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used as
    diasrolic pressure in adults.
    Sources: Data from SL Woods, ES Sivarajian-Froelicher, S Underhill-Moner (eds). Cardiac Nursing (4th ed). Philadelphia: Lippincott, 2000; and LS Bickley. Bate's Guide to Physical Examination and History Taking (7th ed). Philadelphia: Lippincott, 1 999.
    decondirioned individuals, toral CO may nor be able to
    support this increased flow to the muscles and may lead to
    decreased Output to vital areas, such as the brain.
    • If unable to obtain BP on rhe arm, rhe thigh is an appropriate alternative, with auscultation at the popliteal artery.
    •
    Falsely high readings will occur if the cuff is too small
    or applied loosely, or if the brachial arrery is lower rhan
    rhe hearr level.
    • Evaluarion of BP and HR in differenr postures can be
    used to monitor orthostatic hypotension with repeat measurements on the same arm 1-5 minutes after position
    changes. The symbols rhar represent parienr posirion are
    shown in Figure 1 -7.

    22 AClJfE CARE HANDBOOK FOR PHYSICAL THERAPISTS
    0--
    Supine
    Sitting
    Standing
    Figure 1-7. Orthostatic blood pressure symbols.
    • The same extremity should be used when serial BP
    recordings will be compared for an evaluation of hemodynamic response.
    • A BP record is kept on the patient's vital sign flow sheet.
    This is a good place to check for BP trends throughout the
    day and, depending on your hospital's policy, to document
    BP changes during the therapy session.
    •
    An auscultatory gap is the disappearance of sounds
    between phase 1 and phase 2 and is common in patients
    with high BP, venous distention, and severe aortic stenosis.
    Its presence can create falsely low systolic pressures if the
    cuff is not inflated high enough (which can be prevented
    by palpating for the disappearance of the pulse prior to
    measurement), or falsely high diastolic pressures if the
    therapist stOps measurement during the gap (prevented by
    listening for the phase 3 to phase 5 transitions). 13
    Auscultation
    Evaluation of heart sounds can yield information about the patient'S
    condition and tolerance to medical treatment and physical therapy
    through the evaluation of valvular function, rate, rhythm, valvular
    compliance, and ventricular compliance.4 To listen to heart sounds,
    a stethoscope with both a bell and a diaphragm is necessary. For a
    review of normal and abnormal heart sounds, refer to Table 1-9.
    The examination should follow a systematic pattern using both the
    bell (for low-pitched sounds) and diaphragm (for high-pitched
    sounds) and should cover all auscultatory areas, as illustrated in

    CARDIAC SYSTEM
    23
    Table 1-9. Normal and Abnormal Heart Sounds
    Sound
    Location
    Description
    5 1 (normal)
    All areas
    First heart sound, signifies closure of
    atrioventricular valves and corresponds to onset of ventricular systole.
    52 (normal)
    All areas
    Second heart sound, signifies closure of
    semilunar valves and corresponds
    with onset of ventricular diastole.
    53 (abnormal) Best appreciated
    Immediately following S2, occurs early
    at apex
    in diastole and represents filling of
    the ventricle. In young healthy individuals, it is considered normal and
    called a physiologic third sound. In
    the presence of heart disease, it
    results from decreased ventricular
    compliance (a classic sign of congestive heart failure).
    54 (abnormal) Best appreciated
    Immediately preceding S l , occurs late
    at apex
    in ventricular diastole, associated
    with increased resistance to ventricular filling; common in patients with
    hypertensive heart disease, coronary
    heart disease, pulmonary disease, or
    myocardial infarction, or following
    coronary artery bypass grafts.
    Murmur
    Over respective
    Indicates regurgitation of blood
    (abnormal)
    valves
    through valves; can also be classified
    as sysrolic or diastolic ll1llfmurs.
    Common pathologies resulting in
    murmurs include mitral regurgitation and aortic stenosis.
    Pericardia I
    TIlird or fourth
    Sign of pericardial innammation