Blood pressure guidelines and screening techniques.Introduction Taking patients' blood pressure during dental examinations is critical to their overall health. High blood pressure is a proven risk factor for cardiovascular disease Cardiovascular disease Disease that affects the heart and blood vessels. Mentioned in: Lipoproteins Test cardiovascular disease , heart failure, stroke, and kidney disease Kidney Disease Definition Kidney disease is a general term for any damage that reduces the functioning of the kidney. Kidney disease is also called renal disease. . Many patients see a dentist more frequently than a physician, giving the dental team the responsibility to inform their patients of their blood pressure reading and how it can affect their overall health. Blood pressure should be taken at each annual dental examination and before procedures that cause apprehension, such as oral surgery. The patient should always be told what their blood pressure is, so they can keep track of differences themselves. Establishing a baseline reading for your patient, in a nonstress producing environment, is vital in case you need to make a medical referral. Screening for blood pressure by the dental professional has proven to be extremely effective since most patients with hypertension are unaware of their condition. Course Objectives After completing this course, the dental professional should be able to: * Determine causes of hypertension. * Determine how to assess identifiable causes of hypertension. * Explain the terms systolic Systolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. , diastolic Diastolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are being filled with blood. During this phase, the ventricles are at their most relaxed, and the pressure against the walls of the arteries is at its lowest. , and pulse pressures. * Identify the various blood pressure categories. * Identify the factors that influence blood pressure. * Explain the equipment needed to determine blood pressure. * Explain how to take blood pressure. * Determine the follow-up recommendations for patient treatment. * Explain lifestyle modification recommendations. Course Outline I. Introduction II. Course Objectives III. Course Outline IV. Glossary V. Blood Pressure A. Systolic Pressure systolic pressure n. The highest arterial blood pressure reached during any given ventricular cycle. B. Diastolic Pressure diastolic pressure n. The lowest arterial blood pressure reached during any given ventricular cycle. C. Pulse Pressure VI. Blood Pressure Category VII. Factors That Influence Blood Pressure VIII. Causes of Hypertension IX. Assessment for Identifiable Causes of Hypertension X. Equipment for Determining Blood Pressure XI. Procedure for Determining Blood Pressure XII. Recommendations XIII. Lifestyle Modification Recommendations XIV. References XV. Post-test Blood Pressure Blood pressure is the force exerted by the blood on the blood vessel blood vessel n. An elastic tubular channel, such as an artery, a vein, a sinus, or a capillary, through which the blood circulates. blood vessel(s), n the network of muscular tubes that carry blood. walls. This force makes a noise called Korotkoff sounds Ko·rot·koff sounds pl.n. The sounds heard over an artery when blood pressure is determined by the auscultatory method. Korotkoff sounds (kôrot´kôf), n. . When the left ventricle left ventricle n. The chamber on the left side of the heart that receives the arterial blood from the left atrium and contracts to force it into the aorta. of the heart contracts, blood is forced out into the aorta and travels through the large arteries to the smaller arteries, arterioles Arterioles Small blood vessels that carry arterial (oxygenated) blood. Mentioned in: Retinal Artery Occlusion arterioles, n , and capillaries. During the course of the cardiac cycle cardiac cycle n. A complete beat of the heart, including systole and diastole and the intervals between, beginning with any event in the heart's action to the moment when that same event is repeated. , blood pressure is changing constantly. Systolic pressure is the peak or highest pressure. It is caused by ventricular contraction. The normal systolic pressure is less than 120 mm Hg. In patients over 50 years of age, a systolic reading higher than 140 mm Hg is more important as a cardiovascular risk factor than a high diastolic reading. Diastolic pressure is the lowest pressure. It is the effect of ventricular relaxation. The normal diastolic pressure is less than 80 mm Hg. Pulse pressure is the difference between the systolic and the diastolic pressures. The normal or safe difference is less than 45 mm Hg. Blood Pressure Categories Blood pressure readings are broken down into four categories. Prehypertension is not considered a disease category. It is a designation meant to alert patients of a need to intervene and prevent hypertension. Patients in this designation need to make major lifestyle changes to return to a normal reading. Treatment options in Stages 1 and 2 usually require prescription medications and should be discussed, prescribed, and monitored by a physician. Factors That Influence Blood Pressure Blood pressure depends on two factors: 1) the force of the heartbeat and 2) peripheral resistance. The resistance of the blood vessels Blood vessels Tubular channels for blood transport, of which there are three principal types: arteries, capillaries, and veins. Only the larger arteries and veins in the body bear distinct names. depends on the condition of the arteries and the changes in elasticity of the vessels, which may occur more with aging. Exertion, improper eating habits, stimulants, emotional disturbance, and use of oral contraceptives Oral Contraceptives Definition Oral contraceptives are medicines taken by mouth to help prevent pregnancy. They are also known as the Pill, OCs, or birth control pills. are all factors that contribute to increased blood pressure. Blood pressure normally increases with age and length of oral contraceptive oral contraceptive n. A pill, typically containing estrogen or progesterone, that prevents conception or pregnancy. Also called birth control pill. use. Fasting, rest, depressants, quiet emotions (keeping emotions in check), and emergencies such as fainting, blood loss, and shock are all factors that can decrease blood pressure. Causes of Hypertension Hypertension, or high blood pressure, can be caused by a variety of reasons or combination of reasons. The following is a list of the most common causes of a diagnosis of high blood pressure: * Improper blood pressure measurement techniques * Excess sodium intake * Excess body weight * Lack of exercise * Diet low in fruits and vegetables * Inadequate diuretic diuretic (dī'yərĕt`ĭk), drug used to increase urine formation and output. Diuretics are prescribed for the treatment of edema (the accumulation of excess fluids in the tissues of the body), which is often the result of underlying therapy * Medication --Inadequate doses --Drug interactions (i.e., nonsteroidal anti-inflammatory drugs Nonsteroidal Anti-Inflammatory Drugs Definition Nonsteroidal anti-inflammatory drugs are medicines that relieve pain, swelling, stiffness, and inflammation. , illicit drugs, oral contraceptives) --Over-the-counter (OTC OTC See: Over-the-counter. OTC See over-the-counter market (OTC). ) drugs and herbal supplements * Excessive alcohol intake * Identifiable causes of hypertension (see below) Assessment for Identifiable Causes of Hypertension There are also many conditions or diseases that play a role in hypertension. The medical history should include questions on: * Sleep apnea * Drugs being taken that may induce or affect high blood pressure * Chronic kidney disease Chronic kidney disease (CKD), also know as chronic renal disease, is a progressive loss of renal function over a period of months or years through five stages. Each stage is a progression through an abnormally low and progressively worse glomerular filtration rate, which is * Renovascular disease * Cushing's Syndrome or steroid therapy * Coarctation coarctation /co·arc·ta·tion/ (ko?ahrk-ta´shun) narrowing. coarctation of aorta a local malformation marked by deformed aortic media, causing narrowing of the lumen of the vessel. of aorta (localized narrowing of the aorta) * Thyroid/parathyroid disease Equipment for Determining Blood Pressure The mercury sphygmomanometer sphygmomanometer /sphyg·mo·ma·nom·e·ter/ (sfig?mo-mah-nom´e-ter) an instrument for measuring arterial blood pressure. sphyg·mo·ma·nom·e·ter or sphyg·mom·e·ter n. is the preferred instrument for measuring blood pressure. Although finger monitors are improving, generally they are not as accurate and are better used during a constant prolonged period of blood pressure monitoring. Whether the equipment is aneroid, mercury, or electronic, it should be regularly inspected and validated. The sphygmomanometer (Fig. 1), blood pressure cuff or machine, consists of an inflatable cuff and two tubes; one tube is connected to the pressure hand control bulb and the other tube to the pressure gauge. The size of the patient determines the size of the cuff selected. The four cuff sizes are child, average adult, large adult and thigh. The thigh size is needed for grossly obese patients. The cuff width should be 20 percent greater than the diameter of the arm. When a cuff is too narrow, the blood pressure reading is too high; when the cuff is too wide, the reading is too low. [FIGURE 1 OMITTED] The stethoscope stethoscope (stĕth`əskōp') [Gr.,=chest viewer], instrument that enables the physican to hear the sounds made by the heart, the lungs, and various other organs. The earliest stethoscope, devised by the French physician R. T. H. (Fig. 2), a listening aid that magnifies sound, consists of two earpieces that are connected by tubes that carry the sound to the earpieces from the end piece, which is placed over the artery. [FIGURE 2 OMITTED] Procedure for Determining Blood Pressure (Fig. 3) 1. Prepare the Patient a. Tell the patient briefly what is to be done. b. Seat the patient comfortably, with the arm slightly flexed, palm up and the whole forearm supported on a level surface even with the heart. c. Use either arm unless otherwise indicated; for example, for a person who is physically disabled. Repeat blood pressure readings should be completed on the same arm as differences in each arm can be as much as 10 mm Hg. d. Take pressure on bare arm, not over clothing. 2. Apply the Cuff a. Apply the completely deflated de·flate v. de·flat·ed, de·flat·ing, de·flates v.tr. 1. a. To release contained air or gas from. b. To collapse by releasing contained air or gas. 2. cuff to the patient's arm, supported at the level of the heart. b. Place the portion of the cuff that contains the inflatable bladder directly over the brachial artery. The cuff may have an arrow to show the point that should be placed over the artery. The lower edge of the cuff is placed one inch above the antecubital fossa fossa /fos·sa/ (fos´ah) pl. fos´sae [L.] a trench or channel; in anatomy, a hollow or depressed area. acetabular fossa a nonarticular area in the floor of the acetabulum. (crease in the arm). Fasten the cuff evenly and snugly. c. Adjust the position of the gauge for convenient reading. d. Palpate pal·pate v. To examine by feeling and pressing with the palms of the hands and the fingers. pal·pa  tion n. one inch below the antecubital fossa (crease in elbow)
to locate the brachial artery pulse found on the inside of the forearm.
The stethoscope end piece is placed over the spot where the brachial brachial /bra·chi·al/ (bra´ke-al) pertaining to the upper limb. bra·chi·al adj. Relating to the arm. brachial pertaining to the forelimb. pulse is felt. e. Position the stethoscope earpieces in the ears, with the tips directed forward. 3. Locate the Radial Pulse a. On the same arm, feel the inside of the wrist, above the thumb with your index and middle fingers until you feel the pulse. b. Hold your fingers on the pulse. 4. Inflate the Cuff a. Close the needle valve (air lock) attached to the hand control bulb firmly, but so it may be released readily. b. Pump to inflate the cuff until the radial pulse stops. Note the mercury level at which the pulse disappears. c. Look at the dial, and pump to 20 or 30 mm Hg beyond where the radial pulse was no longer felt. This is the maximum inflation level (MIL). It means that the pressure of the cuff collapses the brachial artery and no blood is flowing through the artery. 5. Position the Stethoscope End Piece (Fig. 4) a. Place the end piece over the palpated brachial artery, in the one-inch space above the antecubital fossa, and slightly toward the inner side of the arm. Hold tightly in place. 6. Deflate (file format, compression) deflate - A compression standard derived from LZ77; it is reportedly used in zip, gzip, PKZIP, and png, among others. Unlike LZW, deflate compression does not use patented compression algorithms. the Cuff Gradually a. Release the air lock slowly (2 to 3 mm per second) so that the dial drops very gradually and steadily. b. Listen for the first sound: systole systole /sys·to·le/ (sis´to-le) the contraction, or period of contraction, of the heart, especially of the ventricles.systol´ic aborted systole ("tap, tap"). Note the number on the dial, which is the systolic pressure. This is the beginning of the flow of blood past the cuff. c. Continue to release the pressure slowly. The sound will continue, first becoming louder, then diminishing and becoming muffled muf·fle 1 tr.v. muf·fled, muf·fling, muf·fles 1. To wrap up, as in a blanket or shawl, for warmth, protection, or secrecy. 2. a. , until finally disappearing. Note the number on the dial where the last distinct tap was heard (not the muffled sound). This number is the diastolic pressure. d. Let the rest of the air out rapidly. 7. Repeat for confirmation when there is a question about a reading. a. Wait 30 seconds before inflating the cuff region again. More than one reading is needed within a few minutes to determine an average and ensure a correct reading. 8. Record a. Write the date and arm used. b. Record blood pressure as a fraction. Example: R Arm, Nov. 3, 20XX 120/80. [FIGURES 3-4 OMITTED] Lifestyle Modification Recommendations for Patients with Hypertension Time restraints at dental appointments prevent in-depth counseling for patients with high blood pressure readings. Instead, it is recommended that you hand out information on the Dietary Approaches to Stop Hypertension Dietary Approaches to Stop Hypertension or the DASH diet is a diet promoted by the National Heart, Lung, and Blood Institute (part of the NIH) to control hypertension. Program, or what's called the DASH Eating Plan. Information can be printed out from its website at www.nhlbi.nih.gov/health/public/heart/hbp/dash/. When determining body mass index, use a website such as www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm. Summary Recording and monitoring blood pressure should be a lifetime practice. Studies have shown that people with normal blood pressure readings between the ages of 55 and 65 still have an 80 to 90 percent risk of developing hypertension by the age of 80. The information in this course teaches the dental health professional to be aware of the causes of hypertension and how to determine and assess identifiable causes. Understanding the terms systolic, diastolic and pulse pressure along with knowledge of the various blood pressure categories and the factors that influence blood pressure is important. This course provides you with the appropriate method of taking a blood pressure and how to determine the recommendations for follow-up and lifestyle modifications for patient treatment.
Blood Pressure Category Systolic mm Hg Diastolic mm Hg
Normal <120 <80
Prehypertension 120-139 80-89
Hypertension, Stage 1 140-159 90-99
Hypertension, Stage 2 [greater than or [greater than or
equal to] 160 equal to] 100
Data from the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure. National Institutes of Health, National Heart, Lung,
and Blood Institute, Publication JNC 7, May 2003.
Initial Blood Pressure Initial Blood Pressure Follow-up
Systolic mm Hg Diastolic mm Hg Recommended
<120 <80 Recheck in 1 year
120-139 80-89 Recheck in 1 year
140-159 90-99 Evaluate or refer to
source of care
within 1-2 months
[greater than or equal [greater than or equal Evaluate or refer to
to] 160 to] 100 source of care
immediately or
within 1 week
depending on
clinical
situation.
* If the systolic and diastolic categories are different, follow
recommendations for the shorter time follow-up.
Avg. SBP
Modification Recommendation Reduction Range
Weight Maintain normal body 5-20 mm Hg/10kg
Reduction weight (determine BMI
or body mass index)
DASH Eating Adopt a diet rich in fruits, 8-14 mm Hg
Plan vegetables, and low fat dairy
products with reduced content
of saturated and total fats
Dietary Sodium Reduce dietary sodium intake 2-8 mm Hg
Reduction to 2.4 g sodium or 6 g sodium
chloride
Aerobic Physical Regular aerobic physical 4-9 mm Hg
Activity activity at least 30 minutes
per day, most days of the week
Moderation Men: limit to [less than or 2-4 mm Hg
of Alcohol equal to] 2 drinks * per day;
Consumption Women and lighter weight
persons: limit to [less than
or equal to] 1 drink * per day
* 1 drink = 12 oz. beer, 5 oz. wine, 1.5 oz. 80-proof whiskey
Glossary brachial artery--main artery of the arm. blood pressure--the force exerted by the blood on the blood vessel walls. Cushing's Syndrome--abnormal bodily condition that is caused by excess corticosteroids Corticosteroids Definition Corticosteroids are group of natural and synthetic analogues of the hormones secreted by the hypothalamic-anterior pituitary-adrenocortical (HPA) axis, more commonly referred to as the pituitary gland. . diastolic pressure--the lowest pressure; it is the effect of ventricular relaxation. hypertension--abnormally high arterial blood pressure. Korotkoff Sounds--arterial sounds heard through a stethoscope that change with varying cuff pressure and that are used to determine systolic and diastolic blood pressure Diastolic blood pressure Blood pressure when the heart is resting between beats. Mentioned in: Hypertension . mm Hg--millimeters of mercury. pulse pressure--the difference between the systolic and diastolic pressure. sleep apnea--brief periods of recurrent cessation of breathing during sleep. systolic pressure--the peak or highest pressure, it is caused by ventricular contraction. sphygmomanometer--the blood pressure cuff or machine. stethoscope--a listening aid that magnifies sound. References Malamed SF. Medical Emergencies in the Dental Office, Fifth Edition. Mosby Publishing, 2000. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC JNC Joint National Committee JNC Japan Nuclear Cycle Development Institute JNC Judicial Nominating Commission JNC Jet Navigation Chart JNC Journal of Nuclear Cardiology JNC JNet Consultancy (Netherlands) 7) U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS . National Institutes of Health. http://hyper.ahajournals.org/cgi/ content/full/42/6/1206#FIG18 [Online] February 2005. Wilkins EM. Clinical Practice of the Dental Hygienist, Eighth Edition. Lippincott Williams & Wilkins. 1999. Glick M. The New Blood Pressure Guidelines. JADA 2004; 135(5):585-6 Sources of Materials National High Blood Pressure Education Program High Blood Pressure Information Center 120/80 National Institutes of Health Bethesda, MD 20205 www.nhlbi.nih.gov American Heart Association American Heart Association (AHA), n.pr a national voluntary health agency that has the goal of increasing public and medical awareness of cardiovascular diseases and stroke, and thereby reducing the number of associated deaths and disabilities. 320 Greenville Avenue Dallas, TX 75231 www.americanheart.org Blood Pressure Guidelines and Screening Techniques POST-TEST 1. The diastolic pressure is the lower number when looking at the patient's blood pressure in their chart. A. True. B. False. 2. If a patient's initial systolic blood pressure Systolic blood pressure Blood pressure when the heart contracts (beats). Mentioned in: Hypertension is 150-159, the dental professional will: A. recheck in 1 year. B. confirm within 2 months. C. evaluate or refer to source of care within 1 month. D. evaluate or refer to source of care immediately. 3. The recommended dietary sodium intake for a patient with high blood pressure is: A. no more than 2.4 g sodium. B. no more than 6 g of sodium chloride. C. no more than 12 g of sodium. D. both A and B. 4. Which pressure reading is the highest pressure and is the effect of ventricular contraction? A. Diastolic Pressure B. Systolic Pressure 5. A blood pressure reading of 140-159 Systolic/ 90-99 Diastolic is considered to be: A. Normal B. Prehypertension C. Hypertension, Stage 1 D. Hypertension, Stage 2 6. For a patient with a blood pressure reading of 120/88, the dental professional will recommend to: A. recheck in a year. B. evaluate or refer to source of care within 1-2 months. C. evaluate or refer to source of care immediately or within 1 week depending on clinical situation. D. none of the above. 7. The diastolic pressure is: A. the first sound you hear. B. the last distinct sound you hear. C. the very last sound you hear. D. the muffled sound you hear. 8. Which of the following cause hypertension? A. Excessive sodium intake B. Excessive alcohol intake C. Inadequate diuretic therapy D. A and C only E. All of the above 9. Which of the following does NOT increase blood pressure? A. Stimulants B. Exertion C. Oral contraceptives D. Fasting E. Emotional disturbance 10. When taking blood pressure the inflatable bladder of the cuff is placed directly over the--artery. A. radial B. carotid carotid /ca·rot·id/ (kah-rot´id) pertaining to the carotid artery, the principal artery of the neck. ca·rot·id n. C. brachial D. femoral femoral /fem·o·ral/ (fem´or-al) pertaining to the femur or to the thigh. fem·o·ral adj. Of or relating to the femur or thigh. Connie Myers Kracher is Associate Professor of Dental Education and Chair of Dental Assisting at Indiana University Purdue University, Fort Wayne. She holds a Master of Science in Dentistry from the Indiana University School of Dentistry The only dental school in the Hoosier state, Indiana University School of Dentistry (IUSD) is conveniently situated on the IUPUI campus in downtown Indianapolis. History Under the leadership of Dean Lawrence I. in Oral Biology, and a Bachelor of Science Noun 1. Bachelor of Science - a bachelor's degree in science BS, SB bachelor's degree, baccalaureate - an academic degree conferred on someone who has successfully completed undergraduate studies in Health Occupations Education. In addition to her CDA (1) (Compact Disc Audio) The compact disc file extension that is seen on the computer in Explorer or some other file manager. CDA files are actually pointers to the locations of the individual tracks on the CD medium. See CD-DA. , she holds a Certificate in Expanded Restorative Procedures (EFDA EFDA European Fusion Development Agreement EFDA Expanded Functions Dental Assistant EFDA Equipment Facilities Design Authorization ). Ms. Kracher is a frequent contributor to The Dental Assistant Journal and is the author of four ADAA ADAA Anxiety Disorders Association of America ADAA American Dental Assistants Association ADAA Art Dealers Association of America (since 1962; New York City, NY, USA) ADAA Aberdeen and District Angling Association courses: Sports-Related Dental Injuries & Sports Dentistry, Oral Health Maintenance of Dental Implants, Carbonated Beverages--The Pouring Rights Dilemma, and Current Concepts in Preventive Dentistry. |
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