BP 50's/30's left arm, 130's/60's right arm--?

[RNcDreams]

So this patient was an older gentleman who was being tx for Ca and had a cardiac Hx.

I ran into the room b/c he was alarming low bp; I took it on his other arm, and got a normal reading. He was A=Ox3, getting IV fluids, had clear speech, color was great, no cp/sob, etc.

left arm was 50's/30's, right arm was wnl.

He said "Oh, that has happened to me before in that arm."

I ran it by my charge nurse and she didn't have anything to add/comment.

Did I miss something huge, or can this happen often?

He looked great, his other VS were fine, he was afebrile. He hadn't voided much but he was coming in with c/o decreased PO's.

AGGHH!

Now I'm nervous.

[TigerGalLE, BSN, RN]

Was he a dialysis patient? With an old AV graft in that arm?

[MIcrunchyRN]

Was he a dialysis patient? With an old AV graft in that arm?

usually those are quite obvious... i guess unless you took BP over clothing?

Maybe he has some blockage of arteries higher up so less blood flow is getting down to his arm where you were taking BP? And blockage is just on that one side?

I dunno... you'll have to let us know what happens... ooh did you by any chance leave a note for the doc to investigate?

[mickey56]

Hello,

If thsi patient is stable, assess the limb for any abnormalites, such as edema, absence of pulse. Then ask the pt if he has any sx or trauma to the side.

Big pulse difference may be due to radial harvest, thrombosis, occlusion or more serious disection/leaking artey. Doctor should be made aware of the differences.

[RNcDreams]

Thanks for the pointers!

he was absolutely stable-- ambulating, no dizziness, good CSM in all extremities, no tachycardia. And, no evidence of old fistulas or grafts.

I just kept thinking, if all of us had been taking his BP on his right arm all along, no one would be the wiser. Since he looked so good, we'd never think twice.

I KNEW I should have said something.

Siiiiigh.... live and learn I guess.

Thanks for being kind.

[Dinith88]

Thanks for the pointers!

he was absolutely stable-- ambulating, no dizziness, good CSM in all extremities, no tachycardia. And, no evidence of old fistulas or grafts.

I just kept thinking, if all of us had been taking his BP on his right arm all along, no one would be the wiser. Since he looked so good, we'd never think twice.

I KNEW I should have said something.

Siiiiigh.... live and learn I guess.

Thanks for being kind.

Google 'subclavian steal syndrome'

This is the most common cause of 'big' BP differences in arms...and these patients are nearly always asymptomatic (though if bad enough people can have symptoms...though not in the arms...more usually syncope).

Anyway, and acute cause (like arterial thrombus/occlusion, trauma, etc. will cause extremity 'symptoms' so is less likely in this case).

Run this diagnosis by one of your Docs...and see what he says :typing

[RNcDreams]

Google 'subclavian steal syndrome'

This is the most common cause of 'big' BP differences in arms...and these patients are nearly always asymptomatic (though if bad enough people can have symptoms...though not in the arms...more usually syncope).

Anyway, and acute cause (like arterial thrombus/occlusion, trauma, etc. will cause extremity 'symptoms' so is less likely in this case).

Run this diagnosis by one of your Docs...and see what he says :typing

Have I done major harm by not calling the MD?

It was so darn busy and I had a lot going on, so he sort of fell to the bottom of my list....

Ugh

I will try to improve. And I am googling right now! Found this in Wiki---- makes sense, this patient had had a bypass surg!! So maybe this was baseline for him??

As in vertebral-subclavian steal, coronary-subclavian steal may occur in patients who have received a coronary artery bypass graft using the internal thoracic artery (ITA).[3] As a result of this procedure, the distal end of the ITA is diverted to one of the coronary arteries (typically the LAD), facilitating blood supply to the heart. In the setting of increased resistance in the proximal subclavian artery, blood may flow backward away from the heart along the ITA causing myocardial ischemia. Vertebral-subclavian and coronary-subclavian steal can occur concurrently in patients with an ITA CABG.[4]

[TopazLover, BSN, RN]

Personally, I would not have called the doc. I would mention it when the doc came it to see him or pass it on to the next shift to mention it. This is based on what you describe as his clinical picture of wnl and his response that it was not new. Basic assessments are taught to take B/Ps in both arms as a baseline. I know that sometimes this can be unrealistic, but look how not having this info changed things for you.

You did all the correct assessments following this discovery so, my opinion, learn from it and don't sweat it.

The Eskimos believe that many many of our maladies are caused by poor circulation and they are trained as Eskimo Doctors to do specific massage techniques. Makes you wonder how they knew these things without our fancy machines. (I was just reading the cultural diversity forum).

[RNcDreams]

Personally, I would not have called the doc. I would mention it when the doc came it to see him or pass it on to the next shift to mention it. This is based on what you describe as his clinical picture of wnl and his response that it was not new. Basic assessments are taught to take B/Ps in both arms as a baseline. I know that sometimes this can be unrealistic, but look how not having this info changed things for you.

You did all the correct assessments following this discovery so, my opinion, learn from it and don't sweat it.

The Eskimos believe that many many of our maladies are caused by poor circulation and they are trained as Eskimo Doctors to do specific massage techniques. Makes you wonder how they knew these things without our fancy machines. (I was just reading the cultural diversity forum).

Thank you... I am actually having a little crying moment here because I feel like I really let the patient down.

I'll definitely listen to my instincts next time.

[nrsang97, BSN, RN]

Google 'subclavian steal syndrome'

This is the most common cause of 'big' BP differences in arms...and these patients are nearly always asymptomatic (though if bad enough people can have symptoms...though not in the arms...more usually syncope).

Anyway, and acute cause (like arterial thrombus/occlusion, trauma, etc. will cause extremity 'symptoms' so is less likely in this case).

Run this diagnosis by one of your Docs...and see what he says :typing

I had a pt with this diagnosis. and the bp was like that. Pt was I believe syncopal. I haven't seen another case. This was years ago. I thought the same thing when I read the OP.

[mpccrn, BSN, RN]

on admission we rountinely take BP's in both arms and document......then there is no question later on.

[BSNin2008]

I had a pt. who had stenosis in the L subclavian artery and had very different readings in the 2 arms. I only knew this because her doctor told me .