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SKILL 5-2

Assessing Radial Pulse

NSO

Basic Skills / Vital Signs / Assessing Radial Pulse

Vital Signs Module / Lesson 3

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, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood ow. The number of pulsing sensations occurring in 1 minute is the pulse rate. Assessing the patients peripheral pulse sites offers valuable data for determining the integrity of the cardiovascular system. An abnormally slow, rapid, or irregular pulse indicates the hearts inability to deliver adequate blood to the body; a pulse decit may be present (see Procedural Guideline 5-1, p. 84). The strength or amplitude of a pulse reects the volume of blood ejected against the arterial wall with each heart contraction. If the volume decreases, the pulse often becomes weak and difcult to palpate. In contrast, a full bounding pulse is an indication of increased volume. The integrity of peripheral pulses indicates the status of blood perfusion to the area distributed by the pulse (Table 5-1). For example, assessment of the right femoral pulse determines whether blood ow 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 necessary. You can assess any artery for pulse rate, but the radial and carotid arteries are commonly used because they are easy to palpate (Fig. 5-7). When a patients condition suddenly worsens, the carotid site is recommended for quickly nding a pulse. 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 (see Chapter 6) is conducted or when the radial artery is not available for assessment because of surgery, trauma, or impaired blood ow.

Delegation Considerations
The skill of radial pulse measurement can be delegated to NAP unless the patient is considered unstable or the nurse is evaluating a response to a treatment or medication. The nurse directs the NAP to: Consider specic factors related to the patient history, usual values, or risk for abnormally slow, rapid, or irregular pulse. Obtain appropriate pulse measurement frequency and position for the patient. Report any abnormalities to the nurse.

Equipment
Wristwatch with second hand or digital display Pen, pencil, vital sign ow sheet or record form

FIG 5-7 Palpating the right radial pulse. (From Sorrentino S, Gorek B: Basic skills for nursing assistants in long-term care, St. Louis, 2005, Mosby.)

TABLE 5-1
Site Temporal Carotid

Pulse Sites
Location Over temporal bone of the head, above and lateral to the eye Along medial edge of sternocleidomastoid muscle in the neck Fourth to fth intercostal space at left midclavicular line Groove between biceps and triceps muscles at the antecubital fossa Radial or thumb side of forearm at the wrist Ulnar side of forearm at the wrist Below the inguinal ligament, midway between symphysis pubis and anterior superior iliac spine Behind the knee in popliteal fossa Inner side of each ankle, below medial malleolus Along top of foot between extension tendons of great and rst toe Rationale for Selection Easily accessible site to assess pulse in children Easily accessible site to assess character of peripheral pulse; used during physiological shock or cardiac arrest when other sites are not palpable Site used to auscultate apical pulse Site used to auscultate upper extremity blood pressure; assess status of circulation to lower arm Common site to assess character of peripheral pulse; assesses status of circulation to hand Site used to assess status of circulation to ulnar side of hand; used to perform Allens test Site used to assess character of pulse during physiological shock or cardiac arrest when other pulses are not palpable; assess status of circulation to the leg Site used to auscultate lower extremity blood pressure; assess status of circulation to the lower leg Site used to assess status of circulation to the foot Site used to assess status of circulation to the foot

Apical Brachial Radial Ulnar Femoral

Popliteal Posterior tibial Dorsalis pedis

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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STEP
ASSESSMENT 1 Determine need to assess radial pulse: a Assess for any risk factors for pulse alterations: 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) uid Internal or external hemorrhage Administration of medications that alter cardiac function b Assess for signs and symptoms of altered cardiac function such as presence of dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations (persons unpleasant awareness of heartbeat), edema of dependent body parts, cyanosis or pallor of skin (see Chapter 6). c Assess for signs and symptoms of peripheral vascular disease such as pale, cool extremities; thin, shiny skin with decreased hair growth; thickened nails (see Skill 6-4). d Assess for factors that inuence radial pulse rate and rhythm: age, exercise, position changes, uid balance, medications, temperature, sympathetic stimulation. 2 Determine patients previous baseline pulse rate (if available) from patients record. NURSING DIAGNOSES Activity intolerance Decreased cardiac output

RATIONALE

Certain conditions place patients at risk for pulse alterations. A history of peripheral vascular disease often alters pulse rate and quality.

Physical signs and symptoms often indicate alteration in cardiac function, which affects radial pulse rate and rhythm.

Physical signs and symptoms indicate alteration in local arterial blood ow. Allows nurse to anticipate factors that will alter pulse, ensuring accurate interpretation. Allows nurse to assess for change in condition. Provides comparison with future pulse measurements.

Decient uid volume

Ineffective tissue perfusion

Individualize related factors based on patients condition and needs.

PLANNING 1 Expected outcomes following completion of procedure: Radial pulse is palpable, within usual range for patients age. Rhythm is regular. Radial pulse is strong, rm, and elastic. 2 Explain to patient that you will assess radial pulse rate (HR). Encourage patient to relax as much as possible. If patient has been active, wait 5 to 10 minutes before assessing pulse. If patient has been smoking, wait 15 minutes before assessing pulse. IMPLEMENTATION 1 Perform hand hygiene. 2 If necessary, draw curtain around bed and/or close door. 3 Assist patient with assuming a supine or sitting position.

Usual range for adults is 60 to 100 beats per minute. Cardiac status is stable. Radial artery is patent. Anxiety, activity, or smoking elevates heart rate. Assessing radial pulse rate at rest allows for objective comparison of values.

Reduces transmission of microorganisms. Maintains privacy and minimizes embarrassment. Provides easy access to pulse sites.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-2

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STEP
4 If supine, place patients forearm straight alongside or across

RATIONALE
Fingertips are most sensitive parts of hand to palpate arterial pulsation. Nurses thumb has pulsation that interferes with accuracy. Relaxed position of lower arm and extension of wrist permits full exposure of artery to palpation.

lower chest or upper abdomen with wrist extended straight (see illustration A). If sitting, bend patients elbow 90 degrees, and support lower arm on chair or on nurses arm. Place tips of rst two or middle three ngers of hand over groove along radial or thumb side of patients inner wrist (see illustration B). Slightly extend or ex wrist with palm down until you note strongest pulse.

A
STEP 4

B
A, Pulse check with patients forearm at side with wrist extended. B, Hand placement for pulse check.

5 Lightly compress against radius, obliterate pulse initially, and

then relax pressure so pulse becomes easily palpable. 6 Determine strength of pulse. Note whether thrust of vessel against ngertips is bounding (4 ), strong (3 ), weak (2 ), thready (1 ), or absent (0).
7 After feeling a regular pulse, look at second hand of watch

and begin to count rate. Count the rst beat after the second hand hits the number on the dial, count as one, then two, and so on. 8 If pulse is regular, count rate for 30 seconds and multiply total by 2. 9 If pulse is irregular, count rate for a full 60 seconds. Assess frequency and pattern of irregularity. 10 When pulse is irregular, compare radial pulses bilaterally.

Pulse assessment is more accurate when using moderate pressure. Too much pressure occludes pulse and impairs blood ow. Strength reects volume of blood ejected against arterial wall with each heart contraction. Accurate description of strength improves communication among nurses and other health care providers. Rate is determined accurately only after pulse has been palpated. Timing begins with zero. Count of one is rst beat palpated after timing begins. A 30-second count is accurate for rapid, slow, or regular pulse rates. Inefcient contraction of heart fails to transmit pulse wave, resulting in irregular pulse. Longer time ensures accurate count. A marked difference between pulses indicates arterial ow is compromised to one extremity and nurse needs to take action.

Critical Decision Point If pulse is irregular, assess for pulse decit (see Procedural Guideline 5-1, p. 84), which may indicate alterations in heart function.
11 Assist patient in returning to comfortable position. 12 Discuss ndings with patient as needed. 13 Perform hand hygiene.

Promotes comfort and sense of well-being. Promotes participation in care and understanding of health status. Reduces transmission of microorganisms.

EVALUATION 1 If assessing pulse for the rst time, establish radial pulse as baseline if it is within acceptable range. 2 Compare pulse rate and character with patients previous baseline and acceptable range for patients age.

Used to compare future pulse assessments. Allows nurse to assess for change in patients condition and for presence of cardiac alteration.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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Unexpected Outcomes
1 Weak or difcult-to-palpate radial pulse.

Related Interventions
Assess both radial pulses, and compare ndings. Observe for symptoms associated with ineffective tissue perfusion, including pallor and cool skin distal to the weak pulse. Assess for swelling in surrounding tissues or any encumbrance (e.g., dressing or cast) that may impede blood ow. Obtain Doppler or ultrasound stethoscope to detect low-velocity blood ow (see Chapter 6). Assess both radial pulses, and compare ndings. Have another nurse assess pulse. Identify related data, including fever, pain, fear or anxiety, recent exercise, low BP, blood loss, or inadequate oxygenation. Observe for signs and symptoms associated with abnormal cardiac function, including dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of body parts, cyanosis or pallor of the skin. Auscultate the apical pulse (see Skill 5-3). Confer with health care provider, and be prepared to order/obtain an electrocardiogram. Auscultate the apical pulse (see Skill 5-3). Assess for pulse decit (see Procedural Guideline 5-1).

2 Pulse rate for an adult is more than 100 beats per minute (tachycardia).

3 Pulse rate for an adult is less than 60 beats per minute (bradycardia).

4 Pulse is irregular.

Recording and Reporting

Record pulse rate and assessment site on vital sign ow sheet (see Fig. 5-6) record or nurses notes. Document measurement of pulse rate after administration of specic therapies in narrative form in nurses notes. Report abnormal ndings to nurse in charge or health care provider.

Pediatric Considerations
You can obtain an accurate radial pulse in children over 2 years of age. 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 affects pulse rate.

Teaching Considerations
Patients taking certain prescribed cardiotonic or antidysrhythmic medications need to learn to assess their own pulse rates to detect side effects of medications. Patients undergoing cardiac rehabilitation need to learn to assess their own pulse rates to determine their response to exercise. Teach patients taking heart medications or starting a prescribed exercise regimen how to monitor carotid pulse rate.

Gerontological Considerations
It is often difcult to palpate the pulse of an older adult or obese patient. A Doppler ultrasound stethoscope provides a more accurate reading. The arteries of an older adult often feel stiff and knotty because of decreased elasticity. It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate (Ebersole and others, 2008).

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.