measuring bp in pregnancy - hillingdon hospitals nhs ... · korotkoff sounds summary physiology...
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Measuring BP in Measuring BP in PregnancyPregnancy
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Necessary Equip.
Introduce
Indication
Privacy
Permission
Procedure
Position
Light
Exposure
Size cuff
Position cuff
Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
PreparationPreparation
NNecessary equipment?ecessary equipment?
SphygmomanometerSphygmomanometer(don(don’’t use an automatic BP machine, e.g. t use an automatic BP machine, e.g. dynamap, as these are inaccurate in dynamap, as these are inaccurate in pregnancy)pregnancy)
StethoscopeStethoscopePillow and flat surface (e.g. table)Pillow and flat surface (e.g. table)Check equipmentCheck equipment
e.g. stethoscope set to diaphragm not e.g. stethoscope set to diaphragm not bellbell
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Necessary Equip.
Introduce
Indication
Privacy
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Procedure
Position
Light
Exposure
Size cuff
Position cuff
Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
PreparationPreparation
IIntroduce yourselfntroduce yourself
Establish a rapport with the patientEstablish a rapport with the patient
Try to reduce Try to reduce ““white coatwhite coat”” effecteffect(in some patients BP rises in presence of (in some patients BP rises in presence of doctor)doctor)
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Indication
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Procedure
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Light
Exposure
Size cuff
Position cuff
Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
PreparationPreparation
IIndicationndication
To detect preTo detect pre--eclampsiaeclampsia earlyearly
PrePre--eclampsiaeclampsia often asymptomaticoften asymptomatic
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Exposure
Size cuff
Position cuff
Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
PPrivacyrivacy
May need to take off garments to May need to take off garments to expose upper armexpose upper arm
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Light
Exposure
Size cuff
Position cuff
Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
PPermission to do the testermission to do the testIs any pain in the arm?Is any pain in the arm?Is there is a reason a particular arm Is there is a reason a particular arm should not be used?should not be used?
e.g. mastectomy and e.g. mastectomy and axillaryaxillaryclearance, clearance, a.va.v. fistula for dialysis. fistula for dialysis
Have you been resting for 10 Have you been resting for 10 minsmins??Have you had large amounts of tea or Have you had large amounts of tea or coffee?coffee?
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Exposure
Size cuff
Position cuff
Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
PreparationPreparation
PProcedurerocedure
Explain what you are going to doExplain what you are going to do
What will the patient experience?What will the patient experience?Tight feelingTight feelingMinor discomfort perhapsMinor discomfort perhapsPins and needles in fingersPins and needles in fingers
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Summary
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PreparationPreparationPPositionosition
What could happen to a pregnant ladyWhat could happen to a pregnant lady’’s BP if she were lying s BP if she were lying supine?supine?
Gravid uterus compresses Inferior Vena CavaGravid uterus compresses Inferior Vena CavaVenous return decreasesVenous return decreasesFilling pressure decreasesFilling pressure decreasesCardiac output fallsCardiac output fallsBP drops and pt may faintBP drops and pt may faint
If patient cannot sit up, lie her on left side and document thisIf patient cannot sit up, lie her on left side and document this
Arm should be at heart level (pillow on desk)Arm should be at heart level (pillow on desk)Dropping arm by side may increase systolic by 10mmHgDropping arm by side may increase systolic by 10mmHg
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LLightight
Ensure you have enough light to see Ensure you have enough light to see the manometerthe manometer
Ensure eye is level with manometer Ensure eye is level with manometer to eliminate parallax errorto eliminate parallax error
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ParallaxParallax
Dead on to the sphyg -98mmHg At an angle –94mmHg
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EExposurexposure
Expose the upper armExpose the upper arm
If sleeve is tight when rolled up ask If sleeve is tight when rolled up ask pt to remove outer garmentpt to remove outer garment
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Summary
Physiology
Further work
ProcedureProcedure
Size the cuffSize the cuffFind the bladder (thick rubber bit in Find the bladder (thick rubber bit in cuff)cuff)Length of the bladder should be >2/3 Length of the bladder should be >2/3 of and <1 x circumference of arm.of and <1 x circumference of arm.
If <2/3 If <2/3 –– get larger cuffget larger cuff
If >1 If >1 –– cuff liable to rip off when inflated cuff liable to rip off when inflated ––get smaller cuffget smaller cuff
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ProcedureProcedure
Size the cuffSize the cuff = Length of bladder
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ProcedureProcedure
Position the cuffPosition the cuffCentre of the length of the bladder should be Centre of the length of the bladder should be positioned over brachial artery (medial to positioned over brachial artery (medial to biceps tendon)biceps tendon)
Do not rely on position of tubing Do not rely on position of tubing –– varies varies between cuffsbetween cuffsDo not rely on arrows Do not rely on arrows –– not all cuffs have not all cuffs have themthem
Leave about 2 finger breadths above arm Leave about 2 finger breadths above arm creasecrease
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ProcedureProcedurePalpatory methodPalpatory method
Palpate the radial or brachial pulsePalpate the radial or brachial pulse
Turn the valve on the pump clockwise to close Turn the valve on the pump clockwise to close it (not too tight otherwise difficult to open later)it (not too tight otherwise difficult to open later)
Inflate the cuff by squeezing pumpInflate the cuff by squeezing pumpCan inflate briskly to 60mmHg but then slow downCan inflate briskly to 60mmHg but then slow downPoint at which pulse disappears = rough systolic BPPoint at which pulse disappears = rough systolic BP
Let the cuff downLet the cuff down
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Clockwise to close valve and inflate cuff
Anti-clockwise to release valve and deflate
Squeeze pump with these Squeeze pump with these fingersfingers
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ProcedureProcedure
Auscultatory methodAuscultatory method
Place diaphragm of stethoscope over brachial Place diaphragm of stethoscope over brachial arteryartery
Inflate to 30mmHg above rough systolicInflate to 30mmHg above rough systolic
Undo valve carefully (turn anticlockwise)Undo valve carefully (turn anticlockwise)
Adjust valve to lower cuff pressure by 2mmHg Adjust valve to lower cuff pressure by 2mmHg per second or per heart beat (which ever is per second or per heart beat (which ever is slower)slower)
Korotkoff SoundsKorotkoff Sounds
Cuff pressure
Volume of sound
80
120Phase 1Phase 1
Phase 2Phase 2
Phase 3Phase 3Phase 4Phase 4Phase 5Phase 5
This is called the This is called the auscultatoryauscultatory gapgapIn some patients the In some patients the sounds disappear sounds disappear completely in phase 2completely in phase 2
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ProcedureProcedure
Auscultatory methodAuscultatory method
SYSTOLICSYSTOLICPressure where sounds appear Pressure where sounds appear Korotkoff IKorotkoff I
DIASTOLICDIASTOLICPressure where sounds muffle Pressure where sounds muffle Korotkoff IVKorotkoff IV
ororPressure where sounds disappear Pressure where sounds disappear Korotkoff VKorotkoff V
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Summary
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ProcedureProcedureKorotkoff SoundsKorotkoff Sounds
Korotkoff Korotkoff VV is a more accurate measure of is a more accurate measure of diastolic pressure than diastolic pressure than IVIV
In some pregnant women (more than in the In some pregnant women (more than in the general population) the sounds dongeneral population) the sounds don’’t disappear t disappear (i.e. no Korotkoff (i.e. no Korotkoff V)V)
Therefore use Korotkoff Therefore use Korotkoff IVIV in these patientsin these patients
For all patients For all patients –– document document K4K4 and and K5K5 if present if present to nearest 2mmHgto nearest 2mmHg
e.ge.g 120120//K4=80K4=80 K5=76mmHgK5=76mmHg
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SummarySummaryNNecessary equipmentecessary equipmentIIntroduce yourselfntroduce yourselfPPermissionermission
ask relevant ask relevant questionsquestions
PPrivacyrivacyPProcedurerocedure
explain to patientexplain to patientPPositionosition
arm at heart levelarm at heart levelsitting or lying on L sitting or lying on L sideside
LLightighteliminate parallaxeliminate parallax
EExposurexposureremove tight remove tight clothingclothing
SSize cuffize cuffbladder length >2/3 arm circbladder length >2/3 arm circ
PPosition cuffosition cuffcentre of bladder over art.centre of bladder over art.
PPalpatory methodalpatory methodAAuscultatory methoduscultatory method
down at 2mmHg/secdown at 2mmHg/secDDocumentocument
systolic, K4 and K5 systolic, K4 and K5 to nearest 2mmHgto nearest 2mmHg
DDipstick urineipstick urineEExplain resultsxplain results
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PhysiologyPhysiologyBP=CO x SVR CO = HR x SVBP=CO x SVR CO = HR x SVBP = HR x SV x SVRBP = HR x SV x SVR
SVR falls in early pregnancySVR falls in early pregnancyLeads to fall in BPLeads to fall in BP
Later rise in plasma volume, cardiac output and Later rise in plasma volume, cardiac output and heart rate which compensatesheart rate which compensates
By the beginning of 3By the beginning of 3rdrd trimester BP back to pretrimester BP back to pre--pregnancy levelpregnancy levelMay rise above preMay rise above pre--pregnancy level before termpregnancy level before term
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Light
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Size cuff
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Palpatory method
Auscultatory meth.
Korotkoff sounds
Summary
Physiology
Further work
Further workFurther work
Watch Dr. D. WilliamsWatch Dr. D. Williams’’ lecture on lecture on Hypertension in pregnancyHypertension in pregnancyhttp://ichelix1.cc.ic.ac.uk/ramgen/fom/int/yr5/OG/hypertensionhttp://ichelix1.cc.ic.ac.uk/ramgen/fom/int/yr5/OG/hypertension--DW.rmDW.rm
Watch Prof SteerWatch Prof Steer’’s presentation on s presentation on measuring BP during pregnancymeasuring BP during pregnancyhttp://imperiallectures.com/example10/player.htmlhttp://imperiallectures.com/example10/player.html
Go to Antenatal clinic and practice!Go to Antenatal clinic and practice!