Question on taking Blood Pressure and Respirations

[Rhonda V]

I was wondering how long you should count a patient's respiratory rate. I believe I was taught 30 seconds then multiply by two. However, if the patient is not experiencing respiratory distress, is it OK to count it for 15 seconds then multiply by four like we do the pulse? I work in an urgent care clinic which is fast paced. I've known some nurses to glance down at the patient for only a few seconds and estimate their respiratory rate. I really doubt any of them count the patient's respirations for 30 seconds like I do.

My other question is regarding blood pressures. I don't know if anyone else has the same problems I do, but sometimes I just don't feel like I'm hearing blood pressures well. I even bought a new stethoscope not too long ago. I at first blamed the equipment we had in our clinic which is heavily used (we don't use automatic cuffs). I don't have the problem all the time, but I find that some patients have blood pressures which are somewhat hard to hear. I personally don't feel that I have a hearing problem, but I think I'm having problems determining when I'm really hearing the first beat (it can be easy to miss). Other times while listening to BP, the sound becomes so muffled that I'm not sure what to write down at the diastolic pressure. I usually support the arm at the level of the heart and roll up sleeves as needed. I also at times will tell the patient not to speak while I'm taking BP (when they do I find this so annoying). I pump up most patients to the 160 mark and slowly release until I hear something. If I'm not sure of the BP on one arm, I tend to take it on the other too, and sometimes I get a difference of around 10-12 mmHg which makes me feel like I'm way off. If anyone can offer any suggestions or advice, I'd appreciate it. Thank You!

[Nickle]

Getting good at BP's just takes a lot of practice. It's hard to sort out all the artifact noises (tubes bumping, etc.) from the actual Korotkoff sounds. One way that helps sometimes is to watch for the needle flutter - it usually flutters with the returning pulse before you can actually hear the sounds, so you can generally predict when the next actual Korotkoff sound might come . . . That said, DON'T go by the flutter! It's wrong! It just helps you gauge when the actual pressure is about to become audible (though I've also seen it take as many as 20 or 30 mmHg before the flutter converts to a true tone - it's just a guideline.)

Also, I have weird upwards-slanting ear canals, so it helps me to use my non-dominant hand to hold some tension on the metal auricles (the metal arms of the stetho that end in the soft ear tips) although this can increase artifact noise, you have to be careful.

Don't rely on the cheap clinic equipment - buy the best stetho you can afford. And change out the hard earpieces to the soft ones, they form a better seal in your ear canal.

[Super_RN, BSN, RN]

well, the other day in clinical I had an obese pt. there for gastric bypass and the standard cuff on the wall wouldn't fit her...I searched the floor from top to bottom looking for a larger cuff...when I couldn't find one I asked the nurse what to do and her response was to take the blood pressure on the forearm and palpate the radial pulse...I found this extremely hard and had never heard of anyone doing it that way? The cuff was positioned between her wrist and her elbow. I knew you could take it on the thigh but I had never heard on the forearm...anyone else ever do it this way? just wondering:)

We do that a lot on obese patients. The BP needs to be taken there consistently throughout their stay to have an accurate baseline. Sometimes we will use thigh cuffs for the upper arms if the cuffs are available.

:)

[Antikigirl, ASN, RN]

"actual Korotkoff sounds" OH Thank you so much nickle! I totally forgot the name of that and have been telling my CNA's who do most of our VS about it in discription with the addage "I forgot the name of it!" LOL!!!!!!!!!!!!!!!!!! Silly me!

[Nickle]

Yep, no problem!

[Maverick80]

well, the other day in clinical I had an obese pt. there for gastric bypass and the standard cuff on the wall wouldn't fit her...I searched the floor from top to bottom looking for a larger cuff...when I couldn't find one I asked the nurse what to do and her response was to take the blood pressure on the forearm and palpate the radial pulse...I found this extremely hard and had never heard of anyone doing it that way? The cuff was positioned between her wrist and her elbow. I knew you could take it on the thigh but I had never heard on the forearm...anyone else ever do it this way? just wondering:)

my lab teacher actually told us...that this was better then trying to hold it on the arm to do it. (which he saw a nurse doing to his mother's arm) Make sure you note that you didn't do it in the right spot but below the elbow. he mentioned that if the patient was too obese, try and use a thigh cuff.

[Rhonda V]

I just want to thank all of you who replied to my original post. Your advice and techniques will surely help me a lot, though I'll need to practice that palp thing :) I really appreciate this discussion group and all the wonderful advice I get from all you "expert" nurses out there. Sometimes I'm too embarrassed to ask co-workers certain questions, so I'm glad I have this forum. Thanks Again! Rhonda