Passed my vital signs skill no problem... but now I can't take a BP in clinicals

[dumb_]

BPs were the easiest skill for me to pass. I practiced on my family and classmates, and never once had a problem. My instructor said I performed the skill perfectly.

But ever since beginning clinicals, I have not been able to take an accurate blood pressure on a SINGLE patient. I make sure the cuff fits perfectly; make it snug (fit two fingers fit inside); and I make sure my stethoscope is adjusted properly. But my first issue is, I have difficulty finding the brachial pulse on most of these patients. Then, once I get the cuff lined up and start pumping up, I either can't hear the sounds at all (even though I made sure to place the steth right over the artery), or I miss the first number.

I feel like a complete failure, because there's no reason I shouldn't have this down by now. I'm afraid to speak to my instructors about this because I will get chewed out (the semester is almost over). People have been failed out for not being able to take a BP.

Any tips?

[Double-Helix, BSN, RN]

Are you first palpating the radial pulse while inflating the cuff to get your estimated systolic pressure? That will help you know how high to inflate the cuff. Also, if you're using a dual-diaphragm stethoscope, be sure the diaphragm is turned correctly so that you're hearing sounds on the side you're placing against the patient. Deflate the cuff slowly, and watch for the needle on the dial to start bouncing up slightly. This is your cue that you should be hearing your first korotkoff sound.

Also, please make sure, if you are responsible for obtaining an accurate BP on these patients, that you are not documenting a reading that you are not sure of.

[oceanblue52]

It helps to place the stethoscope just slightly more closer to the inner arm on the elbow when you are doing an arm reading (more medial than lateral). Are you nervous? Or maybe it would help to get a better stethoscope to hear sounds better. It is also important to deflate the valve properly (not too fast or too slow) to get an accurate reading. Other than that, all I can suggest is doing a lot of practice and alerting your clinical instructor so you guys can practice. Some patients have a louder pulse than others. Don't be afraid to recheck a patient either, if you get a poor reading just tell them that it needs to be retaken. With practice you will get better.

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[Lev, MSN, RN, NP]

I second all of the above. In addition, do not be afraid to re-inflate the cuff, even if mid blood pressure check if you didn't hear where the tapping started (systolic).

[AceOfHearts<3]

The problem is you were practicing on people that are probably healthy- it can be harder on people that are elderly and/or sick. Practice makes perfect. A doctor I know showed me on really hard patients to raise their arm up (like they are raising their hand in class) for a minute or so, then to really inflate the cuff (nice and tight), and then lower the arm to take the BP. I filled in at his office for several shifts on the regular nurse's day off (once I passed the NCLEX and before I started my full time job). I don't do that anymore now that I'm confident in my skills, but I still double check when I think I need to.

[al3x117, RN, EMT-B]

All the above comments are correct. Don't worry I had the same thing happen to me when I was starting out. It takes practice just keep in mind to place the stethoscope medial (inner arm), before you do any of that though you need to palpate the brachial artery. Do not guess you need to be sure you have found it and then place the stethoscope right on it. Remember to have the stethoscope flat on the brachial artery so you can auscultate it. Good luck and keep practicing. I just finished my first quarter of nursing school! Keep up the good work and never give up.

[Xlorgguss]

I second going medial than you think. I always palpate first. Another thing is to have the arm supported. Oftentimes patients have their arms flopped on the bed. It should be elevated a bit. To accomplish that I either use a pillow or the overhead table. Sometimes you can't hear the brachial though. Then I try the other or or a radial. If I still can't hear, I use the Doppler.