Not confident taking BPs -- HELP!

Nursing Students Student Assist

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if you don't want to read this whole, long thing (i understand why) look for the bold text below for my specific questions.

i'm nearing the end of a part-time cna course that i am taking before applying to lpn school. clinicals start next week, and i have no confidence whatsoever in my ability to accurately take and measure blood pressure.

our class was taught (read a section in the text, watched a video, practiced once with the teacher listening in and then she told us to practice as much as possible) bps about a month ago. i thought i would have it down by now because i've taken bps on my classmates everytime i've come to class and i practice on anyone that lets me, but apparently i don't. in fact, when our class doubles up to listen on the teaching stethoscope we're all generally off from each others' readings by 6mmhg or more. i think this is because some of the students wait for the first sound they hear and then mark that as the systolic, while some (myself, included) wait until we hear at least two consecutive beats. for instance, i was taking a bp with another student listening in and i recorded 120/78 and she recorded 132/78. she and i had both heard one sound at 132 and then nothing else until 120, but we recorded it differently.

i also know that a big part of the problem is that my teacher spent almost all of our lab time helping one student that has really been struggling to keep up with the rest of the class. i finally got my teacher to listen in with me again (first time since she first introduced taking bps to the class) yesterday, our last day of labs and classroom, and she told me that i:

  1. was deflating the cuff too slowly. (i was deflating at 2mmhg/sec. she said if i do it that slow the reading is inaccurate. she then pumped it up, deflated it, and let it fall so fast i could barely read it. it must have been 6-8mmhg/sec)
  2. wasn't using the right side of the stethoscope (i was using the bell, which seems to sound clearer to me. the book does say to use the diaphragm, but in our first week she told us some people like to use the bell.).

but the thing that really confused me was when she started talking about hearing the sounds change as you deflate the cuff, something she had never mentioned until yesterday. luckily, i had researched it online and had a general idea of what she was talking about (thank god for the internet!) so i guess i wasn't as confused as some of the others.

anyway, she said if you are deflating the cuff and you still hear sounds below 60mmhg or so you should just mark the diastolic as the point where you heard a change in sound and then deflate the cuff. it seems to me that she doesn't listen all the way down to see if the sounds will ever stop (phase 5 of korotkoff sounds) but instead waits until she hears phase 4 and then deflates the cuff.

when i took a bp with her listening in i got a reading of 118/58 (the last sound i heard was at 58mmhg) and she got a reading 118/62. i asked her and she said she heard a change at 62mmhg and that my measurement, while within range (+/- 4mmhg), was wrong. i always listen for another 10mmhg after i hear the last sound and i am almost completely positive there weren't anymore sounds coming through. i'm pretty sure she had already taken the earpieces out of her ears after she got her diastolic reading of 62mmhg, so she wasn't listening with me when i heard the sounds stop. so...ahhh! i just don't know if i'm hearing or doing anything correctly.

specifically, to get the most accurate reading possible:

  1. what should i note as the systolic pressure if i hear one sound and then nothing else for a few mmhg and then i hear consecutive sounds?
  2. how fast should i deflate the cuff?
  3. which side of the stethoscope should i use?
  4. what should i note as the diastolic pressure if i can hear the sounds stop?
  5. what should i note as the diastolic pressure if i hear sounds (even if they are faint) all the way to 0mmhg?

sorry it's so long, but i'm just completely confused and frustrated. any help would be appreciated. :o

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Specializes in med/surg, telemetry, IV therapy, mgmt.

this comes up at the beginning of every school term and i always forget to bookmark the really good threads that have good responses on them. here are the links i have to websites that have information on how to take a blood pressure. one site has a virtual blood pressure cuff that you can practice online with:

you have to take a lot of blood pressures. you have to listen very closely to what you are hearing. eventually, you begin to realize that there are very subtle differences to the sounds you are hearing. part of the trick to taking a blood pressure is learning to control the escape of air from the air bladder--you need to be letting the air out slowly so you can hear the subtle sound changes in your stethoscope that are going on with the arterial bruit you are hearing. no one expects you to master this in one day. the other is that you have your stethoscope postioned over the bruit of an artery.

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Specializes in Nursing Home ,Dementia Care,Neurology..

Oh I like that interactive site but they let the cuff down really quickly!

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Hi all - In the UK the British Hypertension Society advocates using validated automatic upper arm blood pressure monitors - thus eliminating the scope for human hearing error. There is a comprehensive list of BHS Validated blood pressure monitors and a brilliant easy to follow but comprehensive fact sheet "How to measure blood pressure"

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Hi, DavinaSlapp!

I looked at your two links. I also see that you are a pre-nursing student. These blood pressure cuffs look to me to be digital and I couldn't find any of the technical specifications about them. Most nursing schools won't allow a student to use them when learning how to take a blood pressure reading. Also, there are problems with the accuracy of these blood pressure devices when using them in people who have irregular heart rates (arrhythmias). It has something to do with the computer chip within the apparatus and how it is programmed to detect the pulse and then compute the final blood pressure and pulse measurements. I bought and used a similar one for myself as well as my nursing assistants when I worked in a nursing home a few years ago and began to notice a difference in some of the blood pressure readings we were getting in the patients, so I started doing manual B/Ps again and was shocked to find 20 and 30 points of difference between what I was getting manually and what the digital cuff was recording. In almost all cases, the patient's had irregular pulses of some type and this, apparently, was causing a problem with the computation of the patient's true blood pressure reading. In practice, when you need to give or hold a patient's daily dose of a medication based upon their blood pressure reading, you want the B/P reading you take to be as accurate as possible. But, thanks for letting everyone know about the digital cuffs. They still do have their use in healthcare and can be a great timesaver.

Welcome to allnurses! :welcome:

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Thanks for the links, Daytonite. I've seen most of them (I searched allnurses.com like mad before I posted my story and questions) and I have one site to add that has been a big help to me:

http://www.abdn.ac.uk/medical/bhs/index.htm - Click on the tutorial. There are 34 videos to watch and enter your answers for B/P measurement (complete with explanations).

I've done about half of those videos so far and have gotten all of them right except for the first video where the sounds represented someone in atrial fibrillation--I had no clue what to record, but I think I got the hang of it now.

So...from everything I've read, I was doing things correctly in lab. This makes me think that my teacher has no clue how to take a B/P measurement. (Edit: Now that I re-read this I realize I sound like a know-it all. I truly didn't mean this how it reads. I'm just getting so frustrated because the textbook teaches it one way, the teacher does it different way, the state wants it their way for the CNA exam, and then some online sources say something completely different.) So I'm now starting to lose confidence in my teacher in addition to myself. :uhoh3:

Would you (and any other nurses/nursing students reading this) mind going through the list of questions in my original post and answering them? I want to know how nurses/nursing students actually take blood pressure measurements (and any thoughts you have on which is the right way to do it and why) in addition to what is found on other sites.

Thanks for your help!

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Specializes in Gerontological, cardiac, med-surg, peds.

What should I note as the systolic pressure if I hear one sound and then nothing else for a few mmHg and then I hear consecutive sounds?

The pressure on the gauge when you heard the first clear (Korotkoff) sound is the systolic pressure. This is Phase I, the first Korotkoff sound (usually faint but clear tapping sounds that gradually become louder). So, this first sound signifies your patient's systolic pressure.

How fast should I deflate the cuff?

Open the valve slightly (by turning counter clockwise) to allow a slow release of air from the cuff. Slowly deflate by dropping 5 mm Hg per second.

Which side of the stethoscope should I use?

Most sources state use the bell. Since the Korotkoff sounds are low-frequency, the blood pressure sounds are best heard with the bell, rather than the diaphragm.

What should I note as the diastolic pressure if I can hear the sounds stop?

When you can no longer hear the Korotkoff sounds, the corresponding number on the gauge is the diastolic pressure.

What should I note as the diastolic pressure if I hear sounds (even if they are faint) all the way to 0mmHg?

Occasionally, the tapping sounds of the pulse will be heard all the way down to zero (especially with children). When this occurs, use Phase IV - the second to the last sound before a period of continuous silence - as your diastolic pressure.

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Thank so much for answering my questions, VickyRN. I just want to clarify something:

What should I note as the systolic pressure if I hear one sound and then nothing else for a few mmHg and then I hear consecutive sounds?

The pressure on the gauge when you heard the first clear (Korotkoff) sound is the systolic pressure. This is Phase I, the first Korotkoff sound (usually faint but clear tapping sounds that gradually become louder). So, this first sound signifies your patient's systolic pressure.

So, just to make sure I understand, Korotkoff sounds are almost always repetitive tapping sounds. If I heard a "thump" at 132 and then nothing until 120 (at which point I began to hear faint tapping sounds like a "tick" pause "tick" pause, etc) I should mark the systolic as 120. And it doesn't matter how faint the tapping sounds are, as long they are coming through clear enough for me to be sure that they are, in fact, tapping sounds. (Please, please correct me if any of the above is wrong.)

I want to apologize if I'm getting on anyone's nerves with all my questions. :imbar My classmates told me I'm making a bigger deal of of this than I need to, but I just want to make sure I fully understand what I need to do and listen for to get the most accurate measurement possible for the patient's sake.

Also, If anyone else wants to post answers, please do. I think if I can get a consensus among nurses/nursing students and tell my teacher the responses I got, maybe she would see the reasoning behind the way I do some things and be more likely to help me with those things that I am doing incorrectly.

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specifically, to get the most accurate reading possible:

  1. what should i note as the systolic pressure if i hear one sound and then nothing else for a few mmhg and then i hear consecutive sounds?

i know it has been over 6 months since you first posted this thread. not sure if you still need this, but i found the answer to your question in my textbook (fundamentals of nursing: concepts, process, and practice. 6th).

the
palpatory method
is sometimes used when korotkoff's sounds cannot be heard and electronic equipment to amplify the sounds is not available, or when an auscultatory gap occurs. an
ausculatory gap
, which occurs particularly in
hypertensive clients
, is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high followed by the reappearance of the sounds at a lower level. this temporary disappearance of sounds occurs in the latter part of phase 1 and phase 2 and may cover a range of 40 mm hg. instead of listening for the blood flow sounds, the nurse palpates the pulsations of the artery as the pressure in the cuff is released.
the systolic pressure is read from the sphygmomanometer when the first pulsation is felt.
a single whiplike vibration, felt in addition to the pulsations, identifies the point at which the pressure in the cuff nears the diastolic pressure. this vibration is no longer felt when the cuff pressure is below the diastolic pressure. to palpate the diastolic pressure, the nurse applies light to moderate pressure over the pulse point.

hope this helps & good luck on your way to rn.

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