Transcript
INSTRUCTIONS FOR THE ANKLE ARM PRESSURE FORM ABP, Version A, 03/10/05
I.
General Instructions
The Ankle Arm Blood Pressure Form is completed during the participant’s clinic visit. The technician must be certified and should have a working knowledge of the ARIC Blood Pressure Manual of Procedures. He/she should also be familiar with and understand the document titled “General Instructions for Completing Paper Forms” prior to completing this form. ID Number, Contact Year and Sequence are completed as described in that document. There should be no exertion, eating, smoking or exposure to cold for half an hour before recording blood pressure. It is also important that the subject be supine and not change posture for five minutes before recording blood pressure. Blood pressure is measured with a “standard” mercury sphygmomanometer with a male quick release coupler. The mercury column manometer should be mounted at “eye level.” The detailed instructions below for the administration of the Ankle Arm Blood Pressure Form should be reviewed in combination with the instructions for performing these measurements in Manual 2, Cohort Component Procedures. II.
Detailed Instructions for Various Questions
A. Measurement Procedures 1. Start of form and examination: Conduct the examination in a quiet, warm, and comfortable room. Confirm the study participant’s ID with the ID sticker on the AnkleArm Blood Pressure form. Record the date of the examination on the Ankle-Arm Blood Pressure Form. 2. Position participant: Have the participant lie supine, with arms and legs (to mid-calf) bared, on a comfortable horizontal examination table. Ask the participant if he or she would like a pillow. If the room is cool, a blanket may be used to cover the participant (including arms, hands, and feet), except while the actual measurement is being made. The participant should be without any pillows or support under the legs, unless this causes discomfort. In most cases the participant will be comfortable in that position for the short time needed to take the ankle blood pressure. If a participant feels that a pillow under the legs is necessary, provide one and indicate on the log sheet that a pillow was used during ankle blood pressure. Explain the procedure to the participant and allow him/her to ask questions. 3. Rest Period: Have the participant rest quietly in the room by him or herself for at least 5 minutes before beginning the measurement procedure. 4. Cuff Size: The appropriate blood pressure cuff to be used is determined by arm circumference at midpoint: Ankle Arm Blood Pressure (ABPA) QxQ
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Small adult for arm circumference of <24 cm Adult (12 cm width) for arm circumference of 24 to 32 cm Large adult (17 cm width) for arm circumference of 33 to 41 cm Thigh (20 cm width) for are circumference of >41 cm
Where practical, use the same cuff for the ankle as for seated blood pressure. If the participant's ankle is very large and/or strongly tapered, a larger cuff may be necessary. 5. Setting up the device: Confirm that the Elite Doppler apparatus’ settings are set according to the manufacturer’s specifications. The volume knob should be set at an intermediate position; it will be adjusted as described in the steps below. 6. Application of the cuffs: Do not place blood pressure cuffs over any open lesion that could be a potential source of contamination. If there are any skin discolorations present where the cuff will be placed, ask the participant if they are indicative of a health condition that would preclude a blood pressure measurement. Before you begin the procedure, instruct the participant to remain relaxed and to refrain from helping you (e.g., lifting the arm to facilitate placement of the cuff). a. For the arm measurement, place an appropriate blood pressure cuff around the upper arm, based on arm circumference at midpoint. b. For the ankle measurement, place the appropriate contour wrap around the leg, closely following the conical shape of the lower leg (see Figures 1 and 2 in Manual 2). Disregard the artery marker on the cuff for now. The lower edge of the cuff (with the hoses) should be 2 to 2.5 inches above the medial malleolus (the rounded bony structure or bump on the inner side of the ankle). The hoses should point downward toward the toes. i. Follow the contour of the lower leg, and wrap the end of the cuff over the ankle as shown in Figures 1 and 2 (Manual 2). Hold the first side in position, and wrap the other half of the cuff again following the contour of the leg up the shin. Check that the corners of the cuff are equal as in Figures 1 and 2, and readjust if one extends more than the other. ii. Locate the artery marker on the cuff and rotate the cuff so that the artery line is directly over the posterior tibial artery. It may be easier to rotate if it is first pulled down towards the heel, rotated, and then pulled snugly back up towards the calf. There might be a more snug fit at the proximal edge of the cuff and a somewhat looser fit at the distal edge on highly tapered ankles. 7. Measurement instructions: The first steps is optional: Locate the brachial artery on both arms by palpation in the antecubital fossa. Similarly, locate the dorsalis pedis (dorsum of the foot) and posterior tibial (medial ankle) arteries on both legs. Mark the location of each artery with a black marker. Sometimes the arterial location in the feet will not be palpable but can be determined with the Doppler. Using the procedure below, measure systolic arterial pressures in the following order: • right brachial artery Ankle Arm Blood Pressure (ABPA) QxQ
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right dorsalis pedis right posterior tibial left dorsalis pedis left posterior tibial left brachial
a. Place a liberal amount of ultrasound conducting gel over the pulse location. b. Place the Doppler probe over the artery and then turn on the Doppler. After placing the probe over the right brachial artery, adjust the Doppler volume until a faint sound from the blood flow is heard from the speaker. Angle the probe in line with the artery and move it from side to side until the strongest pulse is heard. Do not press hard on the artery with the probe. Rest your hand comfortably so that the probe is secured in place once a strong pulse is heard. Caution should be taken against dropping the small Doppler probe or sliding it off the examination table. In a small percentage (< 10%) of participants, you will not be able to find the dorsalis pedis pulse. If you are having trouble, be patient and continue to search for at least three minutes. If you are still unable to locate a pulse here, enter “999” in Field 1 on the Ankle-Arm Blood Pressure Form. c. Inflate the cuff slowly until the pulse is no longer audible. Inflate to 30 mmHg above the level at which pulse sound disappeared. (If the pulse cannot be obliterated, you may raise pressure to a maximum of 300 mm Hg. If not obliterated at that point, record “unable to occlude.”) Deflate the cuff. Record the pressure at which the first sustained (more than one beat) pulse reappears. This is the systolic pressure at this location. Deflate the cuff completely. Record the measurement in Field 1 on the Ankle-Arm Blood Pressure Form. Wait for 20 seconds and then repeat the process to obtain a pressure measurement at each of the remaining sites. d. If the signal remains faint as more pressure is released or if the probe moves off the artery, deflate the cuff completely, wait for 20 seconds, and then repeat the measurement. e. Record the outcome (completed/not completed) in Item 2. If not completed, continue to Item 3 and record the reason(s) that the procedure was not completed. B. Recording of information Item 1. Record the answers to Item 1a-Item 1f as the readings obtained. Item 2. Record whether the procedure was completed successfully or not. If the procedure was completed successfully, go to Item 4.
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Item 3. Record the reason(s) why the procedure was not completed successfully on the right side using items 3a-3e. If the reason why the procedure was not completed successfully on the right side is not listed, specify the reason in Item 3f. Record the reason(s) why the procedure was not completed successfully on the left side using items 3g-3k. If the reason is not listed, specify the reason in Item 3l. C. Administrative Information 4. Enter the date on which the participant was seen in the clinic. Code in numbers using leading zeroes where necessary to fill all boxes. For example, May 3, 2005, would be entered as: 0
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5. The person at the clinic who has completed this form must enter his/her code number in the boxes provided.
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