Emtenan Alharbi , MSc.
Department of Clinical Pharmacy
Pharmacists & Physical Examination
 Pharmacists do not perform a complete physical examination
 It is important, however, to be familiar with the physical
examination in terms of the principles, methods, and data
obtained to understand findings documented by other
healthcare professionals
Basic Principles of Physical Examination
 Objective of physical examination (PE):
 Obtaining valid info about health status of the patient
 This is achieved by:
Identifying ‘’normal’’ state
Identifying any variations from ‘’normal’’ state by:
1.
2.



Validation of patient’s complaints & symptoms
Screening of the patient general well-being
Monitoring of the patient’s current health problems
Basic Principles of Physical Examination
 The medical record consists of both subjective and objective
information.
 Subjective:
 Subjective information is acquired during patient interview &
from the health history.
 It alerts the examiner regarding areas on which to concentrate
during examination.
 Objective:
 Objective information is obtained through the physical
examination.
Methods of Assessment
 Four assessment techniques are used during PE:
 Inspection
 Palpation
 Percussion
 Auscultation
 They should always be accomplished in the order
given above, with each technique amplifying the
results obtained from the previous one.
Methods of Assessment
Inspection
 Inspection is the visual looking at and evaluating of a person.
 Examiner uses the sense of sight to concentrate attention on
the thorough, persistent, unhurried visualization of the
patient.
 It starts from the moment of first meeting through obtaining
the patient history & throughout entire physical examination.
Methods of Assessment
Inspection
 Observe the patient’s:
 Breathing
 Gait
 Personal grooming
 Body habitus (physical characteristics)
 Body position (e.g. sitting comfortably, leaning forward)
 Affect (mood) & its appropriateness to the situation
 Skin for color, presence of lesions or trauma
Methods of Assessment
Palpation
 Palpation is touching or feeling with the hand
 Palpating individual structures on the surface and within the
body cavities, particularly the abdomen:
 Elicits important information regarding the position, size,
shape, consistency, & mobility of the normal anatomic
components
 Uncovers crucial clues to the presence of abnormalities such as
enlarged organs and palpable masses.
 May be effective in assessing fluid within a space.
Methods of Assessment
Palpation
 Can be performed with the fingertips, palm, or back of the
hand
 Palpation may be:
 Light
 Medium
 Deep
Methods of Assessment
Palpation
 Light palpation
 Always used first
 Superficial, gentle, and useful in assessing for lesions on the
surface or within muscles.
 Serves to relax the patient in preparation for medium and deep
palpation
 Performed by pressing the pads of the fingers lightly into the
patient’s skin, moving the fingers in a circular motion.
Methods of Assessment
Palpation
 Medium palpation
 Assesses for midlevel lesions of the peritoneum and for masses,
tenderness, pulsations, & pain in most structures of the body.
 Performed by pressing the palmar surface of the fingers 1-2 cm
into the patient’s body, using a circular motion.
Methods of Assessment
Palpation
 Deep palpation
 Assesses organs deep within the body cavities, and it may be
performed with one or two hands
 At times, it may be necessary to cause the patient some
discomfort or pain to fully assess a symptom.
Light Vs. Deep Palpation
Methods of Assessment
Percussion
 Involves striking the body’s surface lightly, but sharply, to
determine the position, size, and density of the underlying
structures as well as to detect fluid or air in a cavity.
 Sound reverberations assume different characteristics depending
on the features of the underlying structures.
 The resultant sound is described as one of the following:
 Flat
 Dull
 Resonant
 Hyper-resonant
 Tympanic
Methods of Assessment
Percussion
 The percussion notes are identified and characterized as follows:
 Pitch(also known as frequency) is the number of vibrations or cycles
per second (cps). Rapid vibrations produce a higher-pitched tone,
whereas slower vibrations produce a lower-pitched tone
 Amplitude (also known as intensity) determines the loudness of the
sound. The greater the intensity, the louder the sound
 Duration is the length of time that the note lingers
 Quality a subjective concept used to describe the variance secondary
to a sound’s distinctive overtones
Percussion Sounds
Methods of Assessment
Percussion
 Methods of percussion:
 Direct percussion

Tapping patient’s body directly with the distal end of a finger
 Indirect percussion



Using either the index & middle finger or just the middle
finger of one hand, which strikes against the middle finger of
the other hand.
Touch patient only with the finger that is being tapped (to
avoid dampening the sound)
Another method: tap middle finger with the rubber head of a
reflex hammer
Methods of Assessment
Indirect Percussion
Methods of Assessment
Percussion
 Direct and indirect percussion can also be accomplished with
the fist.
 Direct fist percussion involves making a fist with the dominant
hand and then striking the body’s surface directly.
 Indirect fist percussion, one hand is placed firmly on the body
while the fist of the dominant hand does the striking.
Methods of Assessment
Fist Percussion
Methods of Assessment
Auscultation
 Auscultation is the skill of listening either directly with the ear or
indirectly with a stethoscope to sounds that arise spontaneously
from the body
 Examples: breath sounds, heart sounds, bowel sounds, bruits
 The stethoscope end piece has both a diaphragm and a bell
Methods of Assessment
Auscultation
 The diaphragm is used to
amplify high-pitched sounds
(e.g. breath, bowel, heart)
 The bell is reserved for low
pitched sounds (e.g. heart
murmurs, arterial (bruits) or
venous (hums) turbulence, &
organ friction rubs)
Gathering the Equipment
 Flashlight
 Assess pupillary reflexes, aid in inspection of oropharynx
& skin
Gathering the Equipment
 Ophthalmoscope
 Perform fundoscopic
examination
Gathering the Equipment
 Otoscope
 Assess external ear
canal and tympanic
membranes
Gathering the Equipment
 Tongue Depressor
 Move or hold tongue out of
the way to inspect
oropharynx
Gathering the Equipment
 Watch (digital or sweep
second hand)
 Assess heart & respiratory
rate
Gathering the Equipment
 Thermometer
 Measure body temperature
Gathering the Equipment
 Stethoscope
 Consists of 2 earpieces, rubber
tubing, head with diaphragm &
bell or diaphragm only
 Diaphragm accentuates high-
frequency sounds
 Bell transmits low frequency
sound
 Assess CV, pulmonary,
abdominal systems
Gathering the Equipment
Bulb
 Sphygmomanometer
 Measures blood pressure (BP)
 Consists of:



Cuff
Valved rubber bulb for
inflating cuff
Manometer to measure cuff
pressure
Valve
Manometer
Cuff
Gathering the Equipment
 Sphygmomanometer
 Cuffs come in variety of sizes to
accommodate different arm sizes


Cuffs that are too short or narrow
falsely elevate BP and too big cuffs
decrease BP
Cuff width should be ~ 40% of limb
circumference, length ~ 80% of limb
circumference
Gathering the Equipment
 Sphygmomanometer
 Mercury Based Sphygmomanometer


Durable, easy to read, consistent
accurate measurement
Bulky, must be upright & at eye level to
ensure accuracy, mercury is hazardous
substance
 Aneroid Sphygmomanometer


Inexpensive, work in all positions
Delicate, recalibated if bumped or
dropped
 Automatic Sphygmomanometer
Gathering the Equipment
 Reflex Hammer (Percussion Hammer)
 Consists of rubber head attached to
handle
 Used mainly to elicit superficial &
deep tendon reflexes
 May be used to create percussion
notes
 Pointed end of the head is used to
strike tendon & elicit reflex
Gathering the Equipment
 Tuning Fork
 Consists of a handle & 2 prongs
that form a U-shaped fork
 Vibrates at a set frequency after
being stuck on heel of hand
 Used to assess vibratory
sensation & auditory testing
Vibratory Sensation
Auditory Testing
Performing the Examination
 Meet the patient in either a clinic room or a hospital room.
 Wash hands in the patient’s presence, if possible.
 After the patient history, obtain vital signs.
 The examination begins with the practitioner positioned on
or toward the patient’s right side.
 The patient is in the sitting, Fowler’s, or semi-Fowler’s
position.
Performing the Examination
 Considering patient privacy and modesty, the examiner must
be discreet yet fully expose each area to be examined to
ensure accurate findings
 The examination should proceed in a methodical, slow, and
deliberate manner, with the practitioner asking questions
and encouraging the patient to ask questions
 Each step should be explained as the examination proceeds,
giving advance warning if a maneuver might produce
discomfort.
Performing the Examination
 Continually monitor your level of anxiety and concentrate on
achieving effective therapeutic communication.
 At the end of the examination, summarize the findings and
share the necessary information with the patient.
 Thank the person for the time spent, and reinforce your
teaching regarding medications and home care or follow-up
visit
General Assessment
 The general assessment (general survey) is a quick
assessment of the patient as a whole, including the:
 Physical appearance
 Certain physical parameters (i.e., height, weight, and vital
signs).
 The general assessment should provide an overall impression
of the patient’s health status.
Physical Appearance
 Note the following characteristics:
 Age
 skin color
 facial features
 level of consciousness
 signs of acute distress
 nutrition
 body structure
 dress and grooming
 behavior
 mobility
Physical Appearance
1) Age
 The patient’s facial features and body structure should match
his or her stated age.
 If the person looks much older than the stated age, it could
be a sign of chronic illness, alcoholism, or smoking
Physical Appearance
2) Skin Color
 The patient’s skin tone should be even and pigmentation
should be consistent with the patient’s genetic background.
 A lesion is an area of tissue with impaired function resulting
from disease or physical trauma.
Physical Appearance
2) Skin Color
 Cyanosis is a bluish discoloration resulting from an
inadequate amount of oxygen in the blood.
 Pallor is an abnormal paleness of the skin resulting from
reduced blood flow or decreased hemoglobin level
 Jaundice is a yellowing of the skin resulting from excessive
bilirubin (a bile pigment) in the blood.
 Cyanotic changes can be seen most easily in the lips and oral
cavity, whereas pallor and jaundice are detected most easily
in nail beds and conjunctiva of the eye.
Physical Appearance
3) Facial Features
 Facial movements should be symmetric, and the facial
expressions should match what the patient is saying.
 Abnormal facial features examples:
 If one side of the face is paralyzed => the patient may have
suffered a stroke or physical trauma.
 A flat affect or mask-like expression (no facial emotion)=> can
be associated with Parkinson’s disease and depression.
 Inappropriate affect, in which the facial expression does not
match what the patient is saying => may be a sign of psychiatric
illness.
Physical Appearance
4) Level of Consciousness
 The patient should be alert and oriented to time, place, and
person. (A&Ox3)
 Disorientation occurs with organic brain disorders, stroke, and
physical trauma.
 A lethargic patient typically drifts off to sleep easily, looks drowsy,
and responds to questions very slowly.
 A patient in a stupor responds only to persistent and vigorous shaking
and answers questions only with a mumble.
 A completely unconscious patient (i.e. a patient in a coma) does not
respond to any external stimuli or pain.
Physical Appearance
5) Signs of Acute Distress
 Signs of acute respiratory distress include shortness of
breath, wheezing, or use of accessory muscles to assist
inbreathing.
 Facial grimacing or holding a body part are signs of severe
pain.
 Emotional distress may appear as anxiousness, nervousness,
fidgeting, and/or tearfulness/crying.
Physical Appearance
6) Nutrition
 The patient’s weight should be appropriate for his or her
height and build, and body fat should be distributed evenly.
 Truncal obesity, in which fat is located primarily in the face,
neck, and trunk regions of the body and the extremities are
thin, can be caused by:
 Cushing’s syndrome or
 Taking corticosteroid medication.
Physical Appearance
6) Nutrition
 If the patient’s waist is wider than the hips, then he or she is
at increased risk of developing obesity-related diseases (e.g.,
diabetes, hypertension, coronary artery disease).
 A cachectic appearance, in which the patient looks emaciated
or very thin and has sunken eyes and hollowed cheeks, is
associated with chronic wasting diseases(e.g., cancer,
starvation, dehydration).
Physical Appearance
7) Body Structure
 Both sides of the patient’s body should look and move the
same.
 The person should stand comfortably erect as appropriate for
his or her age.
Physical Appearance
8) Dress & Grooming
 The patient’s clothing should correspond with the climate, be
clean, and fit appropriately.
 The patient should appear clean and be groomed
appropriately for his or her age, gender, occupation,
socioeconomic group, and cultural background.
Physical Appearance
9) Behavior
 The patient should be cooperative and interact pleasantly
and appropriately with others.
 Speech should be clear and understandable, with appropriate
word choices for the patient’s educational level and culture
Physical Appearance
10) Mobility
 The patient’s gait (or walk) should be smooth, even, and well
balanced, with the feet approximately shoulder-width apart.
 Ataxia is a staggering, unsteady gait that can occur with
excessive alcohol or drug ingestion (e.g., barbiturates, benzodiazepines, central nervous system stimulants)
Physical Parameters
 Physical parameters that are measured as part of the general
assessment reflect the patient’s overall health status
 Include
 height
 weight
 vital signs
Physical Parameters
1) Height
 Height can be compared to previous measurements to assess
decreasing bone density or osteoporosis
 Height can be recorded in centimeters or inches
Physical Parameters
2) Weight
 A person’s weight reflects his or her nutritional and overall
health status and is best measured with a standardized
balance scale.
 Weight can be recorded in pounds or kilograms.
Physical Parameters
2) Weight
 To assess the patient’s weight, use body mass index (BMI), which
describes the relative weight for height
 BMI = Weight (kg)/Height (m2)
 BMI (kg/m2)is classified as:
Classification
Underweight
Healthy Weight:
Overweight:
Obesity Class 1:
Obesity Class 2:
Obesity Class 3:
BMI
< 18.5 kg/m2
18.5–24.9 kg/m2
25–29.9 kg/m2
30–34.9 kg/m2
35–39.9 kg/m2
> 40 kg/m2
Physical Parameters
2) Weight
 Patients who are overweight or obese are at a higher risk of
morbidity from:
 Hypertension, type 2 diabetes, dyslipidemia , coronary heart
disease
 In addition, patient’s waist circumference is correlated with
abdominal fat content and subsequently is also a risk factor
for the development of obesity-associated risk related
diseases.
Physical Parameters
2) Weight
 To appropriately assess the overweight patient’s risk,
measure the waist circumference
 Locate the upper hip bone and the top of the iliac crest.
 Place a measuring tape in a horizontal plane around the
abdomen at the level of the iliac crest.
 Before reading the tape measure, be sure that the tape is snug,
but is not compressing the skin, and is parallel to the floor.
 High Risk
 Men > 40 in (102 cm)
 Women > 35 in (88 cm)
Physical Parameters
2) Weight
 Unintended weight loss may be a sign of short-term illness
(e.g. infection) or of long-term disease (e.g. hyperthyroidism,
cancer).
 Also, several medications can decrease the patient’s appetite
or cause nausea or gastritis (e.g. decongestants,
antidepressants, nonsteroidal anti-inflammatory drugs)
 In contrast, disease processes such as hypothyroidism &
depression and medications such as corticosteroids can
cause weight gain; however, weight gain more commonly
reflects excessive caloric intake and a sedentary lifestyle
Vital Signs
 Vital signs include:
 Temperature
 Pulse
 Respiratory rate
 Blood Pressure (BP)
 These measurements should be compared to the normal
range for the patient’s age and to the patient’s previous
measurements, if available.
Vital Signs
1) Temperature
 The normal temperature range for adults is 36.4 to 37.2°C.
 Normal body temperature can be affected by biological
rhythms, hormones, exercise, and age.
 Diurnal fluctuations of roughly 1°C normally occur, with the
lowest temperature in the early morning and the highest in
the late afternoon to early evening.
 In females, progesterone secretion at ovulation causes a
0.5°C increase in temperature that typically continues until
menses.
Vital Signs
1) Temperature
 Moderate to heavy exercise also increases body temperature.
 In children, wider normal variations of temperature occur because
of immature heat-control mechanisms.
 As a person ages, the mean normal body temperature declines
from 37.2°C in young children to 37°C in adults to 36°C in elderly
people.
 Measurement of body temperature provides useful insight
regarding the severity of illness (e.g., infections).
 Temperature is recorded in degrees Celsius or degrees Fahrenheit
Vital Signs
1) Temperature
 Temperature can be measured by a variety of thermometers
(i.e. glass, electronic, tympanic) and by a variety of routes
(i.e. oral, rectal, axillary, tympanic).
 Due to environmental concerns of mercury pollution from
medical waste incinerators, mercury-containing glass
thermometers and sphygmomanometers are being replaced
with electronic equipment
Vital Signs
1) Temperature
Mercury Thermometer
Electronic Thermometer
Digital Thermometer
Tympanic Thermometer
Vital Signs
1) Temperature
 Oral Route:
 Accurate and convenient
 Normal body temperature in adults by the oral route is 37°C
 To measure body temperature using the oral route:




Place the thermometer tip gently under the patient’s tongue in either
of the posterior sublingual pockets, not in front of the tongue (be sure
there is a disposable plastic probe cover on the tip.
Instruct the patient to keep his or her lips closed.
Keep the thermometer in place until the device
Gently remove the thermometer from the patient’s mouth and read
the number.
Vital Signs
1) Temperature
 Rectal Route:
 Preferred in patients who are confused, comatose, or unable to
close their mouth because of intubation, facial surgery.
 Also is commonly used to obtain an infant’s temperature .
 The most accurate way to measure the core body temperature.
Vital Signs
1) Temperature
 Rectal Route:
 Normal temperature in adults by the rectal route is 37.5°C
which is approximately 0.5°C higher than with the oral route.
 To measure body temperature using the rectal route:





Assist the patient into a lateral position with the upper legs flexed.
Wear gloves
Lubricate a rectal, blunt-tipped thermometer
Insert thermometer 2-3 cm into the rectum
Leave in place for at least 2 min
Vital Signs
1) Temperature
 Axillary Route:
 Used in adults only when oral & rectal routes are not accessible
 Safe & accurate in infants & children
 Normal temperature in adults by the axillary route is 36.5°C
which is approximately 0.5°C lower than with the oral route.
Vital Signs
1) Temperature
 Tympanic Route:
 Uses a thermometer with a probe tip that is placed into the ear
 The thermometer has an infrared sensor to detect temperature
of blood flowing through eardrum
 Noninvasive, quick & efficient
 To measure body temperature using the tympanic route:





Place new disposable cover on probe tip
Gently place probe into patient’s ear canal
Be careful not to force the probe or occlude the canal
Activate instrument by pressing appropriate button
Read temperature in 2-3 seconds
Vital Signs
2) Pulse
 Pumping action of the heart causes blood to pound against
artery walls, creating a pressure wave with each heart beat
that is felt in the periphery as pulse
 The peripheral pulse is palpated to assess the heart rate,
rhythm, and function.
 Because it is easily accessible, the radial pulse is most
commonly used to measure a person’s heart rate; it is
palpated over the radial artery on the anterior wrist.
Vital Signs
2) Pulse
 To measure the radial pulse:
 Place the pads of the first and second fingers on the palmar
surface of the patient’s wrist medial to the radius bone
 Press down until pulsation is felt, but be careful not to occlude
the artery (in which case no pulse will be felt).
 Count the number of beats in 30 seconds, and if the rhythm is
regular, multiply that number by two.
 Avoid using only a 15 second counting interval
 If the rhythm is irregular, count the number of beats in 1 min
 Record the finding as beats per minute (bpm).
Vital Signs
2) Pulse
Normal heart rates for various age groups
Vital Signs
2) Pulse
 In an adult, a heart rate of less than 60 bpm is called
bradycardia, and a heart rate of greater than 100 bpm is
called tachycardia.
 A well-conditioned athlete, however, can have a normal,
resting heart rate of less than 60 bpm,
 Heart rates greater than 100 bpm can normally occur in
patients who are exercising or anxious.
Vital Signs
2) Pulse
 In addition to the pulse rate, the pulse rhythm should be
evaluated.
 Normally, the rhythm of the pulse is steady and even.
 If an irregular rhythm, called an arrhythmia, is identified, then the
heart sounds should be auscultated with a stethoscope for a more
accurate assessment
 The force of the pulse generally is described using a fairly
subjective four-point scale:
0
1+
2+
3+
absent
weak, thready
normal
full or bounding
Vital Signs
3) Respiratory Rate
 Inspection is used to evaluate the patient’s respiratory rate.
 Because most people are unaware of their breathing and
sudden awareness may alter the normal pattern, do not tell
the patient that his or her respiratory rate is being measured.
Vital Signs
3) Respiratory Rate
 To measure the respiratory rate:
 Maintain the position for a radial pulse measurement.
 Observe the patient’s chest or abdomen for respirations.
 Count the number of respirations (inhalation and exhalation
are counted as one respiration) in 30 seconds, and if the
rhythm is regular, multiply this number by 2.
 If the rhythm is irregular, count the number of respirations for 1
minute.
 Record the value as respirations per minute (rpm).
Vital Signs
3) Respiratory Rate
 Normal Respiratory Rates for Various Ages
 For adults, a respiratory rate of less than 12 rpm is called
bradypnea, and a respiratory rate of greater than 20 rpm is
called tachypnea
Vital Signs
3) Respiratory Rate
 Observe whether pattern of breathing is normal (normal
depth of breathing & regular rate)
 Abnormal patterns include:
 Kussmaul’s respiration: abnormally fast and deep breathing,
associated with metabolic acidosis
 Fast & shallow breathing associated with obstructive airway
disease
 Slow & shallow breathing associated with narcotics
 Apnea: no breathing, associated with sleep apnea
 Cheyne-Stokes breathing: periods of apnea alternating with
cycles of increasing & decreasing depth of breathing, associated
with diseases affecting central respiratory center
Vital Signs
4) Blood Pressure
 Blood pressure is the force of the blood as it pushes against the
arterial walls.
 It is dependent on cardiac output, the volume of blood ejected by
the ventricles per minute, and the peripheral vascular resistance.
 Heart rate, contractility, and total blood volume, which is primarily
dependent on the sodium content, influence the cardiac output.
 Arterial blood viscosity and wall elasticity influence the peripheral
vascular resistance
Vital Signs
4) Blood Pressure
 Blood pressure has two components: systolic and diastolic.
 The systolic blood pressure represents the maximum pressure that
is felt on the arteries during left ventricular contraction (or
systole), and it is regulated by the stroke volume (i.e., the volume
of blood ejected with each heartbeat).
 The diastolic blood pressure is the resting pressure that the blood
exerts between each ventricular contraction.
 The primary objective of identifying, treating, and monitoring the
patient’s blood pressure is to reduce the risk of cardiovascular
disease and its associated morbidity and mortality.
Vital Signs
4) Blood Pressure
 Method of measurement
 The most common is the indirect, auscultatory method using a
stethoscope and a sphygmomanometer.
 Blood pressure measurement is considered to be indirect,
because the pressure within the blood vessel is indirectly
measured by measuring the pressure in the cuff.
Vital Signs
4) Blood Pressure
 Method of measurement
 As air is pumped into the cuff, the pressure within the cuff
increases. When the pressure within the cuff exceeds the
pressure within the patient’s brachial artery, the artery is
compressed and the blood flow diminishes and, ultimately,
stops.
 As air is released from the cuff, the bladder deflates, and the
pressure within the cuff decreases. When the pressure within
the cuff matches the pressure within the artery, blood begins to
flow through the artery once again
Vital Signs
4) Blood Pressure
 Method of measurement
 Blood flow within the artery produces distinct sounds, called
Korotkoff sounds that occur in five phases:





Phase I: faint, clear, tapping (the systolic pressure).
Phase II: swooshing (softer tapping)
Phase III: crisp, more intense tapping.
Phase IV: muffling
Phase V: cessation of sound (in adults, diastolic pres-sure).
Vital Signs
4) Blood Pressure
 Steps of Measurement:
 Ask the patient if he or she has smoked or ingested caffeine within
the previous 30 minutes. If the patient has, document this
information.
 The patient should be seated in a chair with his or her back
supported and arm bared and supported at heart level, feet flat
supported on ground.
 Measurement should begin after at least 5 minutes of rest.
 Determine the appropriate cuff size
 Palpate the brachial artery along the inner upper arm.
 Center the bladder of the cuff over the brachial artery, and wrap the
cuff smoothly and snugly around the arm placing the lower edge of
the cuff approximately 2.5 cm above the antecubital space
Vital Signs
4) Blood Pressure
 Steps of Measurement:
 Position the manometer in direct line of eye sight.
 Instruct the patient not to talk during the measurement.
 Determine the maximum inflation level. (While palpating the radial
pulse, inflate the cuff to the point at which the radial pulse can no
longer be felt, then add 30 mmHg to this reading.
 Rapidly deflate the cuff, and wait 30 seconds before reinflating.
 Insert the stethoscope earpieces; make sure that they point forward
when in place
 Place the diaphragm of the stethoscope lightly, but with an air-tight
seal, over the palpable brachial artery
Vital Signs
4) Blood Pressure
 Steps of Measurement:
 Rapidly inflate the cuff to the maximum inflation level(determined
previously).
 Slowly release the air, allowing the pressure to fall steadily at 2 to 3
mm Hg/sec.
 Note the pressure at which the first of two consecutive sounds is
heard (Korotkoff Phase I). This is the systolic blood pressure.
 Note the pressure at which the last sound is heard(Korotkoff Phase
V). This is the diastolic pressure.
 Continue listening until 20 mm Hg below the diastolic pressure, then
rapidly and completely deflate cuff
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4) Blood Pressure
 Steps of Measurement:
 Record the patient’s blood pressure in even numbers, along with the
patient’s position (e.g., sitting, standing, lying), cuff size, and the arm
used for measurement.
 Wait 1 to 2 minutes before repeating the pressure measurement in
the same arm
 For the most accurate measurement, two or more readings, each
separated by 2 minutes, should be averaged.
 If the first two readings differ by more than 5 mm Hg, additional
readings should be obtained and averaged.
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4) Blood Pressure
 Classification of Measurements:
 BP readings are classified according to criteria from the Seventh
Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC-VII)
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4) Blood Pressure
 Classification of Measurements:
 Isolated systolic hypertension is defined as a systolic blood pressure
of 140 mm Hg or greater and a diastolic blood pressure of 90 mm Hg
or lower and should be staged appropriately (e.g., 170/82 mm Hg is
stage 2 isolated systolic hypertension).
Vital Signs
4) Blood Pressure
 Follow-Up Based on Initial BP Measurements
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4) Blood Pressure
 Common Errors of Measurement
 Incorrect cuff size is a major source of equipment-related error,
especially with obese patients who have large upper arms.


Using a cuff that is too small for the patient’s arm can produce a
falsely high reading.
In contrast, using a cuff that is too large for an extremely thin patient’s
arm can produce a falsely low reading.
 Thus, always check for the appropriate cuff size.
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4) Blood Pressure
 Common Errors of Measurement
 Because of isometric muscle contraction, hydrostatic pressure,
and gravitational pull, failing to position and support the
patient’s arm properly can also lead to false readings.


If the patient’s arm is above heart level, a falsely low reading will be
obtained.
Conversely, a falsely high reading will occur if the arm is below heart
level.
 Always make sure that the patient’s arm is well supported and
at heart level
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4) Blood Pressure
 Common Errors of Measurement
 Anxiety, pain, discomfort, or strenuous activity can cause
sympathetic nervous system stimulation and, thus, a falsely
high measurement.
 Therefore, allow the patient at least 5 minutes to rest and relax
before you obtain a reading.
Vital Signs
4) Blood Pressure
 Common Errors of Measurement
 Halting during deflation and reinflating the cuff too soon to
recheck the systolic blood pressure can cause forearm venous
congestion and a falsely high diastolic reading.
 If a measurement (systolic or diastolic) needs to be rechecked,
completely deflate the cuff, and obtain a new reading after
waiting for at least 1 to 2 minutes.
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4) Blood Pressure
 Common Errors of Measurement
 Deflating the cuff too quickly (faster than 2 mm Hg/sec)does
not allow enough time to hear the possibly faint tapping of the
systolic pressure and, thus, can cause a falsely low systolic
and/or a falsely high diastolic reading.
 On the other hand, deflating the cuff too slowly can cause
venous forearm congestion and a falsely high diastolic reading.
 Always deflate the cuff at a steady, appropriate speed (= 2mm
Hg/sec).
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4) Blood Pressure
 Factors Affecting BP:
 Age: Blood pressure gradually rises throughout childhood until
adulthood.
 Race: Hypertension occurs twice as often in African Americans
as in Caucasians.
 Diurnal Rhythm: Blood pressure is lowest during the early
morning and highest during the late afternoon or early evening.
 Weight: Excess body weight closely correlates with increased
blood pressure.
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4) Blood Pressure
 Factors Affecting BP:
 Exercise: Increased activity increases blood pressure,which
should return to baseline after 5 minutes of rest.
 Emotions: Blood pressure increases with pain, fear, anxiety,
anger, and stress.
 Medications: An unwanted side effect of some medications
(e.g., cyclosporine, corticosteroids, nasal decongestants) is
increased blood pressure.
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4) Blood Pressure
 Factors Affecting BP:
 When evaluating your readings, note if any of these factors may
be contributing to the patient’s blood pressure