Having trouble hearing one of my pt blood pressure.

Usually I dont have a problem with hearing my patients BP.But I have this particular patient older (87),he is very skinny,it is nearly impossible to feel his pedal pulses and also it is very hard to feel his brachial pulse.Although the radial one I can feel with out no problem.Any suggestions how to listen better for his BP?! Also he is not on any blood pressure meds,he gets constipated (which I think may increase BP) and his heart rate is on the low side (50) I have an awsome stetoscope (LITMANN) .I also do not feel at ease cause his caregiver always watches me when I take the BP. Any suggestions.
I'm sure that you've tried both arms. If you have a doppler, you should have no trouble measuring the BP. But, I suppose that you do not, so use palpation to determine the approximate systolic reading and then when you're using your stethoscope, deflate slowly and listen carefully when you get near that range.

I have a Littman too, but the funny part is when I've used cheapy ones (like for isolation pts) I've heard sounds louder...it's weird.

Don't know if this will help at all. I also have a Littman and what I do is be sure not to add any "noise" as I hold the bell to the brachial. I hold the bell there in place with my first and second finger and brace the forearm by wrapping the remaining fingers/thumb around it. I kind of rest that hand/wrist on the patients forearm. This goes far to quiet any movement/vibrations so that I hear only the beat.

Some pts are just plain hard to auscultate no matter what. Besides a quiet environment, try different handholds on the bell/pt's arm. Also, try the suggestion from above about palpating where the beat starts as the cuff deflates. You may also try a different position with the pt. I've had some who I just couldn't hear until they laid almost flat on the couch/bed. Manipulate your environment however you wish. You might also try one of those el-cheapo steths, cuz they're great for basic stuff like this. They seem to really make EVERYTHING louder, from the skin-to-bell contact and on to the actual beating sound. Good Luck! As for the caregiver watching you. Some people are just really strange. Or perhaps she's curious b/c she doesn't really know how it's done? Or maybe she's one of those "But the OTHER nurse did it THIS way" type people. Ignore her. You're the professional.