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: 1. Identifying normal state 2. Identifying any variations from normal state by: Validation of patients complaints & symptoms Screening of the patient general well-being Monitoring of the patients 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 Inspection Palpation Palpation Percussion Percussion Auscultation 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 patients: 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 patients 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 patients 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 bodys 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 sounds distinctive overtones

Percussion Sounds

Methods of Assessment Percussion Methods of percussion: Direct percussion Tapping patients 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 bodys 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 Sphygmomanometer Measures blood pressure (BP) Consists of: Cuff Valved rubber bulb for inflating cuff Manometer to measure cuff pressure Cuff Valve Bulb Manometer

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 patients presence, if possible. After the patient history, obtain vital signs. The examination begins with the practitioner positioned on or toward the patients right side. The patient is in the sitting, Fowlers, or semi-Fowlers 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 patients 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 patients 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 patients skin tone should be even and pigmentation should be consistent with the patients 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 Parkinsons 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 patients 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: Cushings syndrome or Taking corticosteroid medication.

Physical Appearance 6) Nutrition If the patients 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 patients 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 patients 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 patients educational level and culture

Physical Appearance 10) Mobility The patients 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, benzo- diazepines, central nervous system stimulants)

Physical Parameters Physical parameters that are measured as part of the general assessment reflect the patients 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 persons 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 patients weight, use body mass index (BMI), which describes the relative weight for height BMI = Weight (kg)/Height (m 2 ) BMI (kg/m 2 )is classified as: ClassificationBMI Underweight< 18.5 kg/m 2 Healthy Weight:18.524.9 kg/m 2 Overweight:2529.9 kg/m 2 Obesity Class 1:3034.9 kg/m 2 Obesity Class 2:3539.9 kg/m 2 Obesity Class 3:> 40 kg/m 2

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, patients 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 patients 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 patients 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 patients age and to the patients previous measurements, if available.

Vital Signs 1) Temperature The normal temperature range for adults is 36.4 to 37.2C. Normal body temperature can be affected by biological rhythms, hormones, exercise, and age. Diurnal fluctuations of roughly 1C 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 0.5C 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 37.2C in young children to 37C in adults to 36C 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 Digital Thermometer Electronic Thermometer Tympanic Thermometer

Vital Signs 1) Temperature Oral Route: Accurate and convenient Normal body temperature in adults by the oral route is 37C To measure body temperature using the oral route: Place the thermometer tip gently under the patients 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 patients 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 infants 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 37.5C which is approximately 0.5C 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 36.5C which is approximately 0.5C 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 patients 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 persons 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 patients 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: 0absent 1+weak, thready 2+normal 3+full or bounding

Vital Signs 3) Respiratory Rate Inspection is used to evaluate the patients 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 patients 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: Kussmauls 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 patients 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 patients 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

Vital Signs 4) Blood Pressure Steps of Measurement: Record the patients blood pressure in even numbers, along with the patients 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.

Vital Signs 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)

Vital Signs 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

Vital Signs 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 patients arm can produce a falsely high reading. In contrast, using a cuff that is too large for an extremely thin patients arm can produce a falsely low reading. Thus, always check for the appropriate cuff size.

Vital Signs 4) Blood Pressure Common Errors of Measurement Because of isometric muscle contraction, hydrostatic pressure, and gravitational pull, failing to position and support the patients arm properly can also lead to false readings. If the patients 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 patients arm is well supported and at heart level

Vital Signs 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.

Vital Signs 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).

Vital Signs 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.

Vital Signs 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.

Vital Signs 4) Blood Pressure Factors Affecting BP: When evaluating your readings, note if any of these factors may be contributing to the patients blood pressure

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Emtenan Alharbi, MSc. Department of Clinical Pharmacy