I accompanied the District Nursing Team on placement to a Doppler Clinic for patients referred by their GPs to be assessed for compression bandages. I was talked through the procedure of performing Ankle Brachial Pressure Index (ABPI), which required the following equipments: Hand-held Doppler ultrasound machine; 8 MHz probe (5 MHz probe if required for large or oedematous limbs); ultrasound transducer gel; sphygmomanometer and cuff and cling film/vapour-permeable film dressing or equivalent.
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I was then asked to carry out the task with another nurse. I washed my hands, put on my gloves and apron. I raised the bed to my level so I could reach him. Seeking her consent, I asked the patient to remove any tight articles of clothing, which may cause pressure on the blood vessels proximal to the site where the blood pressure is being measured.
I measured the brachial systolic blood pressure by selecting a sphygmomanometer cuff of an appropriate size and wrapped it around the patient’s upper arm just above the elbow. I palpated the brachial pulse and applied ultrasound gel. I angled the Doppler probe at 45 degrees to the direction of the blood flow (towards the heart) and adjusted the position to locate the best signal. The Doppler emitted an audible signal and inflated the sphygmomanometer cuff until the signal disappeared. I then deflated the cuff slowly and recorded the pressure at which the signal returned. I repeated this procedure using the patient’s other arm. I continued this procedure in measuring the ankle systolic pressure by palpating the posterior tibial artery and that of either the anterior tibial or peroneal artery. I then used the higher of these two readings to calculate the ABPI using the following equation:
ABPI = highest ankle systolic pressure/highest brachial systolic pressure. I then recorded and explained the results to the patients. I thanked the patient for her cooperation.
Feelings
Due to the fact that I had never completed a Doppler observation before, I felt extremely anxious and uneasy. These feelings were made greater as I became more aware of being judged; not only by my mentor and other nurses but also by the patients most of whom came with their spouses. I felt the pressure more as there were other patients waiting to be seen and taking up too much time may delay them. In spite of these, I preserved and completed the task.
Evaluation
Throughout this procedure I really concentrated and made sure no interruptions took place as I can miss the sphygmomanometer sounds. I actually couldn’t get the first sphygmomanometer sounds on my first attempt so I explained to the patient and gained permission again to take the recording to which she agreed, I felt self-conscious and nervous as I had missed the first sphygmomanometer sounds but very pleased when I did manage to get the recording a second time. I feel I have gained a learning skill. The more Doppler recordings I took made me soon realised that no two patients were the same. I also learned that different factors can affect blood pressure, from the patient rushing in late for his appointment which can lead to elevated blood pressure. It has also given me a lot of confidence in myself as I improved my communication skills.
Analysis
An ABPI is a simple non-invasive method of identifying arterial insufficiency within a limb. It compares the ankle and brachial systolic blood pressures. A slight drop in the blood pressure in the legs can be an indicator of peripheral vascular disease. Peripheral vascular disease refers to blockage of arteries. Basically, as compared to the arms, low blood pressure in the lower part of legs can be an indicator of a serious health. In the management of leg ulcers, the ABPI forms a fundamental part of the assessment. Accurate assessment is necessary to determine the correct aetiology of the ulcer and exclude those patients with arterial disease for whom compression is dangerous (Stacey et al, 2002).
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In normal circumstances, the blood pressure in the lower leg area is a bit more than that at the elbow. Where an ABPI is greater than 0.9, it is supposed to be normal and holds no risk of peripheral vascular disease. If the ABPI value is more than 1.3, it is an indicator of severe peripheral vascular disease. If the patient is unable to lie flat, the legs will be elevated to the level of the heart. By elevating the legs, the hydrostatic pressure to the legs is reduced.
In order to prevent cross-infection the Doppler probe should be cleaned twice with an alcohol impregnated wipe prior to its use (Kibria et al, 2002). It should be noted that the ABPI should not be undertaken in isolation, but should be used in conjunction with a holistic assessment, and a medical and clinical examination of the limb.
Conclusion
There is controversy about the circumstances in which an ABPI should not be performed, so more research is required. It has been suggested that an ABPI should not be performed if the patient has a suspected deep vein thrombosis, because there is a risk of emboli; or the patient has cellulitis; or because the procedure would be too painful; or the patient has severe ischemia; or because there is a risk of further tissue damage.
Action Plan
As an inexperienced learner, I hope to read more about Doppler and ABPI. I believe having an underpinning knowledge in the procedure for taking Doppler blood pressure helps to understand the theory behind the practice. I aim to do more at any given opportunity in terms of, patient anxiety; incorrect positioning of the patient; incorrect size of sphygmomanometer cuff; putting excessive pressure on the blood vessel during the procedure; releasing the sphygmomanometer cuff from the patient too quickly; prolonging inflation of the sphygmomanometer cuff or repeated inflation; and moving the Doppler probe during the procedure.
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