Pulse pressure, widened
Pulse pressure, widened: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
Pulse pressure is the difference between systolic and diastolic blood pressures. Normally, systolic pressure is about 40 mm Hg higher than diastolic pressure. Widened pulse pressure — a difference of more than 50 mm Hg — commonly occurs as a physiologic response to fever, hot weather, exercise, anxiety, anemia, or pregnancy. However, it can also result from certain neurologic disorders — especially life-threatening increased intracranial pressure (ICP) — or from cardiovascular disorders that cause blood backflow into the heart with each contraction such as aortic insufficiency. Widened pulse pressure can easily be identified by monitoring arterial blood pressure and is commonly detected during routine sphygmomanometric recordings.
Act Now: Ifthe patient’s level of consciousness (LOC) is decreased and you suspect that his widened pulse pressure results from increased ICP, check his vital signs. Maintain a patent airway, and prepare to hyperventilate the patient with a handheld resuscitation bag to help reduce partial pressure of carbon dioxide levels and, thus, ICP. Perform a thorough neurologic examination to serve as a baseline for assessing subsequent changes. Use the Glasgow Coma Scale to evaluate the patient’s LOC. (See Glasgow Coma Scale, page 196.) Also, check cranial nerve (CN) function — especially in CNs III, IV, and VI — and assess pupillary reactions, reflexes, and muscle tone. (See Exit points for the cranial nerves.) The patient may require an ICP monitor. If you don’t suspect increased ICP, ask about associated symptoms, such as chest pain, shortness of breath, weakness, fatigue, or syncope. Check for edema and auscultate for murmurs.
Assessment
History
Obtain the patient’s history, including a family medical history. Obtain a drug history. Has he experienced chest pain, shortness of breath, weakness, fatigue, or syncope? Ask the patient whether he recently had a fever. Ask about prolonged exposure to hot weather, excessive exercise, anxiety, or anemia.
Physical examination
Assess the patient for signs and symptoms of heart failure, such as crackles, dyspnea, and jugular vein distention. Check for changes in skin temperature and color and strength of peripheral pulses. Evaluate the patient’s LOC. Auscultate the heart for the presence of a murmur, and check for peripheral edema.
Pediatric pointers
Increased ICP causes widened pulse pressure in a child. Patent ductus arteriosus (PDA) can also cause it, but this sign may not be evident at birth. The older child with PDA experiences exertional dyspnea, with pulse pressure that widens even further on exertion.
Geriatric pointers
Widened pulse pressure has been identified as a more powerful predictor of cardiovascular events in elderly patients than either increased systolic or diastolic blood pressure.
Medical causes
Aortic insufficiency
With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial or a ventricular gallop develop. These signs may be accompanied by chest pain, palpitations, pallor, pulsus bisferiens, and strong, abrupt carotid pulsations. Other signs of heart failure, such as crackles, dyspnea, and jugular vein distention, may also be present. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).
Arteriosclerosis
With arteriosclerosis, reduced arterial compliance causes progressive widening pulse pressure, which becomes permanent without treatment of the underlying disorder. This sign is preceded by moderate hypertension and is accompanied by signs of vascular insufficiency, such as claudication, angina, and speech and vision disturbances.
Febrile disorders
Fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder.
Increased ICP
Widening pulse pressure is an intermediate to late sign of increased ICP. Although a decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (Even a gap of only 50 mm Hg can signal a rapid deterioration in the patient’s condition.) Assessment reveals Cushing’s triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.
Nursing considerations
If the patient displays increased ICP, continually reevaluate his neurologic status and compare your findings carefully with those of previous evaluations. Stay alert for restlessness, confusion, unresponsiveness, or a decreased LOC. Keep in mind, however, that increasing ICP is commonly signaled by subtle changes in the patient’scondition, rather than the abrupt development of any one sign or symptom.
Patient teaching
Explain needed dietary modifications such as restricted sodium and saturated fats. Stress the importance of planning rest periods. If the patient has a decreased LOC, discuss specific safety measures. If the condition is related to increased body temperature, discuss fever management, proper cooling measures if exposed to excessive heat for long periods, and proper fluid consumption with the patient.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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