Trouble getting BP cuffs on patients during rideout

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JamesW

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On my second rideout as a student, I was having a little trouble getting the BP cuff on a couple patients. They are so awkward, especially when the patient's arm is pinned under their body or when they are old and their arm looks fragile to the point where I am reluctant to use force to get their arm in position to where I can get the cuff on. How long does it take to become proficient in putting the cuff on? It also hard for me to hear the pulse in the back of an ambulance driving code 3.

My preceptor was scoffing at my inability to put the cuff on. I am guessing that he assumed that I made the numbers up when I finally managed to palpate the patients BP. It was actually very frustrating for me. Later on during the day I was asking him questions about Arrhythmias and he told me something along the lines of "why are you asking me questions about QRS complexes when you can't even put the cuff on the patient?" It sort of dampened my enthusiasm for the rest of the day.
 
It's an easy thing but obviously you need to do it a handful of times before you stop being awkward about it. It's the same with literally everything in the world - the first few times you do anything you're going to fumble around. Just watch how other people do things, try to learn from them, and think about what you'll do differently next time. That applies to moving the stretcher around, talking to patients, radio communications, triage reports, paperwork, etc. Your goal shouldn't be perfection on the first try, it should be to never make the same mistake twice.

I always say, "can I borrow this arm for a moment?" or "do they usually take blood pressures on the left or right?" I like to ask the patient as sometimes they will have a fistula or previous mastectomy or something and you shouldn't take a BP on a certain side. It also prompts them to lift the arm up for you and makes it easier. You shouldn't really be wrenching their arm around to get a BP cuff on.

Just fyi, you can usually put the cuff on over a shirt. The puffier the shirt/jacket the less I trust the numbers, but you can do it and either listen or palpate. Also don't be afraid to just go right to palpating a BP when you're in the back and the truck is moving. If you have the time you may as well practice listening, but meh. I usually like to auscultate a BP once we're in the truck but before we start moving.

Sorry that your preceptor was kind of a jerk - hopefully you have a different one next time? Some people love to teach, most don't. Try not to take it personally. Things will get better once you become a little more competent and get out of 3rd riding.



I think the best advice I could give to any new person is to practice your radio reports and triage reports... If you can sound competent calling a report over the radio or giving report to the ED staff it will go a long way. Figure out how you want to do them, and then practice by yourself in the car or wherever. Make a mental note of any calls you've done, and then practice giving the reports over and over until you can do them perfectly.
 
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It's something that just takes practice. You'll get all sorts of patients of all sorts of body types, and you'll eventually figure out how to manage the fragile arms and the arms with skin drooping 6 inches. I too had the same issue of doing BPs extremely carefully, to the point where I have actually had patients comment during the process, "You're so gentle". Talk about funny looks from teammates. I usually start off gentle now, but have learned to register whether or not it is going to happen, and from there I will be a bit more assertive. Honestly the only thing you should really be worried about is abrading a fragile-skinned patient with the velcro, which is easily avoidable if you're paying attention. Oh, and not doing BPs on the injured side is a good start too.

Also, I agree with Gurby in that a cuff can go over a shirt (I wouldn't auscultate over the shirt, mainly because I've never tried though). I'll do maybe 2 or 3 layers of shirts or a thin sweater, but any jackets are coming off or at least being rolled up.
 
JamesW said:
I am guessing that he assumed that I made the numbers up when I finally managed to palpate the patients BP.
Click to expand...

Hopefully you meant number, as you can't get a diastolic pressure through palpation.
I once worked with a woman who claimed that you could get one by recording when the needle stopped oscillating, and was actually doing this and telling patients their S and D pressures through palpation.
 
Also, make use of the pedi and thigh cuffs... The pedi one is often a better fit for little old ladies with tiny arms, and the thigh cuff is often a better fit for the larger patients.


Underoath87 said:
Hopefully you meant number, as you can't get a diastolic pressure through palpation.
I once worked with a woman who claimed that you could get one by recording when the needle stopped oscillating, and was actually doing this and telling patients their S and D pressures through palpation.
Click to expand...

Good catch, yeah.
 
Underoath87 said:
Hopefully you meant number, as you can't get a diastolic pressure through auscultation.
Click to expand...

When auscultating:
Systolic Pressure - When you hear beats
Diastolic Pressure - When you stop hearing beats.

Only able to gauge systolic when palpation.
 
It’s a little easier to auscultate the BP in a moving ambulance if you lift your feet off the floor. Try to place your feet up on the stretcher crossbars. It just takes practice. When you have time during a transport, practice on a patient even when you don’t really need to get their BP.
 
gotshirtz001 said:
When auscultating:
Systolic Pressure - When you hear beats
Diastolic Pressure - When you stop hearing beats.

Only able to gauge systolic when palpation.
Click to expand...

Yeah, I caught my slip up (obviously meant palpation) and edited right after.
 
Underoath87 said:
Hopefully you meant number, as you can't get a diastolic pressure through palpation.
I once worked with a woman who claimed that you could get one by recording when the needle stopped oscillating, and was actually doing this and telling patients their S and D pressures through palpation.
Click to expand...

I did. I took 2 sets of palpated BPs and He looked at me like I made the numbers up.
 
Hey JamesW. Don't beat yourself up everyone was new and had to get used to the flow of pt assessment and care. This is likely to be one of many things you stumble a bit over. Remember it's not going to hurt anyone to move their limbs for a b/p as long as you are not being absurdly forceful. Try and be gentle but purposeful in your assessment and actions. I think a lot of new folks are a little gunshy about actually touching patients. Most preceptors want to see you showing initiative and becomming more comfortable with taks as you go along. It's also easy to get hung up on aspects of your care you feel are lacking. If you need more education or assistance that is one thing, but if not just go ahead and give it your best shot. If you can't hear the b/p just admit it and try again or have another provider take a listen. If you find that you put on the cuff awkwardly , take a deep breath and fix it. The worst thing in emergency care is to become rattled lose your sense of perspective and ability to prioritize treatment decisions as well as recognize whan an approach or intervention is not working and needs to be altered. Best of luck.
 
Get a nice stethoscope . Get a cheap stethoscope and a cheap bp cuff. Practice taking blood pressures on your friends, family, classmates etc. Use the cheap stethoscope to practice with .. If you can get good using a cheap one it will benefit you down the road. When you are in the ambulance or on a call pull out your nice stethoscope. If you can't get a good bp after 1 try on a call just do one over palpation. Just say " hey I'm having trouble hearing a bp, but I got ---/p". They will trust you if you are honest.
 
I'm glad this topic was brought up, I start ride time next week and it's been one of my fears.

I asked a classmate how taking a manual BP went for him on his ride time and his only response was hard at first so I'm surprised the preceptor was giving the OP a hard time when it sounds like a common problem.
 
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