UKRAINIAN MINISTRY OF PUBLIC HEALTH
Dnepropetrovsk State Medical Academy
«APPROVED»
At the methodological meeting of
the internal medicine propedeutics
department
Chief of the department
____________prof. Khomazuk T.A.
«
»
2013 y.
Guidelines
For Second-year Students of the Dentist Department
Subgect
Module №
Enclosure module №
Topic №7
Propedeutics of the internal medicine
Course
Faculty
2
Assessment of basic indexes of hemodynamics and
breathing.
Dnepropetrovsk- 2013
General purpose: Assessment of basic indexes of hemodynamics and breathing.
Main properties of pulse. Taking a radial pulse. Sites for palpation the pulse.
Measuring of arterial blood pressure, diagnostic value. Normal range of blood
pressure. Obtaining a respiratory rate, assessment of the breathing depth, type,
rhythm.
Specific purpose:
1. To assess pulse: definition, basic properties of pulse.
2. To obtaine a respiratory rate, types of the pathological breathing.
3. To know a technique of measuring blood arterial pressure, normal
values.
4. To control diuresis and liquid use at the patients with cardiovascular
diseases.
5. To know the first aid to patients with shortness of breath, dyspnea,
pain in a heart.
6. To know signs of hypertensive crisis, the first aid during hypertensive
crisis.
Topic content:
DEFINITIONS OF THE CHARACTERISTIC OF THE ACT OF BREATH
1. INVENTORY AND EQUIPMENT FOR ASSESSMENT OF BREATHING:

Hours or stop watch
2. SEQUENCE OF ACTIONS:

To define type of breath, observing for movements of a forward wall of a
thorax and a stomach (chest, abdominal, mixed)

To define depth of breath, observing for amplitude of fluctuations of a chest
wall and a stomach at breath (superficial, average depth, deep)

To define a rhythm of breath, observing for a regularity of respiratory
movements (regular, irregular)

To define frequency of breath within 1 minute (frequent, usual, rare)

To bring the received results in a leaf of dynamic supervision over patients
Technic of estimation main characteristics of breath
Respiratory movements of the chest should be symmetric, without apparent
use of accessory muscles. The type, rate, depth and rhythm of respiration should be
determined. Respiration can be costal (thoracic), abdominal, or mixed type. The
number of respiratory movements in a healthy adult at rest should be 16 to 20 per
minute. The respiration rate decreases during sleep to 12-14 per minute, while
under physical load, emotional excitement, or after heavy meals the respiration rate
increases. Superficial (shallow) breathing often occurs in pathologically
accelerated respiration. Deep breathing is, on the contrary, associated in most cases
with pathological deceleration of the respiration rate. Deep and slow respiration,
with marked respiratory movements, is sometimes attended by noisy sounds. This
is Kussmaul’s respiration occurring in deep coma.
Biot’s respiration is characterized by rhythmic but deep respiratory
movements, which alternate with long respiratory pauses. Biot’s respiration occurs
in meningitis patients and in agony with disorders of cerebral circulation. CheyneStokes’ respiration is characterized by periods (from few seconds to a minute) of
cessation of respiration, followed by noiseless shallow respiration, which quickly
deepens, becomes noisy to attain its maximum at the 5-7th inhalation, and then
gradually slows down to end with a new short respiratory pause. This respiratory
disorder occurs in acute or chronic insufficiency of cerebral circulation and brain
hypoxia, and also in heavy poisoning. Undulant (wave-like) Grocco’s respiration
somewhat resembles Cheyne-Stokes’ respiration except that a weak shallow
respiration occurs instead of the respiratory pause. This type of arrhythmic dyspnea
can probably be regarded as the early stages of the same pathological processes,
which are responsible for Cheyne-Stokes’ respiration.
RESEARCHES OF ARTERIAL PULSE AND ARTERIAL PRESSURE
Pulse is the rhythmical vibration of the arterial walls caused by contractions of
the heart, blood discharge into the arterial system, and changes in pressure in this
system during systole and diastole. Pulse wave is transmitted due to the ability of
arterial walls to distend and collapse. Palpation of the pulse is the main method of
examination of pulse. As a rule, pulse is studied first on the radial artery, since it is
superficial and can thus be readily felt between the styloid process of the radial bone
and the tendon of the internal radial muscle. Both radial arteries should be palpated
simultaneously and the magnitude of pulse waves on both hands compared (normally
it is the same). The pulse wave on one arm may happen to be lower. It occurs in
unilateral structural abnormalities in peripheral course of the artery, its constriction, and
compression by a tumor, or a scar, etc. Pulse may also be different when similar
changes occur in the brachial or subclavian artery, or due to compression of large
arterial trunks by the aortic aneurysm, mediastinal tumor, retrosternal goiter, or
markedly enlarged left atrium. The smaller pulse wave may lag in time. If the pulse on
the two arms is different, its further study should be carried out on that arm where the
pulse wave is more pronounced. The following properties of pulse are examined:
rhythm, rate, tension, filling, amplitude (force), and waveform.
In healthy subjects, cardiac contractions and pulse waves follow one
another at regular intervals: the pulse is said to be rhythmic or regular. When the
cardiac rhythm is upset, pulse waves follow at irregular intervals: the pulse
becomes arrhythmic, or irregular. Pulse rate in normal conditions corresponds to
the rate of cardiac contractions and is 60-90 per minute. If the heart rhythm is
accelerated (tachycardia), the number of pulse waves increases and the pulse rate
increases accordingly (pulsus frequens); slowed cardiac rhythm (bradycardia) is
characterized by a respective slowing of the pulse (pulsus rarus). The pulse rate is
counted for one minute. If the pulse is arrhythmic, the heartbeats should also be
counted and compared with the pulse rate. During frequent and irregular
contractions of the heart, some systoles of the left ventricle can be so weak that the
blood is not ejected into the aorta or the amount of the discharged blood is very
small and the pulse wave does not reach the peripheral arteries. The difference
between the heart rate and the pulse is called the pulse deficit while the pulse itself
is called pulsus deficiens. The greater the deficiency, the worse is the effect it
produces on the circulation of blood.
The force that should be applied to the pulsating artery to compress it
completely determines pulse tension. The higher the systolic arterial pressure, the
more difficult is to compress the artery; such a pulse is tense (pulsus durus). If
arterial pressure is small, the artery is easy to compress and the pulse is soft (pulsus
mollis). A normal pulse is of moderate tension. Pulse filling shows the artery filling
with blood, or how the diameter of the artery changes in the period of dilation and
collapse. To evaluate pulse filling, proximal fingers should press the radial artery
gradually, the distal finger determines its maximum volume. Pulse filling decreases
(pulsus vacuus) in abnormal circulation and blood loss, contractile dysfunction of
the heart. If the stroke volume and the total amount of circulating blood increase,
pulse will be full (pulsus plenus). Pulse amplitude (force) implies its filling and
tension. It depends on the pulse volume, fluctuation of the arterial pressure during
both systole and diastole, and distensibility of the arterial wall. Large, bounding
(pulsus magnus) or high (pulsus altus) pulse is characteristic of aortic incompetence,
hyperthyroidism, fever, etc. The pulse becomes small (pulsus parvus) in aortic or
mitral stenosis, tachycardia, heart failure. The barely perceptible pulse is called thready
(pulsus filiformis). It occurs in shock, heart failure, and massive blood loss.
In normal conditions, pulse is rhythmic and uniform (pulsus aequalis). In
cardiac rhythm disorders, when the heart contracts at irregular intervals, the pulse
waves become non-uniform, and this pulse is called unequal (pulsus inaequalis). In rare
cases (in rhythmic pulse), high and low pulse waves alternate. This is alternating pulse
(pulsus alternans). It is believed that this pulse is due to alternation of heart
contractions that vary in force. It usually occurs in severe myocardial affection.
Pulse form (contour) depends on the rate of change in the arterial pressure
during systole and diastole. Rapid pulse (pulsus celer or pulsus saliens) is
characteristic of aortic insufficiency, since in this condition the stroke volume and
systolic pressure increase, while during diastole the pressure falls rapidly due to blood
regurgitation into the left ventricle. Pulse in such cases is not only quick but also high
(pulsus celer et altus). Rapid pulse is less characteristic of hyperthyroidism or nervous
strain. Slow pulse is, on the contrary, characteristic of aortic stenosis: blood ejection
from the left ventricle is difficult and the pressure in the aorta therefore increases
slowly. The pulse wave decreases and the pulse is therefore not only slow but also
small (pulsus tardus et parvus).
Paradoxic pulse (pulsus paradoxus) is characterized by smaller pulse waves
during inspiration. It develops in cases with adherent pericardium due to compression
of large veins and decreased blood filling of the heart during inspiration.
After examination of the radial artery, pulse is studied on the temporal, carotid,
femoral, popliteal, posterior tibial, dorsalis pedis and other arteries. It is important in
suspected affections of these arteries (arteriosclerosis obliterans, thrombosis).
1. THE PURPOSE: To be able to define characteristics of arterial pulse, to
measure arterial pressure and to bring the given researches in a card of
dynamic supervision over patients
2. INVENTORY AND EQUIPMENT:

Tonometer or sphygmomanometer

Phonendoscope

Card of dynamic supervision over patients
3. SEQUENCE OF ACTIONS:
А. Researches of arterial pulse:

To provide physical and psychological adaptation of the patient to
research

To take a brush of a hand of the patient in same

To make in a line fingers of the second hand

To place finger on a beam artery

To feel a method of search optimum sensation sphygmic impacts

To define characteristics of pulse: a regularity, frequency, fillings, a
pressure, size, the form
 To bring the received results in a leaf of dynamic supervision over
patients
Technic of investigation of arterial pulse
on wrist (а) temporal (б) and coratid (в) arteries
To note: Researches of pulse on a carotid spend in a point which is on a forward
surface of a neck at a level of the top edge of a thyroid cartilage.
Investigation of arterial pressure.
In healthy persons normal levels of arterial pressure equal from 90 to 139 mm
Hg for systolic and from 60 to 89 mm Hg for diastolic one. Elevation of systolic
pressure over 140 mm and of diastolic over 90 mm Hg is called arterial hypertension.
A drop in the systolic pressure below 90 mm and of diastolic below 60 mm Hg is
known as arterial hypotension. Longstanding elevation of blood pressure occurs in
essential
hypertension,
many
renal
diseases
(glomerulonephritis,
vascular
nephrosclerosis), in certain endocrinological diseases, and heart diseases, etc. Systolic
pressure alone is sometimes elevated, whereas diastolic pressure remains normal or
decreased. This causes a marked increase in the pulse pressure and may occur in aortic
incompetence, thyrotoxicosis, less markedly in anemia of any etiology and
atherosclerotic affections of the vessels.
Blood pressure may be decreased due to constitutional properties in asthenic
persons, especially in the upright position (orthostatic hypotension). Hypotension
occurs in many acute and chronic infectious diseases, Addison’s disease, etc. A
sudden drop in the blood pressure is observed in profuse blood loss, shock, collapse, or
myocardial infarction. Systolic pressure alone sometimes decreases while diastolic
pressure does not change or even increases. This causes a decrease in the pulse pressure
and may occur in myocarditis, exudative or adhesive pericarditis when cardiac output
decreases. Pulse pressure decreases also in aortic stenosis.
Aortic coarctation (congenital stenosis of the aorta) is characterized by considerably
lower pressure in the femoral arteries compared with the brachial arteries.
Researches of arterial pressure:
 To provide physical and psychological adaptation of the patient to research
during 5-15 mines
 To release the right shoulder of the patient from clothes
 To impose а cuff so that its bottom edge was on 1 sm above an elbow pole
 To place a hand of the patient on a soft laying (its muscles should be
weakened)
 To define arterial pulse
 To define size systolic arterial pressure on pulse (its disappearance)
 To force air in a cuff to pressure which does not exceed 20 hg after disappearance of
pulse
 To reduce pressure in a cuff is not faster than 2 mm.mercury for sec.
 To measure pressure twice with an interval in 1-2 minutes
 To define an average arithmetic of parameters of two measurements
 To accept for systolic pressure the first tone which has appeared above
vessels
 To accept for dyastolic pressure of disappearance of tones
 To bring value of arterial pressure in a leaf of dynamic supervision over
patients
Every nurse and physician must remember that:
1. The client's perceptions that the physical or interpersonal environment is
stressful affect the blood pressure measurement.
2. Ideally, the arm is at heart level for accurate measurement. Rotate the
arm so the brachial pulse is easily accessible.
3. Not constricted by clothing is allowed to access the brachial pulse
easily and measure accurately.
4. Do not use an arm where circulation is compromised in any way.
5. Exercise and smoking can cause false elevations in blood pressure
6. To avoid misreading of the client’s blood pressure and find any
changes his/her blood pressure from the usual.
7. Allow the client to relax and helps to avoid falsely elevate readings.
8. Providing
information
fosters
the
client’s
cooperation
and
understanding.
9. Cleansing the stethoscope prevents spread of infection.
Investigation of arterial pressure by a Korotkov’ method
а – tonometer, в – phonendoscope, б – sphygmomanometer, г – imposing
of a cuff on a shoulder
Tests self-knowledge and skills that students acquire while exploring themes.
1. What is normal pulse rate?
a)
20-30 in a min;
b)
*60-90 in a min;
c)
50-90 in a min;
d)
80-100 in a min;
e)
30-60 in a min.
2. What is normal level of the blood pressure :
a)
*90/60-139/89;
b)
60/20-100/70;
c)
120/70-150/90;
d)
130/60-160/100
e)
89/69-129/89.
3. If patient has nocturnal cough and dyspnea, peripheral oedema, tachycardia,
what system has been affected?
a)
Nervous,
b)
Respiratory;
c)
Gastrointestinal;
d)
Renal;
e)
*Cardiovascular.
4. If patient’s pulse is 126 in a minute, it’s named:
a)
*tachycardia
b)
bradicardia;
c)
atrial fibrillation;
d)
pulse deficiency;
e)
asystolia
5. If patient’s pulse is 46 in a minute, it’s named:
a) tachycardia
b) *bradicardia;
c) atrial fibrillation;
d) pulse deficiency;
e) asystolia
6. What types of dyspnoea do you know?
a)
*Exertional dyspnoea;
b)
Orthopnoea;
c)
Paroxysmal nocturnal dyspnoea;
d)
Acute dyspnoea;
e)
Everything mentioned above.
Recommended Reading:
1. Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer
Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.
2. Учебное пособие для иностранных студентов медицинских вузов,
обучающихся на английском языке / Мостовой Ю.М, Демчук А.В.,
Константинович Т.В.-1-е издание. - Винница:, 2009.
3. Clinical Nursing Skills and Techniques: basic, intermediate and advanced.
The C.V. Mosby Company, 1986.-1296 p.
4. Clinical Skills and Assessment Techniques in Nursing Practice. Scott,
Foresman and Company, 1989.-1280 p.
5. Emergency Nursing: priciples and practice. The C.V. Mosby Company,
1985.-715p.
6. Instructor's Manual for Fundamentals of Nursing, J.B. Lippincott Company
Philadelphia, 1989.-120 p.
7. Nursing interventions and clinical Skills. Mosby — year Book, Inc., 1996.813p.
8. Nursing Procedures: Student Version. Springhouse Corporation,1992.-788
p.
9. Zh. D. Semidotskaya, O.S. Bilchenko, I.A. Cherniacova, K.P. Zharko
Introduction to the course of internal disease. Book 1. Diagnosis // Kharkiv,
2005. – P. 112-123.