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Aug232010

Taking a Fat Woman's Blood Pressure

(A short word about the term "fat." As I use it, it is not a negative, but merely a discriptive adjective. Using euphemisms like "plump," "fluffy," and "full-figured" are much more insulting to me than the word fat. Many of us who've dealt with fat prejudice for way too much time have come to "reclaim" the word fat so it doesn't have the biting sting it once did, especially when hurled as an epithet. If you are terribly uncomfortable with the word, first, look inside and see why... and second, feel free to substitute the euphemism of your choice.)

 

It happened again. 

I went to the doctor for a follow-up appointment and was called into the ante-cubicle-room, sat down and was asked what my "complaint" was. It's always such a funny question to me because it says exactly what I'm there for on the screen in front of her. But, I suppose if the complaint has changed from "ankle pain" to "hair falling out," that would be something to note.

"I'm going to take your blood pressure" as she grabs the cuff, a small one (for my big arm) and heads for my forearm (at least she didn't consider putting it on my upper arm!). "It's not going to fit," I say, yet she continues her forward movement. "It's not going to fit," I repeat -and watch her wrap it around. I didn’t let her get to the Velcro, pulled my arm out and said, more sternly this time, "It's. Not. Going. To. Fit." She huffs a little and has to (oh my god! the difficulty of the chore!) unscrew the small cuff and then, (tell me it isn't so!) has to pick up the large cuff and (argh!) screw it on the cuff thingie.

Knowing my arm (it's really flappy floppy - I really should tattoo the American flag on it or something), even the large cuff dorks out, electronically squeezing the hell out of my flesh, reading, "Good god! What is that under there! I have to do it again." And again. And again. I don't even go there anymore.

Instead, I have the Fake Nurse (the Tech who thinks she owns the hospital) just put the darn thing on my lower arm.

But, can I tell you how many medical people have no idea that that can even be done? A lot of 'em.

I've taken to watching them, amusingly (when I'm bored), try to figure it out. Where does the tubing go? Oh! up where it's supposed to be like the upper arm cuffing (antecubital), right? "It's not reading there, either." sigh (With a manual cuff, I expect a "Hmmm I don't hear anything," but [and I'm not kidding] there are techs that will make up a number instead of admitting they don't know the answer.) No, this is the wrong way to put a cuff on the lower arm.

The Correct Way to put a blood pressure cuff on the lower arm:

Holding the cuff, let the tubing fall towards the floor, the place where the tubing goes into the cuff closest to the floor as well. Then, as you wrap the cuff around the lower arm, the tubing goes over your inner wrist; the tubing can rest in your hand (don't grab it, though!). This can be done with both electric and manual sphygmomanometers (the technical name for the cuff contraption).

Once the cuff is on, the electric cuff can have its button pushed to get it going, no muss no fuss. With the manual cuff, the technician/provider needs to use a stethoscope to listen for the heart/pulse beats.

(An Aside) Sphygmomanometer Tutorial

When we take the blood pressure manually, once the cuff is on securely, we pump it up beyond what we think will be the highest/top/systolic/when the heart squeezes number. I was taught to pump it up to 200mm Hg in fat folks... WAY too tight and high for the fat women I've had in my practice... a nasty assumption that fat women will have high blood pressure. (I have notoriously low blood pressure, so low that, on more than one occasion, the tech thought the cuff was broken!) When I am the pumper-upper, I usually go up to about 170-180mm Hg, then begin the release of pressure.

When we release the pressure, it needs to be done slowly because we’re listening for the thumping of the pulse in the stethoscope (please don’t talk to the person doing your BP; we’re counting.) We’re listening for two things: 1. when the pulse begins (the systolic/upper number) and 2. when the pulse ends (diastolic/lower number). So, say I pump the cuff up to 170mm Hg then release the pressure (with the twisty button) and hear the first thump when the gauge is at 128. The thumping continues, but when the gauge says 72, all of a sudden, the pulse disappears. The person’s BP is 128/74… the 74 being the last number we heard a heartbeat. While we’re doing the blood pressure, we memorize the numbers (repeating them over and over and over) until we write it (the BP number) down. Note the above numbers are all even. It’s not amusing to hear people use odd numbers with manual cuffs because there are no odd number choices. What they are trying to say is: I don’t know what the hell I’m doing. If that happens, ask for someone else to take it.

For typical blood pressure cuff placement, the stethoscope goes right below the cuff at the bend inside of the elbow (antecubital). When putting the cuff on the lower arm, the stethoscope listens inside the wrist (ulnar).

(Aside over)

 In order to get an accurate blood pressure, there are a few “rules.” If any of them are amiss and you are told your BP is high, think about the steps, tell the nurse/aid/doc you want to wait 5 minutes and re-take it again. Then begin the steps.

When they return to do your blood pressure,

  1. MAKE SURE THEY ARE USING THE RIGHT SIZED CUFF!!

This should give you a much more accurate reading.

If a practitioner takes your BP, doesn’t like the number and re-pumps the cuff on the same arm without removing it for awhile, they are doing it incorrectly. That dorky/stupid machine automatically will do the same thing if it doesn’t get a good reading. Ask for a few minutes to rest, without talking, etc., then have them put the cuff on the other arm. If they whine or balk, tough caca; this is your health, in your records. You have a right to have your BP done correctly.

Elevated Blood Pressure Readings During Pregnancy

When the blood pressure is elevated during pregnancy (130/90 is the dividing line, but is arbitrary depending on the person’s baseline… another discussion for another day.), the above steps can be extremely important to do.

For some women, getting their blood pressure done is the most stressful part of their prenatal visits, especially if they are in that borderline or high BP place. If your blood pressure is always higher at the doctor’s or midwife’s office than it is when you take it somewhere else, this is called “White Coat Syndrome” –it has a name it’s so common. The breathing and visualization can help ensure you’re getting an accurate reading. Everyone can practice lowering their blood pressures at will, doing the above steps, with or without having the real BP taken, but these practice sessions can be really important for those with White Coat Syndrome so a diagnosis of hypertension/Pregnancy Induced Hypertenion/Pre-eclampsia is not assumed.

But, what if you’ve done all the steps and it’s still high? The standard of care is to have mom lie on her left side for about 15 minutes before re-taking it, usually with mom still on her left side. This has long been the standard in medicine as well as midwifery. However, I’ve seen a few studies that de-bunk the myth of using the left lateral position’s blood pressure reading as accurate. Perinatologists I’ve spoken to agreed; the practice of putting a mother on her left side, for readings is a false sense of security because the true reading needs to be done with a mom sitting. The issue of left-side bedrest is another issue I’m not going to get into here. This is already too long!

One more short story. In 1993, I fell at a birth center where I was working and went to the ER. The tech, a young guy, took the small cuff and put it on my upper arm. I told him, over and over, it wouldn’t fit, but he kept pumping it up anyway, the cuff’s Velcro noisily unfastened each time. He was getting pissed, so put it on again, roughly, even though I told him to get a large cuff and proceeded to use medical tape (not kidding) to wrap around the cuff to hold it on. He must have used a roll! When he pumped it up, sure as shit, the tape ripped, the cuff fell off –and I started crying. Why I cried because he was the asshole is beyond me, but I wasn’t as “evolved” about fat as I am now. I told him to get his supervisor and when the Nurse came over and saw what he’d done, she was the sweetest and kindest woman, grabbing the large cuff that wasn’t even 2 feet away, talked to me like I was a human and not a blob of flesh and told me she would absolutely correct his behavior as well as explain to him about human dignity for everyone, our prejudices be damned. I hugged her before she walked away.

After that, I realized I had to take the reigns with regards to my fat care; not leave it in the hands of those who should know better. They don’t. But, hey, we can educate them, can’t we! 

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    - Navelgazing Midwife Blog - Taking a Fat Woman's Blood Pressure

Reader Comments (12)

OK, dumb question here. If you put the cuff on the lower arm where do you put your stethoscope to listen?
I have never done it this way.
There were never enough large cuffs around my hospital. When we had a heavy (I think that is the euphemism I am used to) person on the floor, we would be calling Sterile Processing to find out which floor they had last sent one to, calling that floor, finding out that they gave it to another floor, finding out that no one on that floor had any idea, and sending aides all over the hospital to search in clean utility rooms until we found one.
I am sure the ER had several but they didn't have to share.
I am willing to bet that our aides tried to make the regular ones fit.
We also had a problem with needing smaller ones for tiny little old ladies.
Having enough various sized cuffs should probably be a joint commission criteria.

But anyway, I am so used to slipping the stethoscope halfway under the cuff and listening at the antecube that I am not sure where you listen with it on the lower arm. It would have to be below it, wouldn't it? At the wrist? Can you hear it anywhere on the arm below the cuff?

Thanks,
Susan

I said it was a dumb question.

August 25, 2010 | Unregistered CommenterSusan Peterson

Could I make a request? When you get a chance, could you do a photo or three on how to take a lower arm blood pressure? I kinda get it, but I am so totally visual that a picture would be like BAM! that's just exactly it.

Love this entry. :)

-A

August 25, 2010 | Unregistered CommenterAmy

Brava.

I've noticed that some practitioners and some hospitals have become much better in knowing how to deal with fat patients, both clinically and in terms of treating them with due respect.

But we have a long way to go--I hope that this issue will be on the radar screen more and more in med & nursing schools, given the increasing numbers of fat patients.

August 25, 2010 | Unregistered CommenterSquillo

Amy: You bet! I'll get some pics this afternoon. :)

Susan: that was a glaring oversight, not putting where to place the stethoscope. I fixed it... thanks for saying something!

August 25, 2010 | Registered CommenterNavelgazing Midwife

NG. This is excellently succint and accurate. Better than any text book or handout I've had available while teaching Allied Health.


Susan you said:
"But anyway, I am so used to slipping the stethoscope halfway under the cuff and listening at the antecube that I am not sure where you listen with it on the lower arm."

Alarms went off for me. This is not how I understand opr have taught the placement of the cuff. It should be 1.5 to 2 inches above the antecube so that you can place the stethescope without tucking under the cuff. Under the cuff renders and an inaccurate reading and can potentially produce extraneous sounds in the scope.

August 26, 2010 | Unregistered CommenterFree

regarding the term FAT

As a former "skinny/boney/too tall jones" sort, and now "A FAT"as my 7 year old once asked( as in are you a fat mommy), I personally am not prepared for the term fat. Even thick is offensive though obese/morbidly obese while dismal sounding seems to take the edge off for me 'cause it's a clinical term and actually empowers me 'cause I get this BMI scale visual going and actually feel like I can do something.... um like more pilates/yoga to strech my core and inch grow taller and reduce BMI or set a goal and take action steps towardsl lowering the BMI. Yeah right!

"Many of us who've dealt with fat prejudice for way too much time have come to "reclaim" the word fat so it doesn't have the biting sting it once did, especially when hurled as an epithet. If you are terribly uncomfortable with the word, first, look inside and see why... and second, feel free to substitute the euphemism of your choice.)"

I've only delt with the "fat" prejudice about 5 years but the "tall" prejudice has been most of my life like probably since grade school from the teasing to the ill equiped classrooms, clothes, short toilets etc... So to be tall and fat is a double whammy.

My euphenism of choice is "fluffy" silly I know, but sounds gentlier to me, sounds temporary like a fluffy pillow that gets flat etc...

Took a long international flight @ 2 yrs ago and was abhored by the lack of space for my fluffly ass and long legs. I fit in the seat sort of, but boy was I wishing I was in first class. So now being fat will cost me more, much more than just being tall aever cost me.

So thanks for this opprotunity for introspection. I'll go wallow a minute with my mac and cheese (made with 1/2 the chesse and soy substitute) and contemplate what it's really gonna take for me to modify my behaviors to an extent that will keep me from having to "reclaim" the word fat or continually disilluision myself with the word "fluffy".

Sincerely,
BMI 34.8 and scared

August 26, 2010 | Unregistered CommenterFree

I'd love for you to elaborate more about blood pressure. Doctors talk about "gestational hypertension" and I don't know what to believe. What is an appropriate level to want to induce? c-section? bed rest? Tricks to lower it before an appointment?

August 26, 2010 | Unregistered CommenterMeg

How about the part where they check and recheck your blood pressure so much that it fucking hurts (sorry but it does) and then are amused when you ask the cuff be placed on the other arm: "Do you have asymmetrical readings and the other arm reads better?" "No, my arm is hurting and I tend to have high blood pressure when I am in pain."

Sometimes squeezing fat repeatably starts to really sting and pain raises blood pressure which also gives a false reading, and if it happens enough white coat syndrome is really a reaction the pain associated with blood pressure readings.

August 27, 2010 | Unregistered CommenterEthel

I had "white coat syndrome" but approaching my 35th week of pregnancy I had a bp of 150/90 while using a large bp cuff. I was asked to go left lateral for a bit and then the bp retaken after 10min. It was lower. 12 hours ater in L/D triage serial bp every 20min revealed bps ranging from 120-170/ 80-100. I was induced for preeclampsia and HELLP. I think the left lateral stuff is nonsense as a result.
At the same time I was taught that you keep your preeclamptics on their sides to lower bps during the induction and 24hour postpartum magnesium sulfate therapy.
Which is right?

August 27, 2010 | Unregistered CommenterL/D nurse

Also feeling dumb here. What/where are the five rules or steps you mention? I couldn't find them at the link in that paragraph. Help?

August 30, 2010 | Unregistered CommenterTO Doula

They have to use the extra small cuff with me. :p It's amusing watching them figure that out, too. I think the first few reads with a too-big cuff tell them I'm dead or something. :p

August 30, 2010 | Unregistered CommenterSara

I work as an EMT and I use this method all the time to take blood pressures as in th field people are wearing heavy sweatshirts, coats etc and when they have severe injury and I need a baseline blood pressure before extrication has happened using the forearm is WAY easier and accurate! I think that this should be taught to nurses and EMTs always!!

March 17, 2012 | Unregistered CommenterMiz Angie

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