Measuring blood pressure: Challenge your accuracy

Posted on June 23, 2011 by Konrad | Permalink 0

In the latest edition of the Cardiopulmonary Physical Therapy Journal, authors Frese, Fick and Sadowski present an update on the Guidelines for measuring blood pressure in children and adults. I believe this is an important paper for therapists to review to learn about various sources of error in blood pressure measurement, guidelines and normative values of blood pressure readings in children and special populations and documentation guidelines. Finally, the paper presents an important appendix for recommended techniques when measuring blood pressure in various patient populations.

Did you know that?

  • 22% of people who have hypertension are unaware that they have the condition.
  • Using inappropriate cuff sizes when measuring blood pressure, constitutes the most frequent error in BP measurement. Proper cuffs must have a bladder length of 80% and a width of 40% of arm circumference.
  • Maintaining the arm at the level of the heart promotes accurate measurement of BP to negate the effects of hydrostatic pressure. For every 2.5 cm above or below the level of the heart, BP readings can change by 1 to 2 mm Hg. An arm maintained above the level of the heart lowers BP readings and if placed at a level below the heart falsely increases BP measurements.
  • BP results can be significantly influenced by the rate of cuff deflation. When rapidly deflated systolic BP readings may be underestimated and diastolic readings can be overestimated.
  • Monitoring BP by two methods including measurement of a BP by palpation before auscultation can help catch the auscultatory gap.
  • Differences between BP readings between arms are common, especially when only one reading is obtained. This difference is decreased when 3 or more measurements are taken in each arm.

For more information on blood pressure measurements go to: http://www.cpptjournal.org/pdfs/members/fulltext/2011/june/blood_pressure.pdf

References:

Frese EM, Fick A, Sadowski SH. Blood pressure measurement guidelines for physical therapists. Cardiopulm Phys Ther Jour 2011; 22(2)5-12.

Cardiopulmonary Examination

Sternal Precautions: Are you ready to change?

Posted on June 15, 2011 by Konrad | Permalink 1

If you are like me, you may have often tried to seek out current evidence on sternal precautions because you have seen firsthand that many patients remain functionally impaired long after cardiothoracic surgery.

Unfortunately, very little evidence has been documented in this area and there seems to be no recent literature guiding us on the best approach to managing this patient population.

Fortunately, an excellent review paper has recently been published in the March 2011 edition of the Cardiopulmonary Physical Therapy Journal.

Cahalin, LaPier and Shaw have done an outstanding job presenting an overview of the evidence and proposing an algorithm for prescription of sternal precautions that can be immediately used in practice.

Here are some highlights and considerations to think about on sternal precautions:

  • Interestingly, there is no direct evidence that links the use of arm movements or activity to an increased risk of sternal complications after CT surgery.
  • Patients with chronic sternal instability demonstrated greatest sternal separation when pushing up from a chair with sit to stand transfers and least sternal separation when elevating both arm overhead. (El-Ansary et al, 2007)2
  • In normal health individuals, the greatest amount of sternal skin movement was seen with sit to stand and supine to long sitting transfers and the least movement was noted when raising a unilateral weighted upper extremity (< 8 lbs) above shoulder height. (Irion et al 2006)3
  • Patients with chronic sternal instability tend to experience pain which is greater when raising a unilateral loaded upper extremity compared to raising bilateral loaded upper extremities. (El Ansary et al, 2007)4
  • Cahalin, LaPier and Shaw recommend considering multiple risk factors including but not limited to obesity, COPD, DM, rethoractomy, smoking, PVD, female gender when setting up a prescription of sternal precaution for patients.1
  • As the number of risk factors increase, a given patient can be included into one of three categories including a High risk, Moderate risk or Low risk category of developing sternal complications.
  • Based on the category that a given patient may fall in, therapists can utilize one of three sets of activity guidelines for their patient. The three sets of guidelines include a Conservative, Moderate and Progressive approach. For more information of recommendations for each of these categories and for a complete review of this article, go to http://cpptjournal.org/pdfs/members/fulltext/2011/march/sternal_precautions.pdf

References:

1. Cahalin LP, LaPier TK, Shaw DK. Sternal precautions: Is it time for change? Precautions versus Restrictions -A review of the literature and recommendations for Revision. Cardiopulmonary Phys Ther Jour 2011; 22(1)5-13.

2. El-Ansary D, Waddington G, Adams R. Measurement of non-physiological movement in sternal instability by ultrasound. Ann Thorac Surg. 2007;83:1513-1517.

3. Irion G. Effect of upper extremity movement on sternal skin stress. Acute Care Perspectives. 2006;15:3-6.

4. El-Ansary D, Waddington G, Adams R. Relationship between pain and upper limb movement in patientswith chronic sternal instability following cardiac surgery. Physiother Theory Prac. 2007;23(5):273-280.

Cardiopulmonary surgery