Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Protocol
Estimation of heart rate and blood pressure
Procedures
1. Examination of pulse by palpation
Perform palpation in the arteria radialis, brachialis, carotis, femoralis and poplitea in three
persons. If you have palped the pulse, check the appropriate box in the table. Try all
mentioned arteries.
2. Resting heart rate according to a measured time interval
Resting heart rate is usually examined in a supine patient, but for this exercise a sitting
position will do. After a sufficient rest, count the pulse according the second hand on the
watch in intervals of 5, 10, 20, 30, and 60 seconds. Write down the results and convert
them to minute values (beats per minute).
3. Respiratory sinus arrhythmia
1. Attach the respiratory belt on the chest of the examined person and the finger pulse sensor
on the distal phalanx.
2. Start the program PULSE by double clicking on its icon.
3. Set the sensitivity of the amplifier for pulse registration (PULSE – 1st channel) and
respiratory movements (BREATHING – 3rd channel). Pulse frequency is calculated
automatically from the 1st channel and can be observed in the middle channel (PF –
2nd channel).
4. Record the following situations:
• resting breathing (1 minute)
• slowed breathing for 1 min (e.g. 4 seconds inspirium – 5 s expirium)
• faster breathing for 20 seconds.
5. Measure the pulse rate on top of inspirium and expirium from 5 breathing cycles at resting,
slowed and fast breathing (pulse rate value is given by position of mouse cursor). Calculate
average values of pulse rate on top of inspirium and expirium at resting, slowed and fast
breathing.
4. Heart rate in postural changes
1. Record the following situations
• at least 3 minutes of rest in standing position
• 2 minutes in supine position (lying on the bed)
• 2 minutes of rest in standing position
Changes between positions have to be quick
2. Count average heart rate from
• last 15 seconds of standing
• first 15 seconds of lying
• last 15 seconds of lying
• first 15 seconds of second time standing
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
• last 15 seconds of second time standing
3. Check the calculated values in the graph
5. Non-invasive methods of blood pressure measurement
Measure blood pressure in three persons. The blood pressure of each person will be measured
by palpatory, auscultatory and oscillometric methods. Check the counted values in the graph.
Palpatory (Riva-Rocci) method
1. The sphygmographic cuff is placed on the naked upper arm of the examined
person tightly, but don’t strangulate the arm. The lower margin of the cuff has to
be placed 2.5 cm above the elbow region (the width of the cuff is 12.5 cm for
adults).
2. The radial artery is palpated at the wrist of the same arm. The cuff is inflated to a
pressure of 20–23 kPa (150–170 mmHg) using the rubber bulb the valve of which
is closed. If the pulse is still palpable at this pressure, increase the cuff pressure by
another 4–5 kPa (30–40 mmHg).
3. Opening slightly the valve, let the air slowly escape from the cuff. The first
pulsation felt on the radial artery during the decrease of cuff pressure means that
blood is just starting to flow through the compressed artery. At this moment, the
cuff pressure is equal to the systolic pressure.
Auscultatory (Korotkow) method
6. The arm cuff is inflated to a higher pressure than is the supposed systolic pressure,
and the stethoscope is applied over the brachial artery at the elbow region of an
extended arm.
7. In opening slightly the valve, one allows the air to escape slowly from the cuff (2–
3 mmHg) and observes the pressure indication on the manometer. Listen to the
Korotkow sounds.
Five phases are distinguished: weak sounds – sounds – intensive sounds – sudden
change of loudness – cessation of sounds. the first sounds heard over the artery mean a
beginning arterial flow during the maximal BP and the cuff pressure read at this
moment is thus the SBP. During a further slow decrease of cuff pressure the sounds of
the oscillating arterial wall increase in intensity and after a certain maximum loudness
attenuate a little. At a certain pressure the sounds, as yet distinctly audible, become
almost inaudible if the pressure is slightly reduced (sudden change of loudness) and at
a further decrease in pressure they disappear. At the moment of sudden lowering of
loudness, which is caused by cessation of oscillations of the arterial wall, the cuff
pressure is equal to DBP. Repeat the BP measurement at rest about 5 times, using both
methods, register all results, and calculate the mean.
Oscillomeric measurement
During the measurement the experimental person sits calmly and does not speak.
Wrap the cuff around the naked arm of the experimental subject (the green coloured
band is positioned 2–3 cm above the elbow on the inner side). Lay the arm on a table
so that the cuff is approximately at heart level (below heart level the blood pressure
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
measurement would be artificially high, while above the heart level it would be
artificially low). Switch on the unit by pressing the O/I button.
Wait until the heart symbol appears on the display. According to the type of
instrument either push the START button or inflate the cuff using the rubber bulb. The
instrument measures blood pressure and pulse, then the values are displayed. The
arrow symbol announces the end of the measurement. If the measurement has
finished, switch the device off by pressing the O/I button.
6. Changes of heart rate and blood pressure after work load
1. After a few minutes of sitting at rest the SBP and DBP is measured.
2. Then the examined subject performs 30 deep squats at a frequency of one squat per second.
Then we measure SBP, DBP and heart rate by automatic device in sitting position each
minute until initial values are reached. During squatting the cuff is left on the arm, only the
manometer is disconnected.
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Results
1. Examination of Pulse by Palpation
person a. radialis dx
a. radialis
sin.
a. carotis
dx.
a. carotis
sin.
a.
brachialis
a.
femoralis
a.
poplitea
1
2
3
Table 1: Place a tick where you have palped a pulse.
Describe the differences in the quality of pulse between measured persons
…………………………………………………………………………………………………
………………………………………………………………………………………………….
………………………………………………………………………………………………….
2. Resting heart rate according to the measured time interval
person 10 s bpm 20 s bpm 30 s bpm 60 s = bpm
1
2
3
Table 2: Write the number of pulses measured in time intervals (10, 20, 30 and 60 s) and
convert them into bpm (beats per minute).
Why do heart rate values counted at intervals shorter than 1 minute differ from one another?
………………………………………………………………………………………………..
………………………………………………………………………………………………..
Which time interval is long enough for estimation of heart rate?
………………………………………………………………………………………………..
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
3. Respiratory sinus arrhythmia
Resting breathing Faster breathing Slower breathing
Respiratory
cycle
inspirium expirium inspirium expirium inspirium expirium
1
2
3
4
5
average
Table 3: Heart rate measured in inspirium and expirium during different frequencies of
breathing.
Describe changes in heart rate depending on breathing.
………………………………………………………………………………………………….
………………………………………………………………………………………………..
How do the frequency and depth influence the heart rate difference between inspirium and
expirium?
…………………………………………………………………………………………………..
………………………………………………………………………………………………..
Name at least three possible causes of respiratory sinus arrhythmia formation.
1………………………………………………………………………………………………..
2………………………………………………………………………………………………..
3………………………………………………………………………………………………..
………………………………………………………………………………………………..
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
4. Heart rate in postural changesHeartrate[bpm]
200
Supine position
(3 min)
Laying position (2 min) Supine position (2 min)
180
160
140
120
100
80
60
40
End of orthostasis
Beginning of
clinostasis
End of clinostasis
Beginning of
orthostasis
End of orthostasis
Table 4: Heart rate measured at the beginning and end of postural change. Mark the heart rate
on the graph.
How do the postural changes influence heart rate?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Which mechanism of neural blood pressure regulation changes the heart rate? (one word)
…………………………………………………………………………………………………
How does the cardiovascular system prevent blood pressure from falling during orthostasis?
…………………………………………………………………………………………………
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
…………………………………………………………………………………………………
Explain the reason for the heart rate change during the phase of supine position (from
beginning to end of phase).
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Which part of the autonomic nervous system increases its activity during orthostatic reaction?
…………………………………………………………………………………………………
5. Non-invasive methods of measuring blood pressure
Bloodpressure[mmHg]
200
180
160
140
120
100
80
60
40
SBP
bypalpatorymethod
SBPandDBPby
auscultatorymethod
SBPandDBP
oscillometricmethod
SBP
bypalpatorymethod
SBPandDBPby
auscultatorymethod
SBPandDBP
oscillometricmethod
SBP
bypalpatorymethod
SBPandDBPby
auscultatorymethod
SBPandDBP
oscillometricmethod
person 1 person 2 person 3
Table 5: Blood pressure estimated by palpatory method (Riva-Rocci), auscultatory method
(Korotkow) and oscillometric method in three persons. Mark values of systolic (SBP) and
diastolic (DBP) blood pressure.
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Which method of blood pressure measurement is the less exact? Why?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Which method enables measuring diastolic blood pressure? (2 words)
…………………………………………………………………………………………………
Which values of blood pressure (SBP, DBP, MAP) are really measured by the oscillometric
method and which values are counted?
…………………………………………………………………………………………………..
Which variables of cardiovascular system define mean arterial blood pressure? (3 variables)
…………………………………………………………………………………………………..
Discuss the obtained blood pressure in measured persons.
………………………………………………………………………………………………….
………………………………………………………………………………………………….
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Results 6: Changes of heart rate and blood pressure after work loadBloodpressure[mmHg]andheartrate[bpm]
200
180
160
140
120
100
80
60
40
Resting
values
0 minute
after
squatting
1 minute
after
squatting
2 minutes
after
squatting
3 minutes
after
squatting
4 minutes
after
squatting
5 minutes
after
squatting
Graph 3: Blood pressure and heart rate changes at rest and after squatting. Mark SBP, DBP
(cross) and heart rate (circle).
Describe changes of SBP, DBP and heart rate measured before and after physical activity.
……………………………………………………………………………………………….
……………………………………………………………………………………………….
Why is the SBP change greater than DBP change? (Explain in the context of cardiac output
and total peripheral resistance changes induced by activity)
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Why does peripheral resistance decrease after physical activity? Which mechanism regulates
blood flow in skeletal muscles?
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Conclusion
Summarize blood pressure and heart rate changes observed under various physiological
conditions.
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Theoretical part
Apex beat and heart sounds
Basic evaluation of heart status done during each total patient’s examination includes
examination of external manifestations of heart function. According to the various senses
employed this examination is divided into four groups: Visual (inspection): in meagre
students an apex beat can be observed;
• Touch (palpation): an apex beat is palpable in the 4th to 5th intercostals space on the left
medioclavicular line, in healthy people it can be covered by fingertip;
• Tapping (percussion): tapping of heart borders is not a routine examination since it is
inaccurate; exact information on heart size can be obtained by X-ray or echocardiographic
examinations;
• Listening (auscultation): the most important physical method of examination the heart; the
presence and quality of particular heart sounds can be considered, and pathological heart
sounds (murmurs) can be examined and their cause identified (based on the place and time of
their audibility).
The examiner usually approaches the patient from the latter’s right side and examines him/her
in the following positions: supine position, lying on the left side with the patient’s left hand
the below head and in sitting position, possibly in bending forward. This examination is
performed in a silent room and the patient must be in comfortable position and undressed.
High-frequency sounds (the 1st and 2nd heart sound, regurgitation murmurs) can be better
heard with a membrane stethoscope.
However, the lower-frequency sounds (below 300 Hz) are suppressed and can be better heard
by a bell-shaped membrane-less stethoscope which must be firmly pressed against the chest of
the examined person. This stethoscope enables us to hear well the mitral opening sound, the
3rd and 4th heart sounds, and diastolic mitral and tricuspid murmurs.
Figure: Heart sounds (FCG, fonocardiography) in context of ECG and sfygmography (SFG)
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Apex beat
The apex beat is a mechanical manifestation of heart activity generated by impact of cardiac
apex during ventricular systole to the chest wall. Apex beat can be viewed or palped in the 4th
or 5th intercostal space under the left mammilla and it is better observable in a skinny person.
The apex beat can pathologically shift to the 6th intercostal space in patients with left
ventricular dilatation.
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Protocol
Apex beat and heart sounds
Methods
Apex beat
A meagre person is chosen for the examination, who must undress his/her upper body.
1. With lateral illumination, observe at first the chest wall under the left mamilla and look at
whether the impact of the heart apex is visible. If so, palpate the pulse on the radial artery
at the same time and consider the time relation of both events. Perform the observation also
during a voluntary stop of breathing in inspiratory and in expiratory position and note the
difference.
2. If the apex beat is not visible, place your palm on this chest area and follow the apex beat
during palpation of the radial pulse at normal respiration and at respiration stopped in
inspiratory and expiratory position.
3. The same examination is performed in supine position and in a mild forward bend and the
differences noted.
4. The spot of the apex beat may be more precisely located by palpation with two fingers.
Heart sounds
The stethoscope should be firmly pressed against the skin and not moved during the
auscultation so that no disturbing noise arises.
1. A stethoscope is placed on the naked chest of the examined person at locations of optimal
audibility of the particular heart sounds (Chyba! Nenalezen zdroj odkazů.)
 A: Aortic valve: 2nd intercostal space parasternally on the right
 P: Pulmonary valve: 2nd intercostal space parasternally on the left
 M: Mitral valve: in the region of the apex beat
 T: Tricuspid valve: 5th intercostal space parasternally on the right or on the left or
above the distal sternum
2. Later listen wherever it is necessary. Important areas are Erb’s point (3rd intercostal space
parasternally on the left), the area above the carotid arteries, in the left axilar line, etc.
3. Notice the character of the heart sounds, i.e. the intensity and the duration of particular
sounds and the intervals between them which allows you to discern, in a normal rhythm,
the first and the second sound (a simultaneous palpation of arterial pulse may be helpful).
4. Perform the examination in standing and supine position. During respiratory stop (in
inspiratory and expiratory position) and in slow, deep breathing note the fluctuation of
the heart rate, synchronous with respiration (respiratory arrhythmia).
5. After the examination at rest, the subject performs a series of ten fast squats. Immediately
after this exercise, in supine position, follow changes of the frequency and the character
of heart sounds.
Name: Numer: Study group:
This text was supported by project FRMU no. MUNI/FR/1552/2015 (Faculty of Medicine, Masaryk University).
Figure: Locations of optimal audibility of the particular heart sounds
Results
Did you observe heart beat visually or by palpation?
……………………………………………………………………………………………….
Did the quality of the heart beat change during breathing?
……………………………………………………………………………………………….
Which position was the best for observing heart beat?
……………………………………………………………………………………………….
How did the heart sounds change during deep breathing?
……………………………………………………………………………………………….
How did the heart sounds change after physical activity?
……………………………………………………………………………………………….