need tips how to measure BP on really obese patients

xtxrn, ASN, RN · Aug 9, 2011

We didnt learn about this either, or even learn how to draw blood! With a BSN! Even. Good question

WOW....I'm so sorry- seriously. :eek:

This should have been covered... I'm an ADN who graduated in 1985- we got it back then, the first week of school. :)

It stinks that you didn't get this info.....

Cuff size is the main thing- then (like my post above) if you have to use the wrist, it's better than nothing. For foraging for veins, you probably will need wrist veins (which hurt like a mother.......). If it's a long term patient, ask for a picc for labs.. will save a LOT of hassles, and pain for the patient. :0

Good luck :)

xtxrn, ASN, RN · Aug 9, 2011

While, I have taken issue with the OP on a number of occasions, and I myself, am overweight, I consider a question like this quite valid. While the OP does have history of focusing on "appearance" issues, I feel like cutting her some slack.
Sure, nursing school said plenty about the right size cuff. But cuff size is a very small part of getting a manual BP. No BP cuff is going to suddenly allow to hear easily through a significantly thicker amount of tissue.
I personally recommend getting a very good quality stethoscope that allows one to hear better.
And I question why it is that whenever issues with difficulty treating people with weight issues comes, suddenly posters jump on "fat bias/making fun of the maligned overweight pt" bandwagon. It is a very valid issue to discuss, whether it hits a few sore spots or not. And obesity is creating more and more issues with care.
And, like it or not, human biology has not changed that much over the last several centuries, yet weight issues have increased astronomically. This points to some really unpleasant truths we may not like (me very definitely included).

You're very right- they are valid points and should have been covered in fundamentals-- and nurses need to know how to provide care for the super obese. The facility needs to have the proper equipment- and the patients need to be treated with respect.....IDK how others will reply to this, but there have been a LOT of folks trashing obese patients (not just obesity itself) and it sets a really bad tone for any discussion on care- I apologize if I've offended you or anyone else... it sounded a lot like another way to trash the obese patients....if I overreacted, I'm sorry :)

rn/writer, RN · Aug 9, 2011

No reference about correct cuff size with obese patients (super or not- and yes, I'm aware of the 'super obese' label). ??? Just asking. Even in 1985 we got taught about cuffs for obese patients.....:)

Back in 1985, only one state had more than 20% of its citizens fit the medical definition of obesity. Now, only one state has fewer than 20% who qualify as obese.

What was big back then is bigger now. We used to order bariatric beds that went up to 400 lbs. The newer ones go up to 600 lbs. And we can special order beds that go up to 800 lbs.

Some of the cuffs that used to be labeled extra-large are nowhere near adequate.

Times have changed and people have gotten bigger. Much bigger. Saying so isn't the same as being mean.

xtxrn, ASN, RN · Aug 9, 2011

Back in 1985, only one state had more than 20% of its citizens fit the medical definition of obesity. Now, only one state has fewer than 20% who qualify as obese.
What was big back then is bigger now. We used to order bariatric beds that went up to 400 lbs. The newer ones go up to 600 lbs. And we can special order beds that go up to 800 lbs.
Some of the cuffs that used to be labeled extra-large are nowhere near adequate.
Times have changed and people have gotten bigger. Much bigger. Saying so isn't the same as being mean.

I agree with you- I didn't mean any offense- just very surprised. I've had to use jumbo cuffs on people, and had some pop off... I was just dumbstruck that school hadn't covered this- not intended to be nasty :)

xtxrn, ASN, RN · Aug 9, 2011

Besides apologizing- and having my eyes opened to something I'd taken for granted, I don't know what else to say :)

rn/writer, RN · Aug 9, 2011

No worries. I'm just saying that some folks may have learned information that was accurate when they were in school (even five years ago) that has since become outdated or incomplete.

Another thing is that nursing school usually teaches the ideal and might not have the time (or the foresight) to cover less-than-ideal circumstances--like being in home health and not having a large (no pun intended) selection of cuff sizes to choose from. That's when you hit up the experienced folks to see if there are any tricks of the trade for getting past such difficulties.

cherryblossom88 · Aug 9, 2011

I once had a patient that was over 500 pounds and could never find a b/p cuff big enough. I would always end up using the wrist. Try that.

xtxrn, ASN, RN · Aug 9, 2011

I once had a patient that was over 500 pounds and could never find a b/p cuff big enough. I would always end up using the wrist. Try that.

Yep- have had to use the wrist- it's not ideal, but at least gives some sort of reading, and if used consistently allows for patterns to be noted...:)

nerdtonurse?, BSN, RN · Aug 9, 2011

What we do:

1) upper arms

2)wrists (of course, that may be where your only IV access is, so that can be a problem -- and we've also had folks so fluffy that the IV cannula can't reach the vein, it's simply not long enough)

3) A-line

I know there used to be something called a Vasotec (like the med) but it took BP differently than a standard BP cuff. I've never seen one, just heard about it. And there was something that had 2 cuffs and the distal cuff took the pressure when the proximal cuff inflated and essentially acted like an anchor...?

merlee · Aug 9, 2011

I have used an automatic battery operated wrist cuff for many years. It is surprising accurate. And if you are consistent - same cuff, same wrist - then the results will tell you what you need to know.

And I have had only one or two very skinny people that the cuff didn't fit!

I have a heavy upper arm, partly genetics, partly fat, and if the cuff doesn't fit then the readings are off.

Also, where did the " I have to pump it up to 200" mindset come from? If I tell you I usually run in the 140's then the 160's should be plenty high enough. 200 is PAINFUL and may give an inaccurately high pressure.

Wrist cuffs are also easier to use.

Esme12, ASN, BSN, RN · Aug 9, 2011

the size of the cuff is imperative to an accurate b/p measurement. a cuff to small will give a false high b/p reading and a cuff too large will give a too low false reading. on people of size it can be challenging to obtain a b/p but i have also found a lack of initiative and patience a problem as well as a lack of experience and knowledge on a basic level that is present (or actually absent) i agree with xtxrn.......some of the common necessities, taught years ago in programs more geared towards the technical/practical skills necessary to the practice of nursing, have become glaringly absent from the grads in recent years. they are book smart but are greatly skills lacking. :flmngmd:(before i get flammed....let me clarify.......some grads not all, of course i'm not talking to you, you, or you. and i am sure your school is the very best):sofahider.

to measure size there are markings on the inside of the cuff....usually a white line. the end of the b/p cuff (sphygmomanometer) needs to fit within the white line on the inside of the cuff

http://youtu.be/ja2ub_fag0q

if you are significantly above or below "average" height or weight, then the doctor or nurse should probably not be using the cuff that is already in the room. the "default" cuff that is usually kept in the examining room is meant to be used for average sized people, and will not produce an accurate reading if you are larger or smaller than average.

the official guidelines specify the following cuff sizes:

arm circumference 22 to 26 cm, 'small adult' cuff, 12 x 22 cm
arm circumference 27 to 34 cm, 'adult' cuff: 16 x 30 cm
arm circumference 35 to 44 cm, 'large adult' cuff: 16 x 36 cm
arm circumference 45 to 52 cm, 'adult thigh' cuff; 16 x 42

but......the op mentioned having difficulty hearing the b/p. hearing through all that tissue can be a dilema......... it is usually the technique or the equiptment that is the culprit and not the obesity of the patient at fault. the use of a doppler would alleviate that problem altogether or the purchase of a good stethocope or a good electronic stethoscope usually cures the problem. the stethoscopes that are purchased by the hospital are meant more for ornamental display than actual meaningful usage. i was taught to pump the cuff to 150 and if you heard am immediate beat you went to 200 and if you heard an immediate beat you stopped and went to 250....and so on. yes it's uncomfortable but it's brief. in ultra sensitive patients i go straight to the wrist.

just my point of view....i hope this was helpful.

Medic2RN, BSN, RN, EMT-P · Aug 9, 2011

As far as IVs or blood draws, always ask the patient where she/he has had previous luck. If they are a hard stick, they know it and know where to go. I never assume that if the patient is obese that they will automatically have no veins. Ask the patient. If there is nothing in the lower arm, keep looking higher. Sometimes we have had to start a small gauge IV in the upper chest wall.

The main thing is ask the patient.