Pulse pressure, widened
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 backflow of blood into the heart with each contraction, such as aortic insufficiency. Widened pulse pressure can easily be identified by monitoring of arterial blood pressure and is commonly detected during routine sphygmomanometric recordings.
Emergency Actions
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 396.) Also, check cranial nerve function — especially in cranial nerves III, IV, and VI — and assess pupillary reactions, reflexes, and muscle tone. Insertion of an ICP monitor may be necessary. Check for edema and auscultate for murmurs.
History
Obtain the patient’s medical, family, and drug histories. If you don’t suspect increased ICP, ask about such associated symptoms as chest pain, shortness of breath, weakness, fatigue, or syncope.
Physical assessment
After you detect a widened pulse pressure, assess for signs and symptoms of heart failure, such as crackles, dyspnea, and jugular vein distention. Also check for changes in skin temperature and color, strength of peripheral pulses, and LOC. Auscultate the heart for murmurs. Check for peripheral edema.
Medical causes
Aortic insufficiency
With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial gallop or ventricular gallop develop. These signs may be accompanied by chest pain; palpitations; pallor; strong, abrupt carotid pulsations; pulsus bisferiens; and signs of heart failure, such as crackles, dyspnea, and jugular vein distention. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).
Arteriosclerosis
With arteriosclerosis, pulse pressure progressively widens. 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 but may include fatigue, chills, malaise, anorexia, tachycardia, tachypnea, and diaphoresis.
Increased intracranial pressure
Widening pulse pressure is an intermediate to late sign of increased ICP. Although 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.
Special considerations
If the patient displays increased ICP, continually reevaluate his neurologic status and compare your findings carefully with those of previous evaluations. Be alert for restlessness, confusion, unresponsiveness, or 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.
Pediatric pointers
Increased ICP causes widened pulse pressure in children. 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
Recently, widened pulse pressure has been found to be a more powerful predictor of cardiovascular events in elderly patients than increased systolic or diastolic blood pressure.
Patient counseling
Teach the patient about dietary modifications, such as restricting sodium and saturated fat. Encourage frequent rest periods to reduce metabolic demands. If the patient has a reduced LOC, explain safety measures to him and his family.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to High blood pressure
Read excerpts from these other book chapters related to High blood pressure:
Medical Books Excerpts
- Hypertension
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Hypertension
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of High blood pressure
» Next page: Hypertension (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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