PULSE MEASUMENT
The ejection of blood from the heart distends the walls of the aorta. Because of the
force of the blood exiting the heart aortic distention creates a pulse wave that travels
rapidly toward the extremities. When the pulse wave reaches a peripheral artery, it can
be felt by palpating the artery lightly against underlying bone or muscle. The pulse is the
palpable bounding of the blood flow. The number of pulsing sensa-linns occurring in 1
minute is the pulse rate.
Assessing the client's peripheral pulse sites offers valuable data for determining the
integrity of the cardiovascular system. Pulse rate, rhythm, and strength indirectly
evaluate the heart's cardiac output (CO). An abnormally slow, rapid, or irregular pulse
may indicate the heart's inability to deliver an adequate cardiac output; a pulse
deficit may be present. The strength or amplitude of a pulse reflects the volume of
blood ejected against the arterial wall with each heart contraction, also called stroke
volume (SV). If the heart's stroke volume decreases, the pulse often becomes weak
and difficult to palpate. In contrast, a full bounding pulse is an indication of
increased stroke volume.
The integrity of peripheral pulses indicates the status of blood perfusion to the area
distributed by the pulse. For example, assessment of the right femoral pulse
determines whether blood flow to the right leg is adequate. If a peripheral pulse distal
to an injured or treated area of an extremity feels weak on palpation, the volume of
blood reaching tissues below the affected area may be inadequate and surgical
intervention may be needed.
The radial artery pulse is the most common peripheral site for pulse rate
assessment. The carotid artery site is also commonly used when the radial pulse is
weak or difficult to palpate. Assessment of other peripheral pulse sites, such as the
brachial or femoral artery, is unnecessary when routinely obtaining vital signs. Other
peripheral pulses are assessed when a complete physical is conducted or when the
radial artery is not available for assessment because of surgery, trauma, or impaired
blood flow.
Temporal
Over temporal bone of the head, above and lateral to the eye
Carotid
Along medial edge of sternocleidomastoid muscle in the neck
Apical
Fourth to fifth intercostal space at left midclavicular line
Brachial
Groove between biceps and triceps muscles at the antecubital fossa
Radial
Radial or thumb side of forearm at the wrist
Ulnar
Ulnar side of forearm at the wrist
Femoral
Below the inguinal ligament, midway between
symphysis pubis and anterior superior iliac spine
Popliteal
Behind the knee in popliteal fossa
Posterior tibial
Inner side of each ankle, below medial malleolus
Dorsalis pedis
Along top of foot between extension tendons of great and first toe.
Before delegating this skill the nurse must:
• Inform assistive personnel of client history or risk for ab
normally slow, rapid, or irregular pulse
• Provide assistive personnel the frequency of pulse mea
surement for select client
• Determine that assistive personnel are aware of the
client's usual baseline pulse rate
• Instruct assistive personnel to report any abnormalities
that should be reconfirmed by the nurse
• Wristwatch with second hand or digital display
• Pen, pencil, vital sign flow sheet or record form
ASSESSMENT OF RADIAL PULSE
1. Determine need to assess radial pulse:
a. Note risk factors for alterations in pulse.
b. Assess for presence of dyspnea, fatigue, chest pain, orthopnea, syncope,
palpitations (person's unpleasant awareness of heartbeat), jugular venous
distention, edema of dependent body parts, cyanosis or pallor of skin
c. Assess for signs and symptoms of peripheral vascular disease such as pale,
cool extremities; thin, shiny skin with decreased hair growth; thickened nails.
2. Assess for factors that influence radial pulse rate and rhythm: age, exercise,
position changes, fluid balance, medications, temperature, sympathetic
stimulation.
3. Determine client's previous baseline pulse rate from client's record.
1. Perform hand hygiene.
2. If necessary, draw curtain around bed and/or close door.
3. Assist client with assuming a supine or sitting position.
4. Explain to client that radial pulse rate (HR) is to be assessed. Encourage client to
relax as much as possible. If client has been active, wait 5 to 10 minutes before
as sessing pulse.
5. Expected outcomes following completion of procedure:
• Radial pulse is palpable, within acceptable range for client's age.
• Rhythm is regular.
• Radial pulse is strong, firm, and elastic.
A history of peripheral vascular disease, a history of heart disease, cardiac
dysrhythmia, onset of sudden chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of large volume of intravenous
(IV) fluid, internal or external hemorrhage, or administration of medications can
alter pulse rate and quality.
Physical signs and symptoms may indicate alteration in cardiac function, which
affects radial pulse rate and rhythm. Physical signs and symptoms may
indicate alteration in local arterial blood flow. Allows nurse to accurately
assess presence and significance of pulse alterations Allows nurse to assess
for change in condition.
If client is supine, place client's forearm straight alongside or across lower chest or
upper abdomen with wrist extended straight .
If client is sitting, bend client's elbow 90 degrees, and support lower'arm on chair or
on nurse's arm. Slightly extend or flex wrist with palm down until strongest pulse is
noted. Place tips of first two or middle three fingers of hand over groove along radial
or thumb side of client's inner wrist.
Relaxed position of lower arm and extension of wrist permits full exposure of artery
to palpation.
Finger tips are most sensitive parts of hand to palpate arterial pulsation. Nurse's thumb
has pulsation that may interfere with accuracy.
6. Lightly compress against radius, obliterate pulse initially, and then relax
pressure so pulse becomes easily
palpable.
7. Determine strength of pulse. Note whether thrust of vessel against fingertips is
bounding, strong, weak, or thready.
8. After pulse can be felt regularly, look at watch's second hand and begin to count
rate: when sweep hand hits
number on dial, start counting with zero, then one, two, and so on.
9. If pulse is regular, count rate for 30 seconds and multiply total by 2.
10. If pulse is irregular, count rate for a full 60 seconds. Assess frequency and
pattern of irregularity.
11. When pulse is irregular, compare radial pulses bilaterally.
12. Assist client in returning to comfortable position.
13. Discuss findings with client as needed.
14. Perform hand hygiene.
Pulse is more accurately assessed with moderate pressure. Too much pressure occludes
pulse and impairs blood flow.
Strength reflects volume of blood ejected against arterial wall with each heart
contraction.
Rate is determined accurately only after nurse is ensured pulse can be palpated. Timing
begins with zero. Count of one is first beat palpated after timing begins.
A 30-second count is accurate for rapid, slow, or regular pulse rates.
Inefficient contraction of heart fails to transmit pulse wave, interfering with CO,
resulting in irregular pulse. Longer time period ensures accurate count.
A marked inequality may indicate arterial flow is compromised to one extremity and
action should be taken.
Promotes comfort and sense of well-being.
Promotes participation in care and understanding of health
status. Reduces transmission of microorganisms.
1.If pulse is assessed for the first time, establish radial
pulse as baseline if it is within acceptable range.
2.Compare pulse rate and character with client's previous
baseline and acceptable range for client's age.
1. Pulse rate for an adult is over 100 beats per minute (tachycardia).
2. Weak or difficult to palpate radial pulse.
3. Pulse rate for an adult is under 60 beats per minute (bradycardia).
' Identify related data, including pain, fear or anxiety, recent exercise, low BP, blood
loss, elevated temperature, or inadequate oxygenation.
•
Observe for symptoms associated with abnormal cardiac function:
• Dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, jugular vein
distention, edema of body parts,
cyanosis or pallor of the skin
•
Observe for symptoms associated with altered tissue perfusion:
• Pallor
• Cyanosis
• Cold extremity
•Assess for swelling in surrounding tissues or any en cumbrance (e.g., dressing or
cast) that may impede blood flow.
•Obtain Doppler or ultrasound stethoscope to detect lowvelocity blood flow.
•Assess both radial pulses, and compare findings.
•Have another nurse assess pulse.
•Auscultate the apical pulse.
•Confer with physician, and be prepared to order/obtain
an electrocardiogram.
•Auscultate the apical pulse (see Skill 17-3).
•Assess for pulse deficit (see Box 17-5).
• Clients taking certain prescribed cardiotonic or antidysrhythmic medications should
learn to assess their own
pulse rates to detect side effects of medications. Clients un dergoing cardiac
rehabilitation should learn to assess their
own pulse rates to determine their response to exercise.
• Monitoring carotid pulse rate is taught to clients taking heart medications or starting a
prescribed exercise regimen.
• An accurate pulse can be taken radially in children over 2 years of age
(Hockenberry and others, 2003).
• Children often have a sinus dysrhythmia, which is an irregular heartbeat that
speeds up with inspiration and
slows down with expiration. Breath holding in a child af fects pulse rate.
• It is often difficult to palpate the pulse of an older adult or obese client. A Doppler
ultrasound stethoscope pro
vides a more accurate reading.
• The arteries of an older adult may feel stiff and knotty because of decreased
elasticity.
The older adult has a decreased heart rate at rest (Ebersole and Hess, 2001).
Once elevated, the pulse rate of an older adult takes longer to return to normal
resting rate (Lueckenotte Each ventricular contraction of the heart ejects approximately 60 to 70 ml (stroke volume) of blood into the aorta. The heart rate is the
number of ejections occurring in 1 minute. The volume of blood pumped by the heart
during 1 minute is the cardiac output. The cardiac output equals the product of the
amount of blood pumped by the ventricle per stroke, or the stroke volume, and the
heart rate for 1 minute. The apical pulse is the most reliable noninvasive way to assess cardiac function. The apical pulse rate is the assessment of the number and
quality of apical sounds in 1 minute. Each apical pulse is the combination of two
sounds, Si and S2. Si is the sound of the tricuspid and mitral valves closing at the end
of ventricular filling, just before systolic contraction begins. S2 is the sound of the
pulmonic and aortic valves closing at the end of the systolic contraction.
A stethoscope is used to auscultate sound waves of the apical pulse (Figure 17-7).
It is a closed cylinder that amplifies sound waves as they reach the body's surface.
The five major parts of the stethoscope are the earpieces, binaurals, tubing, bell, and
diaphragm.
The plastic or rubber earpieces should fit snugly and comfortably in the nurse's
ears. Binaurals should be angled and strong enough so the earpieces stay firmly in
place without causing discomfort. The earpieces follow the contour of the ear canal,
pointing toward the face when the stethoscope is in place.
The polyvinyl tubing should be flexible and 30 to 40 cm (12 to 18 inches) in
length; longer tubing decreases sound transmission. The tubing should be thick
walled and moderately rigid to eliminate transmission of environmental noise and to
prevent kinking.
The chestpiece consists of a bell and diaphragm that are rotated into position
depending on which part the nurse chooses to use. To test, lightly tap to determine
which side is functioning.
The diaphragm is positioned to make a tight seal against the client's skin. Enough
pressure is exerted to complete the seal and should leave a temporary red ring on the
client's skin when the diaphragm is removed.
The bell is the cone-shaped portion of the chestpiece usually surrounded by a rubber ring
to avoid chilling the client. It transmits low-pitched sounds created by the low-velocity
movement of blood. The bell is held lightly against the skin for sound amplification
Often the apical pulse is measured when the nurse suspects an irregularity in the radial
pulse or the client's condition warrants a more accurate assessment. In this situation,
delegation of pulse assessment is inappropriate. When measurement of apical pulse is a
routine practice, it can be delegated to assis7 tive personnel. Before delegating this skill
the nurse must:
• Inform assistive personnel of client history or risk for ab
normally slow, rapid, or irregular pulse
• Provide assistive personnel the frequency of pulse mea
surement for select client
• Determine that assistive personnel are aware of the
client's usual baseline pulse rate
• Instruct assistive personnel to report any abnormality in
rate or rhythm that should be reconfirmed by the nurse
1. Determine need to assess apical pulse:
a. Note risk factors for alterations in apical pulse.
b. Assess for signs and symptoms of altered stroke volume and cardiac output
such as dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, jugular
venous distention, edema of dependent body parts, cyanosis or pallor of skin.
2. Assess for factors that normally influence apical pulse
rate and rhythm:
a. Age
b. Exercise
c. Position changes
d. Medications
e. Temperature
f. Sympathetic stimulation
3. Determine previous baseline apical rate (if available) from client's record.
□ Stethoscope
□ Wristwatch with second hand or digital display
□ Pen, pencil, vital sign flow sheet or record form
3 Alcohol swab
□ Certain conditions place clients at risk for pulse alterations: heart disease,
cardiac dysrhythmias, onset of sudden chest pain or acute pain from any site,
invasive cardiovascular diagnostic tests, surgery, sudden infusion of large volume
of IV fluid, internal or external hemorrhage, and administration of medications that
alter heart function.
Physical signs and symptoms may indicate alteration in cardiac output or stroke
volume.
Allows nurse to accurately assess presence and significance of pulse alterations.
Infant's heart rate at birth ranges from 100 to 160 beats per minute at rest; by age 2,
pulse rate slows to 90 to 140 beats per minute; by adolescence, rate varies between
60 and 90 beats per minute and remains so throughout adulthood; no changes occur
in older adults at rest and in absence of disease.
Physical activity requires an increase in CO that is met by an increased HR and SV; a
well-conditioned client may have a slower-than-usual resting HR and returns more
quickly to resting rate after exercise.
Heart rate increases temporarily when changing from lying to sitting or standing
position.
Antidysrhythmics, sympathomimetics, and cardiotonics affect rate and rhythm of
pulse; large doses of narcotic analgesics can slow HR; general anesthetics slow HR;
central nervous system stimulants such as caffeine can increase HR.
Fever or exposure to warm environments increases HR; HR declines with
hypothermia.
Emotional stress, anxiety, or fear results in stimulation of the sympathetic nervous
system, which increases HR.
Allows nurse to assess for change in condition. Provides comparison with future
apical pulse measurements.
PLANNING
1. Expected outcomes following completion of procedure:
• Apical heart rate is within acceptable range.
• Rhythm is regular.
3.Explain to client that apical pulse rate is to be assessed. Encourage client to relax
as much as possible. Ask
client not to speak while assessing pulse. If client has been active, wait 5 to 10
minutes before assessing pulse
1. Perform hand hygiene.
2. Draw curtain around bed and/or close door.
3. Assist client to supine or sitting position. Move aside bed linen and gown to expose
sternum and left side of chest.
4. Locate anatomical landmarks to identify the point of maximal impulse (PMI),
also called the apical impulse. Heart is located behind and to left of sternum with
base at top and apex at bottom. Find Angle of Louis just below suprasternal notch
between sternal body and manubrium; it can be felt as a bony prominence. Slip
fingers down each side of angle to find second intercostal space (ICS). Carefully
move ringers down left side of sternum to fifth ICS and laterally to the left
midclavicular line (MCL). A light tap felt within an area 1 to 2 cm (!/2 to 1 inch) of
the PMI is reflected from the apex of the heart.
5. Place diaphragm of stethoscope in palm of hand for 5 to 10 seconds.
6. Place diaphragm of stethoscope over PMI at the fifth ICS, at the left MCL, and
auscultate for normal Si and
S2 heart sounds (heard as "lub-dub").
7. When Si and S2 are heard with regularity, use watch's second hand and begin to
count rate: when sweep hand
hits number on dial, start counting with zero, then one, two, and so on.
8. If apical rate is regular, count for 30 seconds and multiply by 2.
9. If heart rate is irregular, or client is receiving cardiovas cular medication, count for
a full 1 minute (60 seconds).
10. Note regularity of any dysrhythmia (S, and S2 occurring early or late after
previous sequence of sounds; e.g.,
every third or every fourth beat is skipped).
11. Replace client's gown and bed linen; assist client in returning to comfortable
position.
12. Discuss findings with client as needed.
13. Perform hand hygiene.
14. Clean earpieces and diaphragm of stethoscope with al cohol swab routinely after
each use.
. Normal sounds S,
and S2 are high pitched and best heard with the diaphragm. Apical rate is determined
accurately only after nurse is able
to auscultate sounds clearly. Timing begins with zero.
Count of one is first sound auscultated after timing begins.
Regular apical rate can be assessed within 30 seconds.
Irregular rate is more accurately assessed when measured over longer interval.
Regular occurrence of dysrhythmia within 1 minute may indicate inefficient contraction
of heart and alteration in cardiac output.
Restores comfort and promotes sense of well-being.
Promotes participation in care and understanding of health status.
1. If pulse is assessed for the first time, establish apical rate as baseline if it is
within an acceptable range.
2. Compare apical rate and character with client's previous baseline and
acceptable range of heart rate'for
client's age.
Critical Decision Point
If apical rate is abnormal or irregular, repeat measurement or
have another nurse conduct measurement. Original
measurement may result from error by assessor. Second
measurement confirms initial findings of abnormal HR.
Recording and Reporting
• Record apical rate and rhythm on vital sign flow sheet (see Figure 17-5), record,
or nurses' notes.
• Record any signs or symptoms of alterations in CO in nurses' notes.
• Report abnormal findings to nurse in charge or physician.
Apical rate over 100 (tachycardia).
2. Apical rate under 60 (bradycardia).
3. Irregular apical rhythm indicating a potential for inefficient ventricular ejection
and poor CO.
4. Occasional premature ventricular contractions (PVCs) are common in most
persons. However, frequency of PVCs increases with heart disease. Nurse will hear
premature sequence of S t and S2 and then short pause before normal Si and S2 return.
•Identify related data, including pain, fear or anxiety, recent exercise, low BP, blood
loss, elevated temperature
or inadequate oxygenation.
•Observe for symptoms associated with abnormal cardiac function.
• Dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, jugular vein
distention, edema of body parts, cyanosis or pallor of the skin.
•
Observe for symptoms associated with altered tissue perfusion.
• Pallor
• Cyanosis
• Cold extremity
•Have another nurse assess apical pulse.
•Report findings to nurse in charge and/or physician. It may be necessary to withhold
prescribed medications that alter heart rate and regularity, such as digoxin and
antiarrhythmics, until the physician can evaluate the need to alter the dosage.
•Assess for pulse deficit (Box 17-5).
•Report findings to nurse in charge and/or physician.
•An electrocardiogram may be ordered to detect cardiac conduction alteration.
Numerous PVCs or PVCs that alternate with a normal heartbeat repeatedly should be
reported to physician
Assessing apical-radial pulse
An inefficient contraction of the heart that fails to transmit a pulse wave to the
peripheral pulse site creates a pulse deficit. Pulse deficits are frequently associated
with dysrhythmias and warn of potential alteration of cardiac output. To assess for a
pulse deficit, the nurse and a colleague assess a peripheral pulse rate and the apical
pulse rate simultaneously and compare the measurements. The difference between the
rates is the pulse deficit.
The skill of radial pulse palpation may be delegated to assistive personnel while the
nurse assesses the apical pulse. However, the nurse is responsible for determining the
presence of a pulse deficit and follow-up assessments
Stethoscope; watch with second hand or digital display; pen, pencil, vital sign flow
sheet or record form; alcohol
Swab
1. Determine need to assess for pulse deficit. Clients with irregular heart rate and
signs and symptoms such as dyspnea, fatigue, chest pain, and palpitations may
indicate decreased cardiac output.
2. Perform hand hygiene.
3. Draw curtain around bed and/or close door.
4. Assist client to supine or sitting position. Move aside bed linen and gown to
expose sternum and left side of
chest.
5. Locate apical and radial pulse sites. If two nurses are available, one nurse auscultates
the apical pulse (see Skill 17-3)
and one nurse palpates the radial pulse (see Skill 17-2).
6. The nurse measuring the radial pulse and holding the watch states "start" to
ensure that the pulse rate is mea
sured simultaneously.
7. Both nurses count the pulse rate for 60 seconds simultaneously. The count ends
when the nurse taking the ra
dial pulse states "stop." Sixty seconds is required when a discrepancy between the
pulse sites is expected or the
rhythm is irregular.
8. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse
deficit reflects the number of in
effective cardiac contractions in 1 minute.
9. If a pulse deficit is noted, assess for other signs and symptoms of decreased
cardiac output.
10.Discuss findings with client as needed.
11.Perform hand hygiene; clean earpieces and diaphragm of stethoscope with
alcohol swab routinely after each
use.
Record the apical pulse, the radial pulse and site, and the pulse deficit in the nurses'
notes. Inform the nurse in
charge or physician of the presence of a pulse deficit
Teaching Considerations
• Caregivers of clients taking certain prescribed cardiotonic or antidysrhythmic
medications should learn to assess apical pulse rates to detect side effects of
medications.
Pediatric Considerations
• Point of maximal impulse of an infant is usually located at the third to fourth ICS
near the left sternal border.
• In infants and children less than 2 years an apical pulse is more reliable and should
be counted for a full minute be
cause of possible irregularities in rhythm .
• Breath holding in an infant or child affects apical pulse rate.
• The PMI may be difficult to palpate in an older adult be cause the anteriorposterior diameter of the chest in
creases with age, and the heart becomes repositioned as a result of left ventricular
enlargement.
• When assessing older adult women with sagging breast tissue, gently lift the breast
tissue and place the stetho
scope at the fifth ICS or the lower edge of the breast.
• Heart sound may be muffled or difficult to hear in older adults because of an
increase in air space in the lungs.
Home Care Considerations
•
Assess home environment to determine which room af fords a quiet
environment for auscultation of apical rate