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Pulse

Assessing radial pulse rate

Assessing the rhythm, strength, and rate of a patient’s peripheral pulse provides valuable information about the cardiovascular system. The rhythm of the pulse is usually regular, reflecting the time interval between each heartbeat. The strength of the pulse correlates with the volume of blood being ejected against the arterial walls with each contraction of the heart. Pulse strength is usually described as absent, weak, diminished, strong, or bounding. If blood volume decreases, the pulse is often weak and difficult to palpate. If blood volume increases, the pulse is often bounding and easy to palpate.

Although peripheral pulses are palpable at a variety of body sites, the radial pulse is the easiest to access and is therefore the most frequently checked peripheral pulse. Assessment of other peripheral sites, such as the carotid or femoral pulses, is not usually part of routine vital-sign measurement. Clinicians typically access these sites when performing a complete physical examination. When they cannot palpate peripheral pulses, they use a Doppler ultrasound stethoscope to confirm the presence or absence of the pulse.

A normal adult pulse rate ranges from 60 to 100 beats per minute. It is usually slightly faster in women and more rapid in infants and children. In addition to gender and age, exercise, medications, decreased oxygen saturation, blood loss, and body temperature can all influence a patient’s pulse rate. When assessing pulse, it is important to find out what a normal rate is for that particular patient.

A pulse rate slower than 60 beats per minute is called bradycardia. Conditions such as decreased thyroid activity, hyperkalemia, an irregular cardiac rhythm, and increased intracranial pressure can all slow the heart rate. Many athletes who do a lot of cardiovascular conditioning have pulse rates in the 50s and experience no problems.

A pulse rate faster than 100 beats per minute is called tachycardia. Conditions such as congestive heart failure (CHF), hemorrhage, shock, dehydration, and anemia can all speed up the heart rate. Patients who have tachycardia might experience dyspnea, fatigue, chest pain, palpitations, and edema.

An abnormally irregular, weak, slow, or rapid pulse, especially if sustained, might mean that the heart cannot function properly and requires further evaluation.

1. The radial pulse is easy to find and is the most frequently checked peripheral pulse.
2. To check the radial pulse with the patient supine, position the patient's arm along the side of the body or across the upper abdomen with the patient's wrist relaxed.
3. Apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the patient's inner wrist.

Be careful not to apply too much pressure, as this can impair blood flow.
4. If the pulse is regular, count for 30 seconds, then multiply that number by 2.

If the pulse is irregular, count for 1 full minute.



Palpate a patient's pulse to determine circulation distal to the pulse site and for rhythm, quality, and strength. Is it normal, weak or thready, full or bounding, or absent?

Perform hand hygiene before and after patient care and document your findings on the appropriate flow sheet or record.

Assessing apical pulse rate

Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Each pulsation you hear is a combination of two sounds, S1 and S2. S1 is the sound you hear when the tricuspid and mitral valves close at the end of ventricular filling and just before systolic contraction begins. S2 is the sound you hear when the pulmonic and aortic valves close at the end of systolic contraction.

When determining an apical pulse, it is important to use anatomical landmarks for correct placement of the stethoscope over the apex of the heart so that you can hear the heart sounds clearly. If the apical rate is regular, you can usually determine an accurate rate in 30 seconds. When the apical pulse is irregular, it is best to count for at least 1 minute to obtain an accurate rate.

1. Determining an apical pulse involves locating the point of maximal impulse (PMI), placing the bell or diaphragm of your stethoscope at this site, and listening for 1 minute.
2. Expose the patient's sternum and the left side of the chest.
3. Locate the PMI. Slide your fingers down each side of the angle of Louis to the second intercostal space.

4. Move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line and the PMI.
5. Place the diaphragm of your stethoscope over the PMI and auscultate for normal S1 and S2 heart sounds. You will usually hear them as "lub-dub." If the apical pulse is regular, count for 30 seconds, then multiply that number by 2. If the apical pulse is irregular or the patient is taking cardiovascular medications, count for 1 full minute to ensure an accurate measurement.



Use the apical pulse when the patient has a history of heart-related health problems or is taking cardiovascular medications. Count the apical pulse rate while the patient is at rest. If the patient has been active, wait at least 5 to 10 minutes before beginning.

Assessing pulse deficit

A pulse deficit occurs when the heart contracts inefficiently and does not transmit a pulse wave to a peripheral site. Pulse deficits are often associated with irregular cardiac rhythms and can be a sign of alterations in cardiac output.

To assess for a pulse deficit, you will need another healthcare worker. One person assesses the peripheral pulse rate while the other person assesses the apical pulse rate. Compare the two rates; the difference between the two is the pulse deficit, which reflects the number of ineffective cardiac contractions in 1 minute. If you find a pulse deficit, assess the patient for other signs and symptoms of decreased cardiac output, such as dyspnea, fatigue, chest pain, and palpitations.

1. To determine the pulse deficit, take the radial and the apical pulses simultaneously.
2. Position the patient either in a supine or a sitting position and expose the patient's sternum and the left side of the chest.
3. Using the appropriate anatomical landmarks, locate the radial and the apical pulses.
4. Start counting on command and count the pulse rates simultaneously for 1 full minute. Stop counting on command.
5. To calculate the pulse deficit, subtract the radial pulse rate from the apical pulse rate.



Count the apical pulse rate while the patient is at rest. If the patient has been active, wait at least 5 to 10 minutes before beginning. To calculate the pulse deficit, subtract the radial pulse rate from the apical pulse rate.

References

Duell, D. J., Martin, B. C., & Smith, S. F. (2004). Clinical nursing skills: Basic to advanced skills (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc. pp. 235-270.

Jarvis, C. (2004). Physical examination and health assessment (4th ed.). St. Louis, MO: Elsevier-Saunders. pp. 179-198.

Perry, A. G., & Potter, P. A. (2006). Clinical nursing skills and techniques (6th ed.). St. Louis, MO: Elsevier Mosby. pp. 487-535.