Measurement early in the appointment allows for later reassessment if values are abnormal.
Blood Pressure
Cuff (sphygmomanometer) size
Width of bladder ~40% of the circumference of arm
Length of bladder ~80% of the circumference of arm
Nicotine or caffeine should not be consumed 30 minutes prior to measurement
Examination room quiet and comfortable
Patient to sit quietly for 5 minutes prior to measurement with both feet placed on the floor (uncrossed) and the arm at heart level
Arm must be free of clothing
Palpate brachial artery to verify presence of pulse
Support antecubital crease at heart level
Secure lower border of cuff ~2.5 cm above antecubital crease
Estimate how high to inflate cuff to avoid auscultatory gap
Palpate the radial pulse and inflate the cuff until it disappears
Add 30 mm Hg
Wait ~15 seconds before re-inflating cuff
Place bell of the stethoscope over the brachial artery
Inflate the cuff rapidly to determined value and then deflate it slowly (~2-3 mm Hg/s)
Avoid slow or repetitive inflations of cuff (venous congestion can cause false readings)
Systolic pressure: Level when 2 consecutive Korotkoff sounds are heard
Continue deflating 10 mm Hg after Korotkoff sounds disappear
Diastolic pressure: Level of disappearance of Korotkoff sounds
Record the values to the nearest 2 mm Hg
Repeat the measurement after ~2 minutes
Average the two measurements
Take further measurements if >5 mmHg different
BP should be taken in both arms at first visit
Further measurements should be taken in arm with the higher reading
Classify the BP as per the Blood Pressure Classifications
Weak and Inaudible Karotkoff Sounds
Raise the patient’s arm before and during inflation of the cuff. Lower the arm for the reading of the pressures.
Inflate the cuff and ask the patient to make a fist several times and then continue the measurement.
Arrhythmias
Take several measurements as the pressure values will vary with arrhythmias but keep in mind that the measurements will only be approximations
Anxious Patient ("White Coat Hypertension")
Try to make patient comfortable
Take a measurement at the end of the office visit
Heart Rate and Rhythm
Radial pulse is easily accessible and therefore commonly used
Use the pads of your middle and index fingers over the radial artery
Note rate, rhythm, amplitude, and contour of pulse
If rate and rhythm normal, assess for 15 s and multiply value by 4 to beats per minute (bpm)
If tachycardic (>100 bpm) or bradycardic (<60 bpm), count for full 60 s
If irregular rhythm detected:
Auscultate heart for the most accurate heart rate measurement Differentiate between regularly irregular, irregularly irregular, or variable with respiration
Respiratory Rate and Rhythm
Assess while patient is not paying attention
Useful to observe after the heart rate unbeknownst to the patient
Observe rate, rhythm and effort of breathing
Normals:
Early childhood: 20 – 40 bpm
Late childhood: 15-25 bpm
Adult (>15 years of age): 12 – 20 breaths per minute (bpm)
Temperature
Often reserved for when there is a suspected abnormality
Timings noted are for analog probes; electronic probes provide readings much quicker
Oral Temperatures
37°C (98.6°F) average
Closed lips around thermometer and under tongue for 1 min
Delay readings if hot or cold beverages recently consumed
Oral temperatures not recommended if the patient is unconscious or unable to close mouth
Rectal Temperatures
0.5°C (0.9°F) higher than oral
Patient to lie on side facing away from you with hips flexed
Use lubricated, stubby tip thermometer
Insert thermometer 3-4 cm into the anus in the direction of the umbilicus
Remove after 3 minutes
Tympanic Membrane Temperatures
0.8°C (1.4°F) higher than oral
Ensure external auditory canal clear of cerumen
Aim infrared beam towards the tympanic membrane in the canal and hold it for 2-3 seconds
Axillary Temperatures
1.0°C (1.8°F) lower than oral
Not as accurate as the other measurements (not frequently used)
Requires holding thermometer in the axilla for 5-10 min
References
Bickley LS, Szilagyi, PG. Chapter 4, Beginning the Physical Examination: General Survey and Vital Signs. In: Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2007: 105-112.