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156 PHYSICAL EXAMINATION
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UNIT 2
FIGURE 6.8 Peripheral pulse sites
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Site
Peripheral pulses can be palpated where the large arteries are close to the skin
surface. There are nine common sites for assessment of pulse, as indicated in
Figure 6.8.
When routine vital signs are assessed, the pulse is generally measured at one of two
sites: radial or apical.
Measuring the apical pulse is indicated for consumers with an irregular pulse
or known cardiac or pulmonary disease. The assessment of apical pulse can be
accomplished through palpation but is most commonly accomplished
through auscultation.
Radial pulse
To palpate the radial pulse, follow these steps.
E
1. Place the pad of your rst, second and/or third nger on the site of the radial
pulse, along the radial bone on the thumb side of the inner wrist (see
Figure 6.9).
2. Press your ngers gently against the artery with enough pressure so that you
can feel the pulse. Pressing too hard will obliterate the pulse.
3. Count the pulse rate using the second hand of your watch. If the pulse is
regular, count for 30 seconds and multiply by 2 to obtain the pulse rate per
minute. If the pulse is irregular, count for 60 seconds.
4. Identify the pulse rhythm as you palpate (regular or irregular).
5. Identify the pulse volume as you palpate (using scales from Table 6.2).
N A P
Refer to section on Rate.
Apical pulse
To assess the apical pulse, follow these steps (see Figure 6.10).
E
1. Place the diaphragm of the stethoscope on the apical pulse site.
2. Count the pulse rate for 30 seconds if regular, 60 seconds if irregular.
3. Identify the pulse rhythm.
4. Identify a pulse decit (apical pulse rate greater than the radial pulse rate)
by listening to the apical pulse and palpating the radial pulse simultaneously.
N A P
Refer to section on Rate.
FIGURE 6.9 Palpation of the radial pulse
FIGURE 6.10 Auscultation of the apical pulse
E
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EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 157
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Rate
Normal pulse rates vary with age. Table 6.3 depicts ranges for normal pulse rates
N
by age. The heart rate normally increases during periods of exertion. Athletes
commonly have resting heart rates below 60 beats per minute because of the
increased strength and efciency of the cardiac muscle.
TABLE 6.3 Pulse rate: Normal range according to age
CHAPTER 6
AGE RESTING PULSE RATE
AVERAGE
(BEATS PER MINUTE)
Newborn 100–170 140
1 year 80–160 120
3 years 80–120 110
6 years 70–115 100
10 years 70–110 90
14 years 60–110 85–90
Adult 60–100 72
A
Tachycardia refers to a pulse rate faster than 100 beats per minute in an adult.
Psychophysiological stressors such as trauma, blood volume losses, anaemia,
P
infection, fear, fever, pain, hyperthyroidism, shock and anxiety can increase
pulse rate because of increased metabolic demands placed on the body.
Some tachycardia may not have clinical signicance; however, in consumers
P
with myocardial disease, tachycardia can be a sign of decreased cardiac output,
congestive heart failure, myocardial ischaemia or dysrhythmias.
A
Bradycardia refers to slow pulse rates. Pulse rates that fall below 60 beats per
minute in adults are considered to be bradycardic.
Medications such as cardiotonics (digoxin) and beta blockers decrease the
P
heart rate.
Bradycardia usually occurs with excessive vagal stimulation or decreased
P
sympathetic tone. Conditions that may cause bradycardia are eye surgery,
increased intracranial pressure, myocardial infarction, hypothyroidism and
prolonged vomiting.
A
Asystole refers to the absence of a pulse. Palpate or auscultate for a pulse for
10–15 seconds to establish asystole.
Cardiac arrest resulting from biological or clinical death results in asystole.
P
Pulseless electrical activity (electromechanical dissociation) caused by, for example,
P
hypovolaemia, pneumothorax, cardiac tamponade or acidosis results in the absence
of a pulse despite the presence of electrical activity in the heart muscle.
A
A pulse decit occurs when the apical pulse rate is greater than the radial
pulse rate.
Dysrhythmias (such as atrial brillation, premature ventricular contractions,
P
second-degree heart block, third-degree heart block) and heart failure can cause
pulse decits because some heart contractions are too weak to produce a pulse
pressure to the peripheral site. Severe vascular disease can also cause pulse decits.
Rhythm
N
Normal pulse rhythm is regular, with equal intervals between each beat.
A
Dysrhythmias, or arrhythmias, refer to pulse rhythms that are not regular.
They may consist of irregular beats that are random, or irregular beats that
present in a regular pattern.
Cardiac dysrhythmias that are atrial and ventricular in origin cause abnormal
P
rhythms, such as atrial utter and ventricular brillation.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
158 PHYSICAL EXAMINATION
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UNIT 2
Volume
The pulse volume is normally the same with each beat. A normal pulse volume
N
can be felt with a moderate amount of pressure of the ngers and obliterated
with greater pressure.
A
Small, weak pulses are referred to as weak or thready pulses or as pulses easily
obliterated with light pressure.
Decreased cardiac stroke volume caused by heart failure, hypovolaemic shock or
P
cardiogenic shock can result in weak pulses.
A low pulse amplitude occurs in states of increased peripheral vascular
P
resistance, such as in aortic stenosis and constrictive pericarditis.
Weak pulses occur in conditions in which ventricular lling time is decreased,
P
such as in dysrhythmias.
A
Bounding pulses are full, forceful pulses that are difcult to obliterate with pressure.
Hyperkinetic states such as exercise, fever, anaemia, anxiety and
P
hyperthyroidism can cause bounding pulses.
Early stages of septic shock are characterised by bounding pulses because of
P
decreased peripheral vascular resistance.
Temperature
Scales, variables, routes, and measurement methods for assessing temperature are outlined.
Celsius
42
41
40
39
38
37
36
35
34
To convert:
(9/5 3 temperature in Celsius) + 32°
= temperature in Fahrenheit
5/9 3 (temperature in Fahrenheit – 32°)
= temperature in Celsius
FIGURE 6.11 Correlation between Celsius
and Fahrenheit scales
Fahrenheit
107.6
105.8
104.0
102.2
100.4
98.6
96.8
95.0
93.2
Temperature scales
In Australia and New Zealand, degree Celsius is the most commonly used
measurement scale for
temperature, which reects the degree of core body heat.
Figure 6.11 summarises and correlates both Celsius and Fahrenheit scales and gives
the conversion formulas.
Variables affecting body temperature
Core body temperature is established by the temperature of blood perfusing the
area of the hypothalamus (the body’s temperature control centre), which triggers
the body’s physiological response to temperature. An ideal thermometer would
accurately measure central brain stem temperature at the hypothalamus. Invasive
procedures that provide temperatures of the arterial blood, oesophagus or bladder
are reliable indicators of core temperature, but are impractical. More practical
methods for measurement of body temperature are less reliable and can result
in variations in body temperature readings. In addition, there are physiological
variables that affect body temperature. These include:
> circadian rhythm patterns. Normal body temperature (as well as pulse and
blood pressure) uctuates with a consumer’s activity level and the time of day.
lowest in the early morning just before awakening from sleep, and highest in
the afternoon or early evening. A 0.5°C to 1.0°C uctuation in body temperature
throughout the day is considered within the normal range.
> hormones. In women, increased production of progesterone at the time of
ovulation raises the basal body temperature about 0.35°C.
> age. Infants and young children are affected by the environmental temperature
to a much greater extent than adults because their thermoregulation
mechanisms are not fully developed. The elderly are more sensitive to extremes
of environmental temperature due to a decrease in thermoregulatory controls.
> exercise. Body temperature rises due to increased metabolic activity.
> stress. Stimulation of the sympathetic nervous system increases the production
of adrenaline, resulting in increased metabolic activity and higher
body temperature.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 159
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> environmental extremes of hot or cold.
> health status. Temperature deviations can occur in illnesses such as infections.
as well as in hypothalamus dysfunction.
Measurement routes
There are four basic routes by which temperature can be measured: oral, rectal,
axillary and tympanic. Each method has advantages and disadvantages. The
advantages and disadvantages of each route are summarised in
TABLE 6.4 Advantages and disadvantages of four routes for body temperature measurement
ROUTE NORMAL RANGE ADVANTAGES DISADVANTAGES
Oral
Average 37.0°C 35.5–37.5°C Convenient;
accessible
Rectal
Average 0.4°C higher
than oral
Axillary
Average 0.6°C lower
than oral
Tympanic
Calibrated to oral or
rectal scales
36.6–38.0°C Considered most
accurate
35.5–37.5°C Safe; non-invasive Time frame: Glass thermometer must be left in place for 5 minutes to obtain
35.8–38.0°C Convenient, fast,
safe, non-invasive;
does not require
contact with any
mucous membrane
Table 6.4.
Safety: Consumers need to be alert and cooperative, and cognitively capable of
following instructions for safe use.
Physical abilities: Consumers need to be able to breathe through the nose and
be without oral pathology or recent oral surgery; route not applicable for comatose or
confused consumers.
Accuracy: Oxygen therapy by mask, as well as ingestion of hot or cold drinks
immediately before oral temperature measurement, affects accuracy of the reading.
Safety: Contraindicated following rectal surgery. Risk of rectal perforation in
children less than 2 years of age. Risk of stimulating Valsalva manoeuvre in cardiac
consumers.
Physical aspects: Invasive, uncomfortable, and possibly embarrassing.
accurate measurement. Glass and mercury thermometers are no longer used in
healthcare facilities. Placement and position of thermometer tip affect reading.
Accuracy:
with other body temperature measurements. Technique affects reading. Tympanic
membrane is thought to reect the core body temperature.
Research is inconclusive as to accuracy of readings and correlations
CHAPTER 6
Oral method
E
1. Place the thermometer (Figure 6.12) at the base of the tongue and to the right
or left of the frenulum, and instruct the individual to close the lips and to
avoid biting the thermometer. Ensure that it has been at least 15 minutes
since the individual consumed a hot or cold beverage or food.
2. Leave the thermometer in the mouth until the device has signalled that the
maximum body temperature has been reached.
3. Remove the thermometer from the person’s mouth.
Rectal method
E
1. Position individual with the buttocks exposed. Adults may be more
comfortable lying on the side (with knees slightly exed), facing away from
you, or prone.
2. Put on nonsterile gloves.
3. Lubricate the tip of the thermometer with a water-soluble lubricant.
4. Ask the individual to take a deep breath; insert the thermometer into the
anus 1.5 to 2.5 cm, depending on the person’s age.
5. Do not force the insertion of the thermometer or insert into faeces.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
FIGURE 6.12 Taking a consumer’s oral
temperature with an
electronic thermometer
160 PHYSICAL EXAMINATION
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E
6. Leave the thermometer in the rectum until the device has signalled that the
maximum body temperature has been reached.
7. Remove the thermometer from the individual’s rectum.
UNIT 2
FIGURE 6.13 Taking a consumer’s
axillary temperature
Axillary method
E
1. Place the thermometer into the middle of the axilla (Figure 6.13) and fold the
individual’s arm across the chest to keep the thermometer in place.
2. Leave the thermometer in the axilla until the device has signalled that the
maximum body temperature has been reached.
3. Remove the thermometer from the individual’s axilla.
Electronic thermometer
E
1. Remove the electronic thermometer from the charging unit (Figure 6.14).
2. Attach a disposable cover to the probe.
3. Using one of the methods described (oral, rectal or axillary), measure the temperature.
4. Listen for the sound or look for the symbol that indicates maximum body
temperature has been reached.
5. Observe and record the reading.
6. Remove and discard the probe cover.
7. Return the electronic thermometer to the charging unit.
Plastic holder containing digital
thermometer probes and
rechargeable battery
Rectal
probe
Box of disposable
probe covers
Power
source
FIGURE 6.15 A tympanic thermometer
Disposable
probe cover
FIGURE 6.14 A battery-operated thermometer
Oral
probe
Plastic cord goes
around nurse’s neck
Tympanic thermometer
E
1. Attach the probe cover to the nose of the thermometer (Figure 6.15).
2. Gently place the probe of the thermometer over the entrance to the ear
canal. If the individual is under 3 years old, pull the pinna down, aiming
the probe towards the opposite eye. If the individual is over 3 years old,
grasp the pinna and pull gently up and back, aiming the probe towards the
opposite ear (Figure 6.16). Make sure there is a tight seal.
3. Press the start button on the thermometer handle.
4. Wait for the beep, remove the probe from the ear, and read the temperature.
5. Discard the probe cover.
6. Return the tympanic thermometer to the charger unit.
Normal body temperatures are described in Table 6.4.
N
A
Hyperthermia, pyrexia or fever are conditions in which body temperatures
exceed 38.5°C. Clinical signs of hyperthermia include increased respiratory rate
and pulse, shivering, pallor and thirst.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 161
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There can be many causes of hyperthermia (including infection), which results
P
from an increased basal metabolic rate.
A
Hypothermia occurs when the body temperature is below 34°C. Clinical
signs of hypothermia include decreased body temperature and initial shivering
that ceases as drowsiness and coma ensue.
output, lack of muscle coordination, and disorientation also occur as
hypothermia progresses.
Hypothermia can be caused by prolonged exposure to cold, such as immersion
P
in cold water or administration of large volumes of unwarmed blood products.
Hypothermia can be induced to decrease the tissues’ need for oxygen, such as
P
during cardiac surgery.
Hypotension, decreased urinary
URGENT FINDING
Hypothermia – importance of assessment
Hypothermia can cause bradycardia and cardiac arrest. The focus of care for those with
hypothermia is on comprehensive and multiple methods of rewarming, with close cardiac
monitoring. As the person’s temperature increases, arrythmias can develop. It is important
to identify the consumer’s full history and assessment to ensure correct treatment. Resuscitation efforts do not stop until the person is at a normal body temperature and all other
interventions have been exhausted.
FIGURE 6.16 Taking a consumer’s
temperature with a tympanic thermometer
CHAPTER 6
Blood pressure
Blood pressure measures (in millimetres of mercury [mmHg]) the force exerted
by the ow of blood pumped into the large arteries. Arterial blood pressure is
determined by blood ow and the resistance to blood ow as indicated in the
following formula:
MAP = CO × TPR
mean arterial pressure (MAP) = cardiac output (CO) × total peripheral
resistance (TPR)
Changes in blood pressure can be used to monitor changes in cardiac output.
Ineffective pumping, decreased circulating volume, as well as changes in the
characteristics of the blood vessels, can affect blood pressure. There is a diurnal
variation in blood pressure, as characterised by a high point in the early evening
and a low point during the early deep stage of sleep.
Korotkoff sounds
Korotkoff sounds are generated when the ow of blood through the artery is
altered by inating the blood pressure cuff that is wrapped around the extremity.
Korotkoff sounds may be heard by listening over a pulse site that is distal to the blood
pressure cuff. As the air is released from the bladder of the cuff, the pressure on the
artery changes from that which completely occludes blood ow to that which allows
free ow. As the pressure against the artery wall decreases, ve distinct sounds occur.
Phase I: The rst audible sound heard as the cuff pressure is released. Sounds like
>
clear tapping and correlates to systolic pressure (the force needed to pump the
blood out of the heart).
Phase II: Sounds like swishing or a murmur. Created as the blood ows through
>
blood vessels narrowed by the ination of the blood pressure cuff.
Phase III: Sounds like clear, intense tapping. Created as blood ows through the
>
artery, but cuff pressure is still great enough to occlude ow during diastole.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
162 PHYSICAL EXAMINATION
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UNIT 2
> Phase IV: Sounds are mufed and are heard when cuff pressure is low enough to
allow some blood ow during diastole. The change from the tap of Phase III
to the mufed sound of Phase IV is referred to as the rst diastolic reading.
Phase V: No sounds are heard. Occurs when cuff pressure is released enough to
>
allow normal blood ow. This is referred to as the second diastolic reading.
Measuring blood pressure
Systolic pressure represents the pressure exerted on the arterial wall during systole,
when the ventricles are contracting. Diastolic pressure represents the pressure in the
arteries when the ventricles are relaxed and lling. Blood pressure is recorded as a
fraction, with the top number representing the systole and the bottom number(s)
representing the
rst diastolic sound is written over the second. For example, 120/90/80 indicates
that 120mmHg is the systolic pressure, 90mmHg is the rst diastolic sound, and
80mmHg is the second diastolic sound.
the diastolic and systolic blood pressures.
diastole. If the rst and second diastolic sounds are recorded, the
Pulse pressure is the difference between
Measurement sites
There are several potential sites for blood pressure measurement. The preferred site
is the brachial pulse site, where the brachial artery runs across the antecubital fossa.
The posterior thigh, where the popliteal artery runs behind the knee joint, can also
be used. A site should not be used if there is pain or injury around or near the site;
for instance, a postmastectomy consumer should have blood pressure assessed on
the unaffected side. Surgical incisions; intravenous, central venous or arterial lines;
or areas with poor perfusion should be avoided for blood pressure measurement.
Consumers with arteriovenous (AV) stulas or AV shunts should not have blood
pressure measured in those extremities.
FIGURE 6.17 Blood pressure cuffs come in
various sizes.
FIGURE 6.18 An aneroid manometer dial
Equipment
Blood pressure is measured indirectly with a Doppler or a stethoscope and a
sphygmomanometer, which consists of the blood pressure cuff, connecting tubes
and air pump, and manometer. Blood pressure cuffs come in several sizes (
The size of the cuff bladder should be 80% of the circumference of the limb being
assessed (JNC, 2003). The cuff should completely encircle the limb.
A manometer is attached to the cuff via a second tube. The
manometer
the air pressure within the cuff (
is a calibrated dial with a needle that points to numbers representing
Figure 6.18).
aneroid
Figure 6.17).
HEALTH EDUCATION
Home blood pressure monitoring devices
Many consumers take their blood pressure at home for numerous reasons, for example
to monitor antihypertensive medication treatment. Periodically, consumers should be
instructed to bring their home devices to their healthcare provider appointment. The
consumer should be observed taking their blood pressure to assess their technique.
Reinforcing correct technique can positively inuence an individual’s compliance with their
medical treatment.
It is also appropriate to compare the blood pressure reading on the home device with
that obtained in the healthcare provider’s ofce. The measurements should correlate within
5mmHg of each other. This assists to determine if the readings from home are accurate and
reect the consumer’s actual blood pressure.
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 163
A. When taking a blood pressure
measurement, the nurse can manually
elevate the arm to the level of the patient’s
heart.
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Blood pressure assessment
A Doppler ultrasonic stethoscope can also be used to obtain blood pressure. It is
especially useful when blood pressure sounds are difcult to hear, such as with
infants or very obese consumers.
E
1. Ensure that the consumer has not had any caffeine or tobacco products in
the past 30 minutes. Allow the consumer to rest for 5 minutes before you
take the blood pressure.
2. Select an appropriate size cuff.
3. Position the consumer. The consumer may be sitting, standing or supine.
At the rst encounter, all three positions are recommended.
4. Position the arm or leg to be used so that the extremity is at a level equal to
the heart to prevent a false reading (
the sitting position is usually the position of choice. Ensure that the
consumer’s feet are rmly on the oor in this position.
5. Apply the deated blood pressure (BP) cuff:
a. Upper arm: Wrap the BP cuff snugly around the bare upper arm. The
bottom of the BP cuff should be 3 to 5cm above the antecubital fossa.
The centre of the bladder should be directly above the brachial artery.
b. Leg: Wrap the BP cuff around the bare thigh, with the bottom of the BP
cuff slightly above the knee. The popliteal artery below the cuff is used
for BP measurement. This is usually easier if the consumer is in the prone
position.
6. Establish a baseline systolic blood pressure (palpating the blood pressure),
if needed:
a. Palpate the brachial or radial artery with the finger pads of your
nondominant hand distal to the BP cuff.
b. Inflate the BP cuff, and note when the artery pulsation is no longer
palpable.
c. Release the air from the BP cuff, and wait 1 to 2 minutes.
7. Palpate the pulse distal to the BP cuff.
8. Place the bell of the stethoscope over the blood pressure site (the diaphragm
may be used if sounds are hard to hear):
a. If a Doppler ultrasonic stethoscope is to be used, apply conducting gel to
the site where the pulse was palpated.
b. Place the Doppler transducer over the site.
9. Inate the BP cuff to approximately 20mmHg above the established
baseline blood pressure or 20mmHg above where the Korotkoff sounds
disappear.
10. Slowly open the valve and release the pressure at a rate of 2 to 3mmHg
per second.
11. Listen for the Korotkoff sounds:
a. Onset of Korotkoff sounds correlates to systolic pressure.
b. Muffling or disappearance of sounds correlates to diastolic pressures.
12. Deate the BP cuff completely.
13. Record the blood pressure reading(s). The extremity used and position of
the consumer are important data to record along with the blood pressure
reading. Refer to Clinical reasoning practice tip: Accurate documentation of
blood pressure.
Figure 6.19). At subsequent encounters,
A. When taking a blood pressure
measurement, the nurse can manually
elevate the arm to the level of the
consumer’s heart.
B. The nurse can also rest a consumer’s
elevated arm at the level of the heart
using equipment. Note that this seated
consumer has her feet resting on the oor.
FIGURE 6.19 Measuring a consumer’s
blood pressure
CHAPTER 6
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
164 PHYSICAL EXAMINATION
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UNIT 2
TABLE 6.5 Normal blood pressure range according to age and sex*
AGE (FEMALE) SYSTOLIC (MMHG) DIASTOLIC (MMHG)
1 97–103 52–56
5 103–109 66–70
10 112–118 73–76
15 120–127 78–81
≥ 18 < 120 < 80
AGE (MALE) SYSTOLIC (MMHG) DIASTOLIC (MMHG)
1 94–103 49–54
5 104–112 65–70
10 111–119 73–78
15 122–131 76–81
≥ 18 < 120 < 80
*The measurements listed for paediatric consumers are included; however blood pressure is not taken routinely for children unless they are
in
ICU or in a critical condition.
TABLE 6.6 Errors in blood pressure measurement
IF READING SHOWS SUSPECT
inaccurately high
blood pressure
high diastolic
blood pressure
inaccurately low
blood pressure
low systolic blood
pressure
Blood pressure cuff is too short or too narrow (e.g. using a regular blood pressure
cuff on an obese arm), or the brachial artery may be positioned below the heart. The
consumer may also be stressed, be in an emotional state, or have just completed
physical activity.
Unrecognised auscultatory gap (a silent interval between systolic and diastolic
pressures that may occur in hypertensive consumers or because you deated the blood
pressure cuff too rapidly); immediate reination of the blood pressure cuff for multiple
blood pressure readings (resultant venous congestion makes the Korotkoff sounds
less audible).
contraction can raise the diastolic blood pressure by 10%.
Blood pressure cuff is too long or too wide; the brachial artery is above the heart.
Unrecognised auscultatory gap (a rapid deation of the cuff or immediate reination
of the cuff for multiple readings can result in venous congestion, thus making the
Korotkoff sounds less audible and the pressure appear lower).
If the consumer supports his or her own arm, then sustained muscular
CLINICAL REASONING
Practice tip: Accurate documentation of blood pressure
It is important to record the position of the consumer during the blood pressure
measurement, as there can be differences (e.g. sitting and standing can have a marked
difference), and identify postural hypotension. Document consumer position as follows:
> supine
> sitting or standing
Also, record where the blood pressure was taken. Use the following abbreviations:
> RA = (right arm) LA = (left arm)
> RL = (right leg) LL = (left leg)
Examples of blood pressure readings are:
> 160/122mmHg LL (supine)
> 98/52mmHg RA (sitting)
> 118/85mmHg LA (standing)
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 165
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CLINICAL REASONING
Practice tip: Palpating the blood pressure
If you are unable to hear a consumer’s blood pressure and there is no electronic monitor
or amplication device available, you can use the palpation method. Conduct the blood
pressure measurement as described in steps 1–6 using the brachial artery. When releasing
air from the cuff, note when the brachial artery is palpable. This correlates with the systolic
pressure. This blood pressure is then documented as a number over palpated (e.g. 115/
palpated). It should also be noted that an audible BP reading was unable to be obtained.
TABLE 6.7 Classication of blood pressure in adults
DIAGNOSTIC CATEGORY
Optimal
Normal 120–129 and/or 80–84
High-normal 130–139 and/or 85–89
Grade 1 (mild) hypertension 140–159 and/or 90–99
Grade 2 (moderate) hypertension 160–17 and/or 100–109
Grade 3 (severe) hypertension
Isolated systolic hypertension
a
When a consumer’s systolic and diastolic BP levels fall into different categories, the higher diagnostic category and recommended
action/s apply.
SOURC E: NATION AL HEAR T FOUNDATI ON OF AUST RALIA . GUIDELI NE FOR THE DI AGNOSIS A ND MANAG EMENT OF H YPERT ENSION IN A DULTS – 2016. ME LBOURN E: NATION AL
HEA RT FOUNDAT ION OF AUST RALI A, 2016.
Normal blood pressure varies with age. As a person ages, blood pressure
N
generally increases.
at different ages. Normally, baroreceptors help a consumer to maintain
normal blood pressure when changing from a supine to a sitting or a
standing position. (Baroreceptors are the receptors located in the walls of
most of the great arteries that sense hypotension and initiate reex
vasoconstriction and tachycardia to bring the blood pressure back to normal.)
Processes that increase cardiac output, such as exercise, will normally increase
blood pressure. Pulse pressure is normally 30 to 40mmHg.
in blood pressure measurement.
Hypertension, or high blood pressure, is usually conrmed when an adult
P
consumer has blood pressure readings remaining consistently above 120mmHg
systolic and 80mmHg diastolic on two consecutive visits after an initial
screening. See Table 6.7 for the classication of hypertension.
The cause of hypertension in 90% of consumers who have it is unknown. It is
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thought that the mechanisms that maintain the therapeutic uid volume in the
body (e.g. the heart, kidneys, nervous system, renin–angiotensin–aldosterone
system) may be abnormal. The other 10% of the population with high blood
pressure have secondary hypertension. All of the following pathophysiologies of
hypertension are secondary in nature.
Arteriosclerosis reduces arterial compliance. Elastic and muscular tissues of
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arteries are replaced with brous tissue as part of the normal ageing process,
making the vessels less able to contract and relax in response to systolic and
diastolic pressures. When the systolic pressure alone is elevated in the elderly,
it is called isolated systolic hypertension.
Processes decreasing the size of the arterial lumen cause hypertension.
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Hypercholesterolaemia results in deposits of plaque along the inner walls of the
vessels, reducing the size of the arterial lumen and increasing blood pressure.
a
SYSTOLIC (MMHG) DIASTOLIC (MMHG)
<120
≥180
>140
and
and/or
and
<80
≥110
<90
Table 6.5 presents general ranges for normal blood pressure
Table 6.6 lists errors
CHAPTER 6
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
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