These skills are related to: Vital Signs
Assessing a Peripheral Pulse
Peripheral pulses are obtained for purposes such as:
- To establish baseline data for subsequent evaluation.
- To identify whether the pulse rate is within the normal range.
- To determine the pulse volume and whether the pulse rhythm is regular.
- To determine the equality of corresponding peripheral pulses on each side of the body.
- To monitor and assess changes in the client’s health status.
- To monitor clients at risk for pulse alterations.
- To evaluate blood perfusion to the extremities.
| Phase | Nursing Activities |
|---|---|
| Assessment | Assess clinical signs of cardiovascular alterations, factors that alter pulse rates, and which sites are most appropriate based on the purpose of the assessment. - Signs of cardiovascular alterations: dyspnea, fatigue, pallor, cyanosis, palpitations, syncope, or impaired peripheral tissue perfusion. |
| Planning | Assign: radial or brachial pulse assessment may be assigned to APs or family members or caregivers in nonhospital settings. The nurse bears responsibility for abnormal pulses (rate or rhythm), appropriate action after confirmation, and use of techniques for sites other than radial or brachial artery and Doppler ultrasound devices. Equipment: clock, timer, or watch with a sweep second hand or digital seconds indicator. If a DUS is being used, the probe, headset (for some models), transmission gel, and tissues or wipes are prepared. |
| Implementation | Make sure all gathered equipment are functioning normally. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate.
|
| Evaluation | Compare the pulse rate, rhythm, and volume to recent, baseline, or usual range for the age of the client and other vital signs or health status. In assessing peripheral pulses, equality, rate, and volume are all assessed in corresponding extremities. Appropriate follow-up is conducted for notifying the primary care provider of any abnormalities or after the administration of medication. |
Assessing an Apical Pulse
The apical pulse is obtained for purposes such as:
- To obtain the heart rate of an adult with an irregular peripheral pulse.
- To establish baseline data for subsequent evaluation.
- To determine normalcy and regularity of the cardiac rate.
- To monitor clients with cardiac, pulmonary, or renal disease and those receiving medications to improve heart action.
| Phase | Nursing Activities |
|---|---|
| Assessment | Assess clinical signs of cardiovascular alterations, and factors that may alter pulse rate. - Signs of cardiovascular alterations: dyspnea, fatigue, pallor, cyanosis, palpitations, syncope, or impaired peripheral tissue perfusion. |
| Planning | Assign: apical pulse assessment is not performed by APs. Equipment: clock, timer, or watch with a sweep second hand or digital seconds indicator; stethoscope; and antiseptic wipes. If a DUS is being used, the probe, headset (for some models), transmission gel, and tissues or wipes are prepared. |
| Implementation | Make sure all gathered equipment are functioning normally. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate.
|
| Evaluation | Compare the pulse rate, rhythm, and volume to recent, baseline, or usual range for the age of the client and other vital signs or health status. Report to the primary care provider and other relevant members of the healthcare team any abnormal findings such as irregular rhythm, reduced ability to hear the heartbeat, pallor, cyanosis, dyspnea, tachycardia, or bradycardia. Appropriate follow-up is conducted, such as administering medication ordered based on apical heart rate. |
Assessing an Apical-Radial Pulse
In cases of suspected peripheral circulation inadequacy or a pulse deficit, an apical-radial pulse is obtained. This involves obtaining apical and radial rates simultaneously to determine abnormalities such as a pulse too weak to be felt at the peripheral pulses, or the presence of vascular disease that prevents impulses from being transmitted. A discrepancy in apical pulse rate and peripheral pulse rate is called a pulse deficit and must be reported immediately. This technique can be performed by one or two nurses.
| Phase | Nursing Activities |
|---|---|
| Assessment | Assess clinical signs of hypovolemic shock (hypotension, pallor, cyanosis, and cold, clammy skin). |
| Planning | Assign: apical-radial pulse assessment is not performed by APs. Equipment: clock, timer, or watch with a sweep second hand or digital seconds indicator; stethoscope; and antiseptic wipes. |
| Implementation | If using the two-nurse technique, ensure that the second nurse is available. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate.
|
| Evaluation | Compare the pulse rate, rhythm, and volume to recent, baseline, or usual range for the age of the client and other vital signs or health status. Report any changes from previous measurements or any discrepancy between the two pulse rates. |