Pulse and Blood pressure measurement for the first-year students Clinical Module By Usama Ragab “Blood pressure is the single most important test that we do, if left untreated it causes strokes, heart attacks, and peripheral vascular disease”.

1. General physical
Examination
Vital Signs: Pulse and Blood Pressure (BP)
Usama Ragab Youssif (MD)
Assistant lecturer of Medicine
Email: usamaragab@medicine.zu.edu.eg
Slideshare: dr4spring
1st grade – Faculty of Medicine – Clinical Module
10 – 11 – 12 February 2020

2. Vital signs: 5 components
1- Pulse.
2- Blood pressure.
3- Temperature.
4- Respiratory Movement.
5- Oxygen saturation.

3. Pulse

4. Pulse
• Ejection of blood from the heart into the systemic arterial
circulation creates a pressure wave that can be felt as a
‘pulse’
• Artery to be felt:
1. Accessible
2. Felt against bone

5. How to feel
• Use pads of your fingers, apply firm pressure but not so
hard that pulsation is occluded
• It is good practice not to use your thumb to feel pulses
as you may mistake your own pulse (which can be felt
weakly in the thumb) for the weak pulse of the patient.
• Assess rate, and rhythm.
• If regular count the pulse rate over 15 or 30 seconds;
multiply by 4 or 2 to obtain the beats per minute (bpm).

6. Rhythm
• Normal: regular
• Abnormal: irregular

7. Rate
• Count in 15 sec and multiply by 4 (in whole minute if
irregular).
• Normal rate = 60-100 b/min.
TachycardiaBradycardia
> 100< 60Rate
StressAthelets, sleepPhysiological

8. Volume
• = Pulse Pressure:
 Pulse Pressure= Systolic-Diastolic Blood pressure =
120-80= 40 mmHg
 Average pulse pressure = 30-60 mmHg
 Abnormal: small volume, big volume

9. Arteries to be felt
There is a lot of arteries that colud be felt but,
• Radial artery
• Brachial artery
• Carotid artery

10. Radial artery
•Compress the radial artery with
your index and middle fingers (or
index, middle & ring fingers).
•Semipronated hand.
•Against styloid process.
•Palpate both radial pulses
simultaneously, assessing any
difference in pulse volume.

12. Brachial artery
• Feel at the medial side of the antecubital fossa, just
medial to the tendinous insertion of the biceps.

14. Carotid artery
• Find the larynx, move a couple of centimeters laterally
and press backwards medial to the sternomastoid
muscle.
• Be sure not to compress both carotids at once for fear of
stemming blood flow to the brain—particularly in the frail
and elderly.

16. Blood Pressure

17. “Blood pressure is the single
most important test that we
do, if left untreated it causes
strokes, heart attacks and
peripheral vascular disease”.

18. “Silent Killer”.

19. What is Blood Pressure?
 The blood pressure reading is taken in 2 numbers:
systolic and diastolic.
Systolic
Diastolic
Measure of
pressure as the
heart is beating
Measure of
pressure while
the heart is at rest
between beating

20. Nowadays BP monitors

21. Sphygmomanometer
• BP is usually measured using a sphygmomanometer.

22. Sphygmomanometer (cont.)
• BP is usually measured using a sphygmomanometer.

23. • BP is measured in mmHg and recorded as systolic
pressure/diastolic pressure, together with where, and
how, the reading was taken.
• e.g. BP: 146/92 mmHg, right arm, supine.

26. Rest the
patient for 5
minutes, not
talking
Always measure BP
in both arms
(brachial arteries);
the higher of the two
is closest to central
aortic pressure and
should be used to
determine treatment.
Tight arm
clothing
removed
Arm supported with cuff horizontal with heart
Inform patient of discomfort and
that several measurements will be
taken

27. • Not too loose
• Not too tight

28. Cuff Size
Type Size Suitability
Adult 12cm by 23cm for smaller arms

29. Cuff Size (cont.)

32. • Apply the cuff to the upper
arm, with the centre of the
bladder over the brachial
artery.
• Palpate the brachial or
radial pulse.

33. • Inflate the cuff until the
pulse is impalpable.
• Note the pressure on the
manometer; this is a rough
estimate of systolic
pressure (Palpatory
method).

34. Examination Sequence (cont.)
• Put the diaphragm of
stethoscope gently on
brachial artery
• Inflate mercury rapidly,
30 mmHg above
occlusion of pulse
(Auscultatory method).

35. • As you are occluding
artery completely you will
not hear any sound

36. • Deflate very slowly, 2
mmHg per second

37. • Record first of regular
sounds (systolic BP)
• First sound appears is
phase I Korotkoff

38. • Continue to deflate the
cuff slowly until the
sounds disappear.
• This is the diastolic
pressure (phase 5).

40. Korotkoff sounds
• Phase I: Sound start to
appear (Record SBP)
• Phase II: Sound muffle
• Phase III: Sounds sharp
• Phase IV: Sound muffle
(Record DBP in
hyperdynamic state)
• Phase V: Sounds disappear
(Record DBP)

41. • If muffled sounds
persist (phase 4) and
do not disappear, use
the point of muffling as
the diastolic pressure

42. If blood pressure is elevated
• Repeat twice more and average last two.
• Measure in both arms
• Use the arm with high reading

43. BP: 146/92 mmHg, right arm, supine.

44. British Hypertension Society classification of
blood pressure (BP) levels????

45. Common problems in BP measurement
• BP is different in each arm: a difference >10 mmHg
suggests the presence of subclavian artery disease.
• Measure BP in both arms, record the highest pressure
and use this to guide management

46. Common problems in BP measurement
(cont.)
• Wrong cuff size: the bladder should be approximately
80% of the length and 40% of the width of the upper arm
circumference.
• A standard adult cuff has a bladder approximately 13 ×
30 cm and suits an arm circumference 22 – 26 cm.
• In obese patients a standard adult cuff will overestimate
BP, so use a large adult (bladder 16 × 38 cm) or thigh
cuff (20 × 42 cm).

47. Common problems in BP measurement
(cont.)
• Auscultatory gap: up to 20% of
elderly hypertensive patients have
Korotkoff sounds which appear at
systolic pressure and disappear
for an interval between systolic
and diastolic pressure.
• If the first appearance of the
sound is missed, the systolic
pressure will be recorded at a
falsely low level.
• Avoid this by palpating the systolic
pressure first

48. Common problems in BP measurement
(cont.)
• Patient’s arm at the wrong level: the patient’s elbow
should be level with the heart.
• Hydrostatic pressure causes ~5 mmHg change in
recorded systolic and diastolic BP for a 7 cm change in
arm elevation

49. Common problems in BP measurement
(cont.)
• Terminal digit
preference: record the
true reading rather than
rounding values to the
nearest 0 or 5
• Each line 2 mmHg

50. Common problems in BP measurement
(cont.)
• Postural change: the pulse increases by about 11 bpm,
systolic BP falls by 3–4 mmHg and diastolic BP rises by
5–6 mmHg when a healthy person stands.
• The BP stabilizes after 1–2 minutes.
• Check the BP after a patient has been standing for 2
minutes; a drop of ≥20 mmHg on standing is postural
hypotension

51. Usama Ragab Youssif (MD)
Assistant lecturer of Medicine
Email: usamaragab@medicine.zu.edu.eg
Slideshare: dr4spring