muscle until the base of the neck. Cervical, Submandibular and Submental Lymph Node Evaluation Procedure • For the submandibular nodes, place the fingertips along but under the edge of the jawbone and massage the patients' skin between your fingers and the underlying tissue. • For the submental nodes, place the fingertips under the tip of the chin. • If any swollen lymph nodes are noted as the patient, is they are tender and note any warmth, the size and whether or not it is mobile. Recording • No palpable preauricular, cervical, submandibular or submental lymph nodes. • Positive right preauricular node. Approx. 1cm in size, mobile, tender, with no overlying warmth. • No palpable cervical, submandibular, or submental lymph nodes. • https://youtu.be/SZkIq6P-0UQ?si=OEzuYYi_7Q2U0bk3 Expected Findings • Normal: no palpable lymph nodes. • Abnormal: palpable lymph nodes • These are commonly seen in • Viral conjunctivitis (greater on the more involved side) • Severe bacterial lid conditions (presceptal cellulitis) • (+) preauricular and submental lymphadenopathy • Parinaud’s Oculoglandular conjunctivitis • (+) preauricular lymphadenopathy • Upper respiratory infections • (+) cervical and submandibular lymphadenopathy • Non-Hodgkin’s and Hodgkin’s lymphoma