Diagnosis 101 - Student Tutorials

BLOOD PRESSURE EXAMINATION INSTRUCTIONS:

Accuracy of blood pressure readings can be affected by many things during the measurement, such as improper cuff sizing, tight clothing, improper posture, excessive movement, stress, talking, and physical position. Follow the steps below to complete a proper blood pressure reading.

Select Cuff Size
Select the proper cuff size for the patient. If the cuff is too small or too large, you may obtain false high or low readings respectively. The cuffs have a sizing scale printed on them. After properly applying the cuff to a patient’s arm, check to see if the pointer arrow is within the size range indicator. If the pointer falls outside the range, use either a smaller or a larger cuff size as needed.

Seat Patient Comfortably
Have the patient seated comfortably, feet on the floor and back supported. Have the patient remove loose clothing or push sleeves up above the elbow.

Allow Patient to Rest
Allow the patient to rest for five minutes in this position before taking a blood pressure reading.

Position the Cuff on the Patient
Place the blood pressure cuff snuggly on the patient’s arm. The preferred blood pressure measurement site is the left upper arm because the left arm is closer proximity to the heart. Position the cuff on the bare arm midway between the shoulder and the elbow. Position the alignment mark, the arrow, on the cuff directly over the branchial artery. The brachial artery is located on the inside of the elbow just above and to the inside of the arm.

Check that the cuff is not too tight
Be sure the cuff is neither too snug nor too tight. When putting a cuff on a patient, you should be able to comfortably fit two fingers between the cuff and the arm. Also, be sure that the blood pressure hose is not kinked or twisted. While taking a blood pressure measurement, limit the movement of the cuff and the cuffed extremity.

Raise Patient's Arm to Heart Level
Once the cuff is secured, raise the arm to heart level and place your arm beneath it to support it asking the patient to relax his or her arm. Palpate, feel for, the brachial pulse and place the diaphragm of the stethoscope on this spot. Listen for the brachial pulse.

Inflate the Cuff
Inflate the cuff, continue inflating until the pressure on the gauge is 20 to 30 millimeters of mercury above systolic. On most patients, 160 to 180 millimeters of mercury is a good starting point if you don’t know the systolic pressure.

Begin BP Reading
With your stethoscope in place, open the valve slowly and allow the cuff to deflate at a rate of roughly five millimeters of mercury per second while listening. The first Korotkoff sound often sounds like a clicking or swooshing. It occurs when the pressure in the cuff is just slightly below the pressure the heart creates when contracting. Mentally record the gauge reading when you hear this first sound. This is the systolic pressure.

Continue deflating the cuff until you no longer hear any sound. Mentally record the reading on the gauge where sounds disappear. This is the diastolic pressure. At this point, you can open the valve completely to allow the cuff to deflate rapidly. If you did not hear clearly, wait at least one minute before repeating the procedure.

Auscultation Examination Instructions:

When performing auscultation, you need to be able to characterize four properties of a heart sound:

Location, where the sound is heard in the chest
Timing, when the sound occurs
Grade, or intensity of the sound
Quality. And shape of the sound
Auscultation should proceed in an orderly manner over four general areas, with the patient typically lying down. These regions should be listened to using the flat diaphragm of the stethoscope.

The aortic region, between the second and third intercostal spaces at the right sternal border.
The pulmonic region, between the second and third intercostal spaces at the left sternal border.
The tricuspid region, between the third, fourth, fifth, and sixth intercostal spaces at the left sternal border.
Mitral region, near the apex of the heart, between the fifth and sixth intercostal spaces in the midclavicular line.
Find a quiet area
Auscultation is the most important clinical technique you will ever learn for evaluating a patient’s respiratory function. When listening to the lungs try to find as quiet an environment as possible.

Position patient properly
The patient should be in the proper position for auscultation, ideally sitting up in bed or on the examining table.

Ensure patient comfort
Always ensure patient comfort and cleanliness. Be sure to clean the stethoscope head with a disinfecting wipe before and after touching the patient. It is considerate to warm the diaphragm of your stethoscope with your hand before auscultation.

Place stethoscope on the patient's bare skin
Your stethoscope should be touching the patient’s bare skin so that you don’t mistake the rubbing of the patient’s clothes against the stethoscope for abnormal sounds. If needed, wet the patients chest hair with warm water or gel to decrease the sounds of hair against the stethoscope.

Begin ausculation
As you are auscultating your patient, ask yourself:

Are the breath sounds increased, normal, or decreased?
Breath sounds are the noises produced by the lungs as the patient breathes.
Are there any abnormal or adventitious breath sounds?
Abnormal, adventitious sounds refers to the extra or additional sounds that might be heard in addition to normal breath sounds such as crackles or wheezes.
Listen to each location
Auscultate using the diaphragm of your stethoscope. Ask the patient not to speak and to breath deeply through the mouth. You should listen to at least one full breath in each location. Always compare what you hear on one side of the lungs with what you hear on the corresponding opposite side.

There are 12 and 14 locations for auscultation on the anterior and posterior chest respectively. Generally you should listen to at least six locations on both the anterior and posterior chest. Begin by auscultating the apices of the lungs, moving from side to side and comparing one side to the other. If you hear a suspicious breath sound, listen to a few other nearby locations and try to delineate its extent and character

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