血壓脈搏檢查

血壓、脈搏檢查

血壓檢查

BloodPressure

U.S.DepartmentofHealthandHumanServicesNationalInstitutesofHealthNationalHeart,Lung,andBloodInstituteNationalHeart,Lung,andBloodInstitute

NationalHighBloodPressureEducationProgram

TheSeventhReportofthe

JointNationalCommitteeon

Prevention,Detection,

Evaluation,andTreatmentofHighBloodPressure(JNC7)BPMeasurementTechniquesMethodBriefDescriptionIn-officeTworeadings,5minutesapart,sittinginchair.Confirmelevatedreadingincontralateralarm.AmbulatoryBPmonitoringIndicatedforevaluationof“white-coat”HTN.Absenceof10–20%BPdecreaseduringsleepmayindicateincreasedCVDrisk.Self-measurementProvidesinformationonresponsetotherapy.Mayhelpimproveadherencetotherapyandevaluate“white-coat”HTN.Self-MeasurementofBPProvidesinformationon:ResponsetoantihypertensivetherapyImprovingadherencewiththerapyEvaluatingwhite-coatHTNHomemeasurementof>135/85mmHgisgenerallyconsideredtobehypertensive.Homemeasurementdevicesshouldbecheckedregularly.OfficeBPMeasurementUseauscultatorymethodwithaproperlycalibratedandvalidatedinstrument.Patientshouldbeseatedquietlyfor5minutesinachair

(notonanexamtable),feetonthefloor,andarmsupportedatheartlevel.Appropriate-sizedcuffshouldbeusedtoensureaccuracy.Atleasttwomeasurementsshouldbemade.Cliniciansshouldprovidetopatients,verballyandinwriting,specificBPnumbersandBPgoals.間接測(cè)量方法及步驟1、病人仰臥位，右上肢裸露并伸直輕度外展，肘部與心臟同一水平。2、袖帶縛于上臂，袖帶下緣距肘彎?rùn)M紋上約2-3cm。3、聽(tīng)診器胸件置于肘窩肱動(dòng)脈上（不能壓在袖帶下面）。4、最高充氣壓的確定向袖帶內(nèi)充氣，邊充氣邊聽(tīng)診，待肱動(dòng)脈搏動(dòng)消失，再將汞柱升高20-30mmHg。間接測(cè)量方法及步驟5、收縮壓的確定：緩慢放氣，兩眼平視汞柱緩慢下降，按Korotkoff分期法，聽(tīng)到第一聲響的汞柱數(shù)值為收縮壓（第一期）。6、舒張壓的確定：最終聲響消失時(shí)的汞柱數(shù)值為舒張壓（第五期）。7、記錄：收縮壓/舒張壓mmHg如126/88mmHg。8、脈壓差：收縮壓-舒張壓9、平均動(dòng)脈壓：舒張壓加1/3脈壓。血壓標(biāo)準(zhǔn)根據(jù)1999年10月中國(guó)高血壓聯(lián)盟參照了WHO/ISH指南（1999）公布的中國(guó)高血壓防治指南新標(biāo)準(zhǔn)，規(guī)定如下:Purpose

WhyJNC7?Publicationofmanynewstudies.Needforanew,clear,andconciseguidelineusefulforclinicians.NeedtosimplifytheclassificationofBP.

下肢血壓測(cè)量方法與上肢測(cè)量血壓方法基本相同不同點(diǎn)病人采取俯臥位選用較寬的袖帶袖帶縛于腘窩上3～4cm處聽(tīng)診器胸件置于腘窩處腘動(dòng)脈上。血壓測(cè)量方法血壓變動(dòng)的臨床意義4、上下肢血壓差異常：正常下肢血壓高于上肢血壓20-40mmHg。如下肢血壓等于或低于上肢血壓見(jiàn)于主動(dòng)脈縮窄，胸腹主動(dòng)脈型大動(dòng)脈炎，閉塞性動(dòng)脈硬化，髂動(dòng)脈或股動(dòng)脈栓塞等。5、脈壓改變：脈壓>40mmHg為脈壓增大，見(jiàn)于主動(dòng)脈瓣關(guān)閉不全、動(dòng)脈導(dǎo)管未閉、動(dòng)靜脈瘺、甲亢和嚴(yán)重貧血，老年主動(dòng)脈硬化癥。若脈壓<30mmHg為脈壓減少，見(jiàn)于主動(dòng)脈瓣狹窄，心衷，低血壓，心包積液，縮窄性心包炎等。動(dòng)態(tài)血壓監(jiān)測(cè)兩種方法：袖帶麥克風(fēng)感知柯氏音法和振蕩法設(shè)定間期24小時(shí)記錄血壓，白天每（6am-10pm）每15分鐘測(cè)血壓一次，晚上（10pm-次晨6am）每30分鐘記錄一次。正常上限參考標(biāo)準(zhǔn)：24小時(shí)平均血壓<130/80mmHg白晝平均<135/85mmHg夜間平均<125/75mmHg白晝血壓兩個(gè)高峰，上午8am-10am,下午4pm-6pm.夜間血壓較白晝下降>10%是杓型，為正常晝夜節(jié)律。血管雜音靜脈雜音臨床多見(jiàn)于：頸靜脈營(yíng)營(yíng)音：聽(tīng)診在頸根部近鎖骨處，甚至在鎖骨下，特點(diǎn)為低調(diào)柔和的連續(xù)性雜音，坐位和立位明顯腹壁靜脈營(yíng)營(yíng)音：肝硬化時(shí)，由于門(mén)靜脈高壓，腹壁側(cè)枝循環(huán)靜脈曲張，血流增快所致腹部連續(xù)性雜音動(dòng)脈雜音多見(jiàn)于周?chē)鷦?dòng)脈甲狀腺功能亢進(jìn)：頸部血管雜音，為連續(xù)性。多發(fā)性大動(dòng)脈炎：根據(jù)累及部位不同，雜音部位不同。腎動(dòng)脈狹窄：上腹部和腰背部聽(tīng)到收縮期雜音。周?chē)鷦?dòng)靜脈瘺：病變相應(yīng)部位聽(tīng)到連續(xù)性雜音肺內(nèi)動(dòng)靜脈瘺：胸部相應(yīng)部位聽(tīng)到連續(xù)性雜音BenefitsofLoweringBP

AveragePercentReduction Strokeincidence 35–40%

Myocardialinfarction 20–25% Heartfailure 50%AmbulatoryBPMonitoringABPMiswarrantedforevaluationof“white-coat”HTNintheabsenceoftargetorganinjury.AmbulatoryBPvaluesareusuallylowerthanclinicreadings.Awake,individualswithhypertensionhaveanaverageBPof>135/85mmHgandduringsleep>120/75mmHg.BPdropsby10to20%duringthenight;ifnot,signalspossibleincreasedriskforcardiovascularevents.Self-MeasurementofBPProvidesinformationon:ResponsetoantihypertensivetherapyImprovingadherencewiththerapyEvaluatingwhite-coatHTNHomemeasurementof>135/85mmHgisgenerallyconsideredtobehypertensive.Homemeasurementdevicesshouldbecheckedregularly.脈搏檢查脈搏（1）檢測(cè)方法：觸診：主要方法脈搏計(jì)描記波形床邊監(jiān)護(hù)儀檢測(cè)血管：淺表的動(dòng)脈橈動(dòng)脈：常用其他：顳動(dòng)脈、頸動(dòng)脈、肱動(dòng)脈、股動(dòng)脈、足背動(dòng)脈脈律是心搏節(jié)律的反應(yīng)正常人：規(guī)整或稍有不整（吸氣時(shí)增快，呼氣時(shí)減慢—竇律不齊）病理：心律失常，如房顫、早搏、II°AVB脈搏短絀：見(jiàn)于房顫、頻發(fā)早搏脫落脈：見(jiàn)于II°AVB緊張度與血壓高低（主要是收縮壓）有關(guān)檢查方法：

檢查者以食指、中指、環(huán)指置于橈動(dòng)脈上，以近端手指按壓橈動(dòng)脈，此時(shí)所施的壓力及感知的血管壁彈性情況，即為脈搏的緊張度動(dòng)脈壁的狀態(tài)正常人光滑、柔軟，有一定彈性動(dòng)脈硬化程度不同，動(dòng)脈壁改變也不同早期硬化僅可能觸知?jiǎng)用}壁彈性消失，呈索條狀，嚴(yán)重時(shí)動(dòng)脈壁有鈣質(zhì)沉著，動(dòng)脈壁硬、迂曲、呈結(jié)節(jié)狀強(qiáng)弱決定于心輸出量、脈壓和周?chē)茏枇Υ笮『槊}或跳脈：見(jiàn)于高熱、甲亢、主動(dòng)脈瓣關(guān)閉不全細(xì)脈或絲脈：見(jiàn)于心衰、主動(dòng)脈瓣狹窄、休克波形(1)正常脈搏：見(jiàn)圖a水沖脈：脈搏驟起驟落,有如潮水沖涌.（見(jiàn)圖b）檢查方法：握緊患者手腕掌面，將其前擘高舉超過(guò)頭部，可明顯感知猶如水沖的脈搏。見(jiàn)于：主動(dòng)脈瓣關(guān)閉不全、動(dòng)脈導(dǎo)管未閉、甲亢、嚴(yán)重貧血遲脈：見(jiàn)圖c。見(jiàn)于：主動(dòng)脈瓣狹窄重搏脈：見(jiàn)圖d。見(jiàn)于：傷寒、長(zhǎng)期發(fā)熱、波形(2)交替脈：節(jié)律正常而強(qiáng)弱交替出現(xiàn)的脈搏。（見(jiàn)圖e）意義：左室衰竭的重要體征。見(jiàn)于：高血壓心臟病、急性心肌梗塞、主動(dòng)脈瓣關(guān)閉不全等奇脈：平靜吸氣時(shí)脈搏明顯減弱甚至消失的現(xiàn)象.（見(jiàn)圖f）見(jiàn)于：心包積液、縮窄性心包炎、心包填塞脈搏消失：見(jiàn)于嚴(yán)重休克、多發(fā)性大動(dòng)脈炎各種脈搏波形AlgorithmforTreatmentofHypertensionNotatGoalBloodPressure(<140/90mmHg)

(<130/80mmHgforthosewithdiabetesorchronickidneydisease)InitialDrugChoicesDrug(s)forthecompellingindicationsOtherantihypertensivedrugs(diuretics,ACEI,ARB,BB,CCB)

asneeded.WithCompelling

IndicationsLifestyleModificationsStage2Hypertension

(SBP>160orDBP>100mmHg)

2-drugcombinationformost(usuallythiazide-typediureticand

ACEI,orARB,orBB,orCCB)Stage1Hypertension

(SBP140–159orDBP90–99mmHg)

Thiazide-typediureticsformost.

MayconsiderACEI,ARB,BB,CCB,

orcombination.WithoutCompelling

IndicationsNotatGoal

BloodPressureOptimizedosagesoraddadditionaldrugs

untilgoalbloodpressureisachieved.

Considerconsultationwithhypertensionspecialist.PublicHealthChallenges

andCommunityProgramsPublichealthapproachescanachieveadownwardshiftinthedistributionofapopulation’