NUR 111: SKILL 5-2: ASSESSING RADIAL PULSE

ASSESSING RADIAL PULSEThe strength or amplitude of a pulse

reflects the volume of blood ejected against the arterial wall with each heart contraction.

If the volume decreases, the pulse often becomes weak & difficult 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 disturbed by the pulse.

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.

RADIAL PULSE - ASSESSMENTDetermine need to assess radial

pulse

Assess for any risk factors for pulse alterations – i.e.: What would make the pulse irregular?History of heart diseaseCardiac dysrhythmiasOnset of sudden chest pain or

acute pain from any siteInvasive cardiovascular

diagnostic testsSurgeryInternal or external

hemorrhageAdministration of medications

that alter cardiac function

ASSESSMENT – CONT’DAssess for signs & symptoms of altered

cardiac function, such as presence of dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema or dependent body parts, cyanosis, or pallor of skin.

Assess for signs & symptoms of peripheral vascular disease such as pale, cool extremities; thin, shiny skin with decreased hair growth; thickened nails.

Assess for factors that influence radial pulse rate & rhythm: age, exercise, position changes, fluid balance, medication & temperature.

Determine patient’s previous baseline pulse rate (if available) from patient’s record.

PLANNING – RADIAL PULSEExpected outcome following completion of procedure:Radial pulse is palpable, within usual

range for patient’s age. Rhythm is regular Radial pulse is strong, firm & elastic Encourage patient to relax as much as

possible. If they have been active, wait 5 to 10

minutes before assessing pulse. If patient has been smoking or

ingesting caffeine, wait 15 minutes before assessing pulse.

IMPLEMENTATIONPerform Hand Hygiene

If necessary, provide privacy to the patient – draw curtain around the bedside.

Assist patient with assuming a supine or sitting position

If patient is supine, place their forearm straight alongside or across lower chest or upper abdomen with wrist extended straight. If sitting bend patient’s elbow 90 degrees & support lower arm on chair or on nurse’s arm. Place tips of first two or middle

three fingers of hand over groove along radial or thumb side of patient’s inner wrist. Slightly extend or flex wrist with palm down until you note strongest pulse.

Lightly compress against radius, obliterate pulse initially & relax pressure so pulse becomes easily palpable.Determine strength of pulse: Note whether thrust of vessel against fingertips is bounding:

4+ = Bounding3+ = Full Increased, Strong2+ = Expected1+ = Barely palpable, diminished0+ = Absent, not palpable

IMPLEMENTATION – RADIAL PULSE, CONT’D

After palpating a regular pulse, look at watch second hand & begin to count rate. Count the first beat after the second hand hits the number on the dial; count as one, then two & so on.

If a pulse is regular, count rate for 30 seconds & multiply total by 2.

If pulse is irregular, count rate for a full 60 seconds. Assess frequency & pattern of irregularity.

When pulse is irregular, compare radial pulse bilaterally.

Assist patient to comfortable position.

Discuss findings with patient as needed.

Perform hand hygiene.

UNEXPECTED OUTCOMES OF RADIAL PULSE

Patient has weak, thread, or difficult-to-palpate radial pulseAssess for swelling in surrounding tissues or any

encumbrance (dressing or cast) that may impede blood flow.

An adult patient’s pulse rate is more than 100 beats/min (tachycardia).

An adult patient’s pulse rate is less than 60 beats/min (bradycardia).

Patient has an irregular pulse.

VIDEO TO WATCH FOR ASSESSING RADIAL PULSE:

Now that you have read over this skill, you will need to watch the video, as well as practice in the lab.

This power-point presentation is only meant to be “an extra study guide.” You should not rely on this alone in order to pass your skills.

The video for this is:http://booksite.Elsevier.com/Perry-Potter/ClinicalSkills/video02.p

hp

Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques. 8e – 5.2 Assessing Radial Pulse.

END OF SKILL 5-2: ASSESSING A RADIAL PULSE

• Remember to:

• Record pulse rate & assessment site on vital sign flow sheet, nurses’ notes, or HER.

• Document measurement of pulse rate after administration of specific therapies in nurses’ notes & HER

• Report abnormal findings to nurse in charge or health care provider.

PLEASE TO SKILL 5-3: ASSESSING AN APICAL PULSE

The next skill you will need to accomplish is assessing an apical pulse.

This assessment will be on a separate power-point demonstration.

For this skill, you will need to know the landmarks, such as:

Intercostal Space

5th Intercostal space

PMI

Left MCL

Before you go to the next power point, try and figure out what PMI is, as well as left MCL!

JUST ANOTHER LEARNING TOOL TO HELP YOU LEARN ABOUT TAKING AN APICAL PULSE

TAKING AN APICAL PULSE

• While I have given you numerous learning tools to pass your skill, you must practice in the skills lab.

• Figure out where Erb’s point is, for example. Remember what tool I gave you on learning the five areas of listening to the heart!

• All People Enjoy Time Magazine!

• All: Aortic: Right 2nd Intercostal Space

• People: Pulmonic: Left 2nd Intercostal Space

• Enjoy: Erb’s Point: (S1 S2) Left 3rd Intercostal Space

• Time: Tricuspid: Lower Left Sternal Border 4th Intercostal Space

• Magazine: Mitral: Left 5th Intercostal, Medial to Mid-clavicular Line

END OF SKILL 5-2: ASSESSING A RADIAL PULSEFor SKILL 5-3, please go to the power point presentation labeled 5-3: taking an APICAL PULSE