The Old Problem of Systolic Blood Pressure

[hazyblue]

I'm sorry I wasn't sure if it's okay to post this on the many old threads regarding blood pressures...

It is the question of what should be the systolic BP the first sound or the first loudest sound but this time with the palpatory method. My patient has always had a weak pulse so I had to go by palpation...

I've always known that the first pulse you feel is the systolic. On my experience, the trend is always a strong pulse gradually becoming normal like those Korotkoff sounds. This was always the case that on many situations that I can't hear those sounds clearly I just palpate my systolic and diastolic. However today I encountered something new. The first few pulses were kind of weak then came a set of stronger pulses. Thinking of Korotkoff sounds wherein the first sound is the systolic irregardless of a stronger sound following it, I used the first weak pulse as my systolic. I got a BP of 130/60.

Moving on the problem, I settled with 130/60 which is a BP not quite different from my initial assessment. Considering my patient stable I went on the usual. Approximately 30 to 40 minutes later, my patient's BP dropped to 60/40 and he's the type who goes lethargic.

Now if I had used the first strong pulse, I will get 100/60 a BP that reflects a gradual hypotension for my patient. I am now tormented by the fact that maybe if I used the stronger pulse as my systolic, I could have prevented such a drop.

Basically my question is, what is the true systolic? I've read many resources saying that it's the first thumping sound but I'm not so sure anymore? Is the case of palpatory method different? Should I go with the first strongest pulse when palpating for BP?

I would really appreciate answers. I don't wish to make such a mistake again.

[dudette10, MSN, RN]

Moving on the problem, I settled with 130/60 which is a BP not quite different from my initial assessment. Considering my patient stable I went on the usual. Approximately 30 to 40 minutes later, my patient's BP dropped to 60/40 and he's the type who goes lethargic.

I can't answer your question--I'm looking forward to answers from experienced nurses--but I have to ask did you change method you used for the 60/40 BP? In other words, did you change your method from the time you took the 130/60 BP to the time you took the 60/40 BP?

My thoughts are that if you used the same method for both BPs (using first sound/pulse instead of strongest sound/pulse), you wouldn't necessarily have been able to catch the drop in time anyway. I may be wrong, though...

[hazyblue]

I didn't take the 60/40 BP, another nurse did. I just happened to finish my endorsement.

Is it common for blood pressures to drop from 130 something to 60?

[SuesquatchRN, BSN, RN]

Is it common for blood pressures to drop from 130 something to 60?

If they're septic or bleeding, yes.

[Biffbradford]

I didn't take the 60/40 BP, another nurse did. I just happened to finish my endorsement.

Is it common for blood pressures to drop from 130 something to 60?

If there's something wrong.

Some people still manage to stay conscious with SBP in the 60's, but not for long.

Where are you taking the pressure? Arm?

[nerdtonurse?, BSN, RN]

Blood pressures are like apples and oranges. If you use a small cuff on a wrist, you'll get a different BP than for a BP taken on an upper arm or a thigh. Different cuff sizes will change the result. Measure same cuff, same site to make sure you're not getting a difference in cuff or technique, first. You said you palpated your BP, did the second person palpate or auscultate? SBP is the first sound, DBP is the point where the sounds stop, but you're supposed to palpate for a pulse and then inflate the cuff at least 30 above the point where you feel the pulse stop as you're inflating the cuff. Had your patient not gone lethargic, I would have wondered if the second person didn't inflate the cuff high enough.

[hazyblue]

Well, he is on hemodialysis. It was my first time to see a sudden decrease so I was wondering if it was really a sudden decrease in blood pressure.

I measured using an adult cuff for my geriatric patient with his arm. I didn't see if my co-worker auscultated for it but I saw the cuff removed from the arm.

So back to the main problem, is the first sound being the systolic applicable to the first pulse?

[SuesquatchRN, BSN, RN]

I use the first sound. Have never palpated.

[Sun0408, ASN, RN]

Did the pt have HD that day, many tend to drop after or during hemo.. Also, I hope you did not check BP in the arm with the graft or fistula.. That is a no no.. I work HD/renal for a year and many have very up/down BP's ranging from very high to very low..

I use the first sound also no matter how faint or strong.

[netglow, ASN, RN]

I don't palp pulse

You note the first sound. If that sound is rapid/faint and immediate and then gets more audible, that is your signal to let out your pressure, wait a few minutes and do it again because you have not pumped high enough, clearly.

You can almost be sure that you need to pump up quite high if, in addition to what I just said, that first more audible beat is bounding. Then I know the patient might be in some serious hypertension. You need a cuff with some serious velcro when you find you have to pump high.

Make sure you are not drifting to center or lateral with your scope placement, and make sure your cuff has not wandered down into the anticubital space. Change your earbuds on your scope. I have some now that fit me so good that I have a hard time hearing people talk when I have them in

[DixieRedHead, ASN, RN]

First. Just like they taught me school.

[xtxrn, ASN, RN]

If there's something wrong.

Some people still manage to stay conscious with SBP in the 60's, but not for long.

Where are you taking the pressure? Arm?

In general, yes- this is true. I did have a patient who routinely had SBP in the low 60s and functioned normally. She was a frequent flier, and it was low, no matter what the problem was. :)