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Pulse: Clinical skills notes

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Notes

Cardiovascular

Pulse

INTRODUCTION
With every heartbeat, the heart creates a wave, or pulse, that’s sent to arteries all over the body in order to deliver oxygenated blood to our organs and tissues. As a nurse, you need to be able to obtain a pulse and determine its characteristics.
NORMAL & ABNORMAL PULSE RATE
You can calculate the pulse rate by counting the number of pulses in one minute. This is equal to the heart rate, or the number of times the heart beats per minute (bpm).

AGE
PULSE RATE
12+ years old
60–100 bpm
School-aged children (5–12 years old)
75–100 bpm
Preschoolers (3–5 years old)
80–120 bpm
Toddlers (1–3 years old)
80–130 bpm
Infants (< 1 year old)
120–160 bpm

Besides age, the pulse rate can also be influenced by many factors, including physical activity; body temperature; emotions, like anger, fear, or stress; medications; or even the weather! 

Tachycardia is when the pulse rate is faster than normal, and this can occur in response to strenuous exercise, fever, pain, anxiety, or specific medications. In contrast, bradycardia means that the pulse rate is too slow and can be due to heart problems or various medications.

NORMAL & ABNORMAL PULSE RHYTHM

Another important characteristic is the pulse rhythm, which is normally regular, meaning that the intervals between the beats are equal. In an irregular rhythm, also known as arrhythmia, the beats do not follow an even tempo and some of them might even be skipped. Arrhythmia can be a result of heart problems or a complication of a heart attack or heart surgery. It can also be caused by problems with the balance of electrolytes, such as potassium, in the blood.

NORMAL & ABNORMAL PULSE AMPLITUDE

The pulse amplitude, or character, refers to how strong, forceful, or full the pulse is. A weak, thready, or feeble pulse is typically considered an emergency and could be an indication of low blood pressure, like when a client is hemorrhaging, as well as a serious heart problem or a blockage of a blood vessel. In contrast, a bounding pulse refers to a pulse that’s stronger than normal and could be caused by an abnormally forceful heartbeat. 

Figure 1: Pulse character.
PULSE SITES
The pulse can be easily felt as a thumping sensation in arteries that are located near the skin’s surface. This includes the radial, carotid, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries.
Figure 2: Pulse sites.
OBTAINING A PULSE
Before taking a client's pulse, gather the supplies you’ll need, including a watch that measures seconds. Remember to also practice hand hygiene.

The radial pulse is one of the most easily accessible pulse locations.
  1. Start by assisting the client into a comfortable position.
    • If the client is lying supine, place their arm alongside their body.
  2. Place the middle two or three fingers on the front of the wrist, just under the thumb. That's where you'll be able to feel the radial artery.
Figure 3: Measuring the radial pulse.
In an emergency or if the radial artery is not easily accessible, the carotid pulse can be obtained.

  1. Check for obvious pulsations.
  2. Using your middle two or three fingers, gently palpate the left, then right artery between the larynx and the anterior border of the sternocleidomastoid muscle.
    • Do not palpate both arteries at once and don't apply excessive pressure because that would reduce blood flow to the brain.
    • In both cases, make sure to press firmly to obliterate the pulse and then apply a little less pressure until you can clearly feel it.
  3. Count the first beat you feel as zero. The second beat is one, the third beat is two, and so on.
    • Count the pulse for one full minute.
    • While you count, notice the pulse amplitude on a subjective scale from 0-4.
  4. Now, check the other side to assess for symmetry.
    • Both sides should be equal, which means both are receiving the same blood flow.

When you're done, remember to practice hand hygiene.
APICAL PULSE
The apical pulse is the pulse that's felt right over the heart. Obtaining an apical pulse is the most reliable and accurate way to measure the pulse.

First, gather the supplies you'll need, including:
  • a watch that measures seconds
  • alcohol wipes
  • a stethoscope

Once again, start by practicing hand hygiene.
  1. If tolerated by the client, lift the head of the bed and assist the client to a sitting position.
  2. Adjust the client's clothing and use your fingers to identify anatomical landmarks that will help you locate the apical pulse.
    • Find the apical pulse at the apex of the heart on the left side of the chest between the fifth and sixth ribs. That's usually just below the left nipple or under the breast.
  3. Use the alcohol wipes to clean the different parts of your stethoscope, including the earpieces, the diaphragm, and the bell. After that, put the earpieces in your ears.
  4. Gently tap on your diaphragm. If you don't hear the tap, turn the chest piece at the tubing. Once you hear the tap, place your stethoscope against the client's apical pulse. You should now hear something that sounds like lub dub, lub dub, lub dub, which repeats over and over again. Each lub dub is a heartbeat. Begin counting the heartbeats for one minute.
  5. Take the stethoscope off the clients' chest, adjust the head of the bed, and assist them back into a suitable position. Finally, wipe the stethoscope clean and practice hand hygiene.
Figure 4: Measuring the apical pulse.
PULSE DEFICIT
Normally, every time the heart beats, there is a pulse, so the apical pulse matches the one measured in the arteries. Sometimes, though, the heart beats irregularly, too quickly or weakly, to send enough blood to the arteries; as a result, some heartbeats might be heard with a stethoscope placed on the apex but not felt as a pulse in the arteries. This can be checked by having one healthcare worker assess the apical pulse with a stethoscope and another one measure the radial pulse at the same time for one minute. To find the pulse deficit, subtract the radial pulse from the apical pulse. 
DOCUMENTATION
When measuring a client’s pulse, there are a few things you should report to the healthcare provider, such as:
  • a pulse rate above or below normal or a value specific for the client;
  • an irregular pulse rhythm
  • a weak, thready, or feeble pulse
  • an usually strong, bound pulse

Remember to document:
  • the date and time
  • pulse rate, rhythm, and amplitude
  • any observations you made while measuring the client's pulse