2.  The pulse may be palpated at any place that allows an artery to be compressed against a bone.  Pressure waves generated by the heart in systole moves against the arterial wall.  The pulse can be used as a tactile guide to determine the systolic blood pressure (diastolic not palpable).  The pulse pattern can be clinically significant, so it is important to note; 1.The rate in beats per minute. 2.The rhythm of pulse. Fast Slow irregular 3.The strength of the pulse. 1.Absent 2.Barely palpable 3.Easily palpable 4.Full 5.bounding

3.  Your pulse varies depending on your age, level of fitness and how active you are being.  A resting pulse is used in practice to record rate.  The pulse rate needs to be taken over 1 full minute.

4. Terminology  Slow pulse rate <60b/min = bradycardia  Fast pulse rate >100b/min (resting) = tachycardia  Irregular pulse – related to palpitations All these need to be referred to a healthcare professional as they indicate an underlying problem – ask the patient if they are aware of any problems When you document the rate also document the rhythm (e.g.regular or irregular)

5. What else can affect the heart rate?  Caffeine & alcohol – increases the strength and frequency of the heartbeat therefore increasing the rate  Exercise increases the heart rate, but someone who exercises regularly may have a low resting rate.  Disease affect the heart rate. Thyroid disease can either make the rate faster or slower depending type of disease.  Drugs (medical & recreational) e.g. digoxin & bets blockers slow the HR. Recreational drugs tend to increase HR.

6. Count the heart beats for 60 seconds It needs to be a resting pulse rate Remember to check rate, rhythm & strength

7. 1.Temporal 2.External maxillary (facial) 3.Carotid 4.Brachial 5.Radial 6.Femoral 7.Popliteal 8.Posterior tibial 9.Dorsal pedis

8. What is blood pressure?  Blood pressure refers to the force exerted by circulating blood on the walls of blood vessels.  The pressure of the circulating blood decreases as blood moves through arteries, arterioles, capillaries, and veins.  Blood pressure values are reported in millimetres of mercury (mmHg).  Blood pressure is recorded as systolic over diastolic e.g. 120/60.

9.  Short term control – ANS – barareceptors – vagus nerve.  Intermediate control - Trans- capillary shift – osmosis/plasma proteins.  Long term control – Renin/angiotensin system; aldosterone. How is blood pressure controlled

10.  The systolic arterial pressure is defined as the peak pressure in the arteries, which occurs near the beginning of the cardiac cycle.  The diastolic arterial pressure is the lowest pressure (at the resting phase of the cardiac cycle  Measures of arterial pressure are not static, but undergo natural variations from one heartbeat to another and throughout the day.  Blood pressure also changes in response to stress, nutritional factors, drugs, or disease.

11. Systole is the contraction of heart chambers, driving blood out of the chambers. The chamber valves are closed.

12. Diastole is the period of time when the heart fills with blood after systole (contraction). The chamber valves are open. The heart is at rest.

13.  High blood pressure (or hypertension) is defined in an adult as a blood pressure greater than or equal to 140 mm Hg systolic pressure or greater than or equal to 90 mm Hg diastolic pressure.  High blood pressure directly increases the risk of coronary heart disease (which leads to heart attack) and stroke, especially when it's present with other risk factors.  High blood pressure is the most important preventable cause of premature ill-health.

14.  Around 5.7 million people have hypertension which is undiagnosed.  There is no universally accepted definition of hypotension (low blood pressure).  Chronic disease have a lower target threshold e.g. diabetes; CKD.

15. Risk factors for developing hypertension  Obesity  Physical inactivity  High consumption of alcohol  High intake of dietary sodium  Low intake of dietary potassium  Stress  Increasing age  Cigarette smoking  Increased blood cholesterol  Patients with systemic diseases including: Diabetes mellitus; renal disease; peripheral vascular disease  Family history of hypertension, CHD or stroke

16. Measuring blood pressure NICE clinical guideline 127; Quick reference guide; Aug 2011  HCP need adequate training and should have their performance reviewed periodically  Devices for measuring BP must be properly validated, maintained and regularly recalibrated according to manufacturers instruction  Ensure an appropriate cuff size for the patient ’ s arm is used  Standardize the environment; relaxed temperate setting with the person quiet and seated with arm outstretched and supported  Palpate the radial or brachial pulse before measuring BP

17. Blood Pressure Measurement With Electronic Blood Pressure Monitors

18. Points to note;  If checking an electronic device against a mercury or aneroid sphygmomanometer the blood pressure may differ slightly between devices.  It is good practice to occasionally check the monitor against a aneroid sphygmomanometer or another validated device.  It is important to have a monitor calibrated according to manufacturer’s instruction.  These devices should not be used for people with an irregular heart beat (Atrial Fibrilation) or heart rate lower than 50 beat/min

19. Blood pressure measurement Estimation of blood pressure by auscultation (NICE clinical Guideline 34 Partial update of CG 18)  Standardise the environment as much as possible: − relaxed temperate setting, with the patient seated − arm out-stretched, in line with mid-sternum, and supported.  Correctly wrap a cuff containing an appropriately sized bladder around the upper arm and connect to a manometer. Cuffs should be marked to indicate the range of permissible arm circumferences; these marks should be easily seen when the cuff is being applied to an arm.  Palpate the brachial pulse in the antecubital fossa of that arm.  Rapidly inflate the cuff to 20 mmHg above the point where the brachial pulse disappears.  Deflate the cuff and note the pressure at which the pulse re-appears: the approximate systolic pressure.  Re-inflate the cuff to 20 mmHg above the point at which the brachial pulse disappears.

20.  Using one hand, place the stethoscope over the brachial artery ensuring complete skin contact with no clothing in between.  Slowly deflate the cuff at 2–3 mmHg per second listening for Korotkoff sounds.  Phase I: clear tapping sound (SBP)  Phase II: Auscultatory gap: swishing sound or soft murmur  Phase III: Loud slapping sound  Phase IV: sudden muffling of sound  Phase V: disappearance of sound (DBP)  The first appearance of faint repetitive clear tapping sounds gradually increasing in intensity and lasting for at least two consecutive beats: note the systolic pressure.  A brief period may follow when the sounds soften or ‘swish’. In some patients, the sounds may disappear altogether.  The return of sharper sounds becoming crisper for a short time.  The distinct, abrupt muffling of sounds, becoming soft and blowing in quality.  The point at which all sounds disappear completely: note the diastolic pressure.  When the sounds have disappeared, quickly deflate the cuff completely if repeating the measurement.  When possible, take readings at the beginning and end of consultations.