Vitals-blood pressure

Peak pressure exerted against arterial walls as the ventricles contract and eject blood

Minimum pressure exerted against arterial walls, between cardiac contractions when the heart is at rest

Measurement for blood pressure

Millimeters of mercury

Is measured as. Systolic over Diastolic

• Due to difference of systolic and diastolic pressure (120/80 -> 40 mm Hg pulse pressure)
• Indication of the volume output of the left ventricle
• Should be no greater than 1/3 of the systolic pressure

• Current: <120 systolic and <80 diastolic =normal
• Encourage life style modification if risk factors present
• Recheck in 1-2 years, with risk factors sooner

• 120-139 systolic and 80-89 systolic
• Encourage life style changes
• Recheck in 1year or sooner,

Antihypertensive are prescribed only with compelling (zwingende) indications, such as renal disease

• 140-159 systolic and 90-99 diastolic
• Encourage lifestyle modification,
• Follow up with primary care provider in 1-2 months
• Most patients will be started on thiazide-type diuretics

• >= 160 systolic and >= 100 diastolic
• Encourage lifestyle modification
• refer for care within 1 week or immediately if warranted
• Most patients will be given a 2-drug combination therapy, e.g. thiazide-type diuretics and angiotensin converting enzyme (ACE) inhibitors

Cardiac function

Peripheral vascular resistance

Blood volume

• increase in cardiac output causes and increase in blood pressure
• A decrease in cardiac output decreases BP
• A change in either stroke volume or heart rate alters cardiac output

Increased blood volume (e.g. pregnancy)

More forceful contraction of the ventricles (e.g. exercise)

• dehydration
• Active bleeding
• Damage to the heart (e.g. myocardial infarct/ heart attack)
• Very rapid heart rate ( not enough time to refill the ventricles)

Arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls

• Viscosity (thickness) of the blood
• Arterial size
• arterial elasticity/compliance

The walls themselves influence very little, as they are very this and distensible (dehnbar)

• hematocrit =percentage of red blood cells in plasma
• Disorder dehydration -> hematocrit increase-> blood. Viscosity increase-> increase blood pressure
• Conversely, low hematocrit e.g. anemia

• Constricted arteries prevent the free flow of blood -> increase BP
• Dilated arteries allow free blood flow-> decrease in BP
• The sympathetic nervous system regulates vasoconstriction and vasodilation

• Arteries with good elasticity can extend and recoil easily and adequately
• Age or disease related changes may cause a loss of elasticity-> peripheral resistance-> possibly BP (e.g. Arteriosclerosis (hardening of arteries) often cause an increase of BP in middle aged and older adults)

• Normal blood volume is 5 liters = 5000 mL
• Volume decrease e.g. blood loss (hemorrhage) or. Other fluid losses-> decrease vascular (gefaess) volume-> BP falls
• Volume increase e.g. renal (kidney) disease/failure and fluid retention-> BP increases

• 1 developmental stage 2 family history
• 3 lifestyle 4 exercise 5 body position 6 stress
• 7 pain 8 race 9 obesity 10 diurnal variations
• 11 medications 12 diseases 13 sex

• The average BP for men is slightly higher than that for women of comparable age
• After menopause women's BP increases

• Average newborn has an average BP of 80/40 mm Hg
• It increases gradually throughout childhood
• Smaller child/adolescent has lower BP
• Than a larger one
• Systolic and diastolic BP increase with age

A family history of hypertension markedly increases the likelihood of an individual developing hypertension

• Increased sodium consumption
• smoking
• 3 or more alcoholic beverages per day
• -> elevate BP
• Caffeine increases BP for. Short time but no long-term effect

Physical fitness reduces BP in many individuals

Muscular exertion temporarily increases BP as a result of increased heart rate and cardiac output -> wait about 30 minutes before assessing BP of somebody after exercising

• The BP is higher if somebody is standing, than when sitting down or lying down.
• Readings are higher when arm above heart level
• reading higher when arm unsupported
• Reading higher when feet are dangling
• Reading higher when legs are crossed

• Fear, worry, excitement and other stressing factors cause the BP to rise sharply (sympathetic nervous system response -> fight or flight)
• Here also white coat hypertension -> but this shows also effect of other stress types

Pain often causes an increase in BP

Severe or prolonged pain can also cause a dicrease in

Blacks have a higher rate of hypertension than European Americans and they have a higher incidence of complications and hypertension related deaths

It increases BP, related to the additional vascular supply required to perfuse the large body mass -> increase in peripheral resistance

BP varies according to the person's daily schedules and routines. Usually it is lowest after waking up in the morning

• Many medications alter BP
• Effect may be intended (antihypertensive meds) or unintended (e.g. drop of BP after pain meds)
• Many over the counter meds and herbs and illicit (illegal) drugs affect BP (cocaine raises BP significantly)

Diseases that affect the circulatory system or any of the major organs of the body (e.g. kidneys) may affect the BP

Direct: catheter treated into artery attached to electronic monitoring system (constant display)

Indirect/noninvasive method: accurate estimate with stethoscope, blood pressure cuff and sphygmomanometer

Android : dials that register BP by pointers attached to a spring (frequent calibration)

Mercury: measure BP using a calibrated upright tube containing mercury (health hazard, but easier to maintain)

 Electronic use microphones or sensors that detect pressure waves, can be set to monitor and record BP at timed intervals. Can be less accurate, test baseline BP before using electronic)

• May detect high BP
• Allows for observation of BP pattern
• Distinguishes "white coat hypertension"
• Self-monitoring can increase participation in treatment, may improve compliance with treatment

• Possible incorrect use of device
• Needless anxiety over a single high reading
• patient may make adjustment on medication based on the BP readings without asking their doctor

• Teach proper use of device
• Periodically check patient's technique
• Teach meaning of BP, patterns, single reading anxiety,
• Explain need for calibration (once a year)
• Teach about abnormal high and low readings
• Advice regarding written record

Width of bladder: should cover approx.

2/3 of the upper arm (or other extremity) for an adult

Entire arm for a child

Or cuff width is 40% of the arm circumference and the length of the bladder encircles 80% of the arm in adults

too narrow -> too high

Too wide -> too low

Error can be as much as 30 mm Hg, it is better to use a cuff that is too large than one that is too small ( document cuff size if improper size)

• Usually the brachial artery, not if
• -intravenous access device
• - renal dialysis fistula
• -skin graft
• -paralyzed
• -diseased
• -extensive trauma
• -cast or dressings
• -not on same side of breast or shoulder surgery

• Korotkoff sounds
• First systole, last diastole
• 1st hear a sound that occurs during systole,
• 2nd soft swishing sound (blood turbulence)
• 3rd begins midway through BP, sharp, rhythmic tapping sound
• 4th like 3rd, but softer and fading
• 5th silence, it corresponds with diastole

• If BP is difficult to hear (cardiac conditions, shock, other conditions) use pulsation alone.
• When deflating the cuff remember systole rate when pulse can be felt , no record of diastole (e.g. Pleated low Fowler's left arm 86/_ or 86 systolic)

• If patient has hypertension
• -may hear loss of sound for as much as 30mm Hg, followed by return of sound (isolated first sound do not miss when plating correctly)  record range of pressure when gap occurs
• (e.g. BP left arm, sitting, 170/90 with an auscultatory gap from 170-140)

Failure to notice the gap can result in serious misreading of the systolic BP

• Systolic < 100 mm Hg
• Usually no problem, further evaluation if

Dizziness, fatigue, concentration problem, activity intolerance, shortness of breath

• Or
• The low BP is of sudden onset

Sudden drop in BP when moving from a lying position into a sitting or standing position

• -decrease of 10 mm Hg in standing BP
• -together with dizziness/ fainting

• Cause: vasodilator without increase of cardiac output
• ! risk to fall related to dizziness or fainting

• Persistently higher than normal BP
• > 140 mm Hg or > 90 mm Hg diastolic on two or more separate occasions
• Caused by thickening of the arterial walls and decreased elasticity of the arteries

• Increases stress on heart and blood vessels
• May lead to
• Heart attack,
• Heart failure
• Peripheral vascular disease
• Kidney damage
• stroke
• The higher the BP the more dangerous the situation
• Often delayed diagnosis, as symptoms are mild or absent

• Early morning suboccipital headaches
• fatigue
• Visual changes

• Diagnosed if there is no known cause
• At least. 90% of all cases of hypertension
• Although no single cause is identified it can be race, family history,... could contribute

• Clearly identified cause for hypertension like
• Renal or endocrine disorders
• Drugs (cocaine, amphetamine,)
• Medications nonsteroidal anti-inflammatory drugs (NSAIDs)
• Chronic overuse of alcohol