Nursing Students General Students
Published Apr 6, 2015
Summers3
201 Posts
I believe I just did something stupid....
Patient had bilateral IV on both arms...... nurse asked me to take vital signs so I did but after taking BP, IV site started bleeding out!!!! It bleed through taping and onto pt's gown. IV had to be removed afterwards by nurse. Oh and both of the IV sites were non-infusing (locked).
Did this before on arm of other patients who also had bilateral IVs on both arms but nothing happened until now! Is this a common thing? How else can I take BP on patient with bilateral IVs?
I just feel really bad and stupid after this rookie mistake (not to mention I probably caused my nurse more work and frightened my patient).
BrandonLPN, LPN
3,358 Posts
For the future, know that BPs can be taken on the forearm if the upper arms are not viable. It's actually not unheard of to take them on the leg, too. Just make sure you note where you obtained the BP when you chart the results. And if you're an aide or a student, make sure the patient's nurse is aware you are doing so.
IVRUS, BSN, RN
1,049 Posts
I believe I just did something stupid.... Patient had bilateral IV on both arms...... nurse asked me to take vital signs so I did but after taking BP, IV site started bleeding out!!!! It bleed through taping and onto pt's gown. IV had to be removed afterwards by nurse. Oh and both of the IV sites were non-infusing (locked).Did this before on arm of other patients who also had bilateral IVs on both arms but nothing happened until now! Is this a common thing? How else can I take BP on patient with bilateral IVs? I just feel really bad and stupid after this rookie mistake (not to mention I probably caused my nurse more work and frightened my patient).
It is quite acceptable to take a BP, or place a tourniquet BELOW an IV site to assess ones blood pressure or draw labs, but it should NOT be placed ABOVE the IV site. You are compressing the vein above the venipuncture site and it easily leads to bleeding at the site, as well as vein irritation and subsequent phlebitis/thrombus formation. Some places actually will post signs above the bed saying NO BP's or Tourniquets on XYZ arm.
NurseGirl525, ASN, RN
3,663 Posts
I was going to say the forearm. You can do the legs but I'm assuming if it's a regular BP cuff that may be difficult as the legs are much bigger than the arms. We often have done the forearm in clinical.
Thank you for your reply!
IV was in the middle of forearm, too low to take BP below the IV site...... So this meant that BP shouldn't be taken on arm at all, right?
So I only have to do legs then?
Is there a specific "time" to do so? I have seen nurses take BP right above IV all the time and nothing happened. So I followed them and did the same and nothing happen....... until now where IV site bleed out. Does it depend on pt or something?
Thank you for your replies!
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
BP cuffs come in different sizes, and you MUST use a properly sized one for whatever limb you use. The same cuff you select for a 100-lb teenaged cheerleader is inappropriate for a 160-lb teenaged football player or a 245-lb office worker. This applies also if you use those stupid automatic cuffs (which have so many technologically-based limitations I can't believe they're still allowed in clinical settings).