Special Problems

The Apprehensive Patient. Anxiety is a frequent cause of high blood pressure, especially during an initial visit. Try to relax the patient. Repeat your measurements later in the encounter. Some patients will say their blood pressure is only elevated in the office ("white coat hypertension") and may need to have their blood pressure measured several times at home or in a community setting.

The Obese or Very Thin Arm. For the obese arm, it is important to use a wide cuff (15 cm). If the arm circumference exceeds 41 cm, use a thigh cuff (18 cm wide). For the very thin arm, a pediatric cuff may be indicated.

eg Pulses and Pressures. To rule out coarctation of the aorta, two nervations should be made at least once with every hypertensive patient:

■ Compare the volume and timing of the radial and femoral pulses.

■ Compare blood pressures in the arm and leg.

To determine blood pressure in the leg, use a wide, long thigh cuff that has a bladder size of 18 x 42 cm, and apply it to the midthigh. Center the bladder over the posterior surface, wrap it securely, and listen over the popliteal artery. If possible, the patient should be prone. Alternatively, ask the supine patient to flex one leg slightly, with the heel resting on the bed. When cuffs of the proper size are used for both the leg and the arm, blood pressures

A pressure of 110/70 would usually be normal, but could also indicate significant hypotension if past pressures have been high.

A femoral pulse that is smaller and later than the radial pulse suggests coarctation of the aorta or occlusive aortic disease. Blood pressure is lower in the legs than in the arms in these conditions.

should be equal in the two areas. (The usual arm cuff, improperly used on the leg, gives a falsely high reading.) A systolic pressure lower in the legs than in the arms is abnormal.

Weak or Inaudible Korotkoff Sounds. Consider technical problems such as erroneous placement of your stethoscope, failure to make full skin contact with the bell, and venous engorgement of the patient's arm from repeated inflations of the cuff. Consider also the possibility of shock.

When you cannot hear Korotkoff sounds at all, you may be able to estimate the systolic pressure by palpation. Alternative methods such as Doppler techniques or direct arterial pressure tracings may be necessary.

To intensify Korotkoff sounds, one of the following methods may be helpful:

■ Raise the patient's arm before and while you inflate the cuff. Then lower the arm and determine the blood pressure.

■ Inflate the cuff. Ask the patient to make a fist several times, and then determine the blood pressure.

Arrhythmias. Irregular rhythms produce variations in pressure and therefore unreliable measurements. Ignore the effects of an occasional premature contraction. With frequent premature contractions or atrial fibrillation, determine the average of several observations and note that your measurements are approximate.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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