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CARDIAC SYSTEM 19

Table 1-6. Pirring Edema Scale

Scale

Degree

Description

1 + Trace

Slighr

Barely perceprible depression

2+ Mild

0-{}.6 em

Easily idenrified depression (EID)

(skin rebounds in <15 secs)

3+ Moderare

0.6-1.3 em

EID (rebound 15-30 sees)

4+ Severe

1.3-2.5 em

EID (rebound >30 sees)

EID = easily identified depression.

Sources: Dara from SL Woods, ES Sivarajian Froelichcr, 5 Underhill-Moner (cds). Cardiac

Nursing (4th cd). Philadelphia: Lippincott, 2000; and EA Hillegass, HS Sadowsky (cds).

Essentials of Cardiopulmonary Physical Therapy (2nd cd). Philadelphia: Saunders, 2001.

B)ood Pressure

BP measurement with a sphygmomanometer (cuff) and auscultation is an indirect, noninvasive measurement of the force exerted against the arterial walls during ventricular systole (systolic blood

pressure [SBPJ) and during ventricular diastole (diastolic blood

pressure). BP is affected by peripheral vascular resistance (blood

volume and elasticity of arterial walls) and CO. Table 1-7 lists

normal BP ranges. Occasionally, BP measurements can only be

performed on certain limbs secondary ro the presence of conditions Stich as a percutaneous inserted central catheter, arteria-Table 1-7. Normal Blood Pressure Ranges

Systolic

Diastolic

Age 8 yrs

85-1 14 111m Hg

52-85 mOl Hg

Agel2 yrs

95-'135 mm Hg

58-88 mm Hg

Adulr

100- 140 mm Hg

60-90 mm Hg

Borderline

140-150 mm Hg

90-100 mm Hg

hypertension

Hypertension

>150 mm Hg

> 100 mm Hg

Normal exer

Increases during rime and wirh

,,) O mm Hg

cise

increased load or intensity

Sources: Data from SL Woods, ES Sivarajian Froelicher, S Underhill-Moner (cds). Cardiac Nursing (4th cd). Philadelphia: Lippincott, 2000; :md LS Bickley. Bate's Guide to Physical Examination and Hisrory Taking (7th cd). Philadelphia: Lippincon, 1999.

20

ActITE CARE HANDBOOK FOR PHYSICAL TIIERAPlm

venous fistula for hemodialysis, blood clots, scarring from brachial

artery cutdowns, or lymphedema (i.e., status-post mastectomy).

BP of the upper extremity should be measured ill the following

manner:

1 . Check for posted signs, if any, at the bedside that indicate

which arm should be used ill taking BP. BP variations of 5- J 0 mm Hg

between the right and lefr upper extremity are considered normal.

Patients with arterial compression or obstruction may have differences of more than 10-15 mm Hg.12

2.

Use a properly fitting cuff. The inflatable bladder should have

a width of approximately 40%, and length of approximately 80% of

the upper arm circumference. 13

3 .

Position the cuff 2.5 em above the antecubital crease.

4.

Rest the arm at the level of the heart.

5.

To determine how high to inflate the cuff, palpate the radial

pulse, inllate until no longer palpable, and nOte this cuff inflation

value. Deflate the cuff.

Note: With a patient who is in circulatory shock, auscultation may

be too difficult. In these cases, this method can be used to measure the

SBP and is recorded as systolic BPfP (i.e., "BP is 90 over palp").13

6.

Place the bell of the stethoscope gently over the brachial arrery.

7.

Re-inflare rhe cuff to 30-40 mm Hg greater rhan the value in

srep 5. Then slowly deflare rhe cuff. Cuff deflation should occur at

approximately 2-3 mm Hg per second.13

8.

Listen for the onset of tapping sounds, which represents blood

flow returning to the brachial arrery. This is the systolic pressure.

9.

As the pressure approaches diastolic pressure, the sounds will

become muffled and in 5-10 mm Hg will be completely absent. These

sounds are referred to as Korotkoff's sounds (Table 1_8). 12.13

Clinical Tip

•

Recording pre-, para-, and posrexerrion SP is important

in identifying BP responses [0 activity. During recovery

from exercise, blood vessels dilate to allow for greater

blood flow to muscles. In cardiac-compromised or very

CARDIAC SYSTEM

2 1

Table 1-8. Kororkoff's Sounds

Phase

Sound

Indicates

First sound heard,

Systolic pressure (blood stans to flow

faint tapping

through compressed artery).

sound with

increasing intensity

2

Start swishing sound

Because of the compressed artery, blood

flow continues to be heard while the

sounds change due to the changing

compression on the anery.

3

Sounds increase in

inrensity with a

distinct tapping

4

Sounds become muf

Diasrolic pressure in children <13 yrs old

ned

and in adults who are exercising, pregnanr, or hyperrhyroid (see phase 5).

5

Disappearance

Diastolic pressure in adults-occurs 5-10

mm Hg below phase 4 in normal

adults. In states of increased rate of

blood flow, it may be greater than 10

mm Hg below phase 4. In these cases,

the phase 4 sound should be used as

diasrolic pressure in adults.

Sources: Data from SL Woods, ES Sivarajian-Froelicher, S Underhill-Moner (eds). Cardiac Nursing (4th ed). Philadelphia: Lippincott, 2000; and LS Bickley. Bate's Guide to Physical Examination and History Taking (7th ed). Philadelphia: Lippincott, 1 999.

decondirioned individuals, toral CO may nor be able to

support this increased flow to the muscles and may lead to

decreased Output to vital areas, such as the brain.

• If unable to obtain BP on rhe arm, rhe thigh is an appropriate alternative, with auscultation at the popliteal artery.

•

Falsely high readings will occur if the cuff is too small

or applied loosely, or if the brachial arrery is lower rhan

rhe hearr level.

• Evaluarion of BP and HR in differenr postures can be

used to monitor orthostatic hypotension with repeat measurements on the same arm 1-5 minutes after position

changes. The symbols rhar represent parienr posirion are

shown in Figure 1 -7.