auscultation...palpation...telemetry - can you help me?

  1. I am an RN and my assessment skills need improvement. (I know there's always room for improvement but I feel like I should have understood this.)

    I work registry on a small med/surg unit.

    Anyway... when visitimg my retired parents yesterday, Dad asked if I had my BP cuff to listen to his pressure. At first I got 104/62 on his left which is LOW for him. He also said that just didn't seem right.

    So I said that we'd wait a few minutes and I'd listen on his right arm. I got 152/70 on his right. What is up with that? I can't fathom that I would not "hear" it correctly. He said that this is more in line with what his battery-operated cuff has shown.

    Also, when listening to his BP, his heart rate seemed really slow. So I auscultated his apical rate at 42. This was freaking me out. He said that he is so easily fatigued. I thought it might have to do with Toprol XL 200mg QD that he's been taking since Feb of this year. He has been having generalized fatigue since then. (And I know not to give Toprol if the patient's HR is below 60 so this concerned me even though his "bradycardia" seemed unsymptomatic other than generalized fatigue.)

    OK so here's what his heart sounded like to me. A loud tone followed by three soft tones. I only counted the first loud tone. I asked Dad to get checked at the ER if his heart rate was actually 42. That's just too low. And let Mom drive until he was checked.

    The ER doc told Dad that I was not counting correctly. I don't mind being told I did something wrong but I don't understand it. Had I been working at the hospital and heard this heart rhythm, I would have had another nurse listen. I probably would have had telemetry to watch. But at Mom/Dad's house I had my ears and just don't feel like my assessment skills are good or perhaps rely too much on the other info like labs, tele, etc. which I obviously didn't have at my folk's house. KWIM?

    Have you ever had such differences in the sides in terms of palpating the pulse?

    Have you ever heard the "loud-soft-soft-soft-pause" heart tones?

    I told my DH that I'm supposed to be an RN and he of course reminds me that I am an RN but this "mistake" and not "getting it" really unsettle me.

    Advice?

    TIA.

    P.S. They kept Dad last night and had him on tele for the night. He said all EKGs were normal and he has bloodwork at 1430 today and if all is well he can be DCd. I'm assuming the bloodwork is cardiac enzymes. He said his MD mentioned an arrythmia but said that the Toprol should take care of it. I don't know what arrythmia. I live 90 minutes away and debated whether to go and listen to DC instructions and DH stay with our little ones but decided that I would stay home. Dad said not to feel badly about mis-counting but I know that I scared him yesterday but I was scared if his HR was only 42.

    Sorry so long-winded!
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  2. 4 Comments

  3. by   MargRN
    Ack!

    I don't think I mentioned that his HR at the hospital has ran upper 60s to mid 80s since he's been there. Hence his actual HR was 84 not 42 when I was listening.
  4. by   Renee' Y-Y
    Did you palpate a pulse while you were listening to his heart tones? Some of those "soft-soft-soft" tones may have been different pressure but perfusing beats. And yes, there is pathology associated with differing BP in the arms...I just don't recall what it is.
  5. by   suzanne4
    You should always try checking a radial pulse first, you are interested in what is perfusing..........................Yes, you can get a significant difference in BPs in each arm.

    Hope that this helps...........................
  6. by   dianah
    If he had bigeminy, often the ectopic beat isn't as strong as the normal beat, so you'd only feel 42 at the radial artery, when actually the rate is 84. That may explain the sounds you auscultated, too, the pause being the compensatory pause after the ectopy. Even the cardiac monitors we use at work will only count the normal beats, and not the ectopy (if the R-wave is a downward deflection). And my NIBP machine has trouble taking a BP when it perceives the rate that low (in the low 40's).

    A site I checked with re: Toprol quoted stats of 10% of pts c/o "tiredness" while taking it.

    I'd be curious as to what arrhythmia the MD was speaking of (would like it named/clarified); could be frequent ectopy.

    I have seen many pts with very different BPs in respective arms. Spmetimes it's normal for that patient, and sometimes it's due to vascular disease. I'd be curious as to what his BP readings were while in the hospital, and was he evaluated for any abnormalities r/t any differences in the readings (were bilat. readings even done?)

    I'm glad your dad was at least admitted and checked out, and glad he's doing better.

    Take care -- D

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