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Nursing 20G - Vital Signs > 11) Assessment Of Pulse > Flashcards

11) Assessment Of Pulse Flashcards

1
Q

Where are pulses most easily felt?

A
  • At points where the artery approaches the body surface
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2
Q

Which artery is commonly used to assess pulse rate?

A
  • The radial artery, as it is easily palpated
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3
Q

Which artery should be used when a patient’s condition suddenly worsens?

A
  • The carotid artery, to quickly find a pulse before peripheral pulses weaken
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4
Q

What pulses do nurses commonly assess in adults?

A
  • Radial and apical pulses
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5
Q

Who uses the radial or carotid pulse to monitor heart rate?

A
  • Athletes, cardiac patients, those starting an exercise regimen
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6
Q

When should the apical pulse be assessed instead of radial?

A
  • If radial is abnormal, intermittent or inaccessible
  • If patient takes medication affecting heart rate
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7
Q

Which pulse sites are best for infants/young children?

A
  • Brachial or apical, as other peripheral pulses are difficult to palpate accurately
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8
Q

When are other peripheral pulses like popliteal/femoral assessed?

A
  • During complete physical exam
  • If surgery/treatment impaired blood flow to a body part
  • If clinical signs of impaired peripheral blood flow
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9
Q

What is a stethoscope used for?

A
  • To assess the apical heart rate
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10
Q

What is the location / use and assessment criteria for the temporal pulse site?

A
  • Over temporal bone of head, above and lateral to eye
  • Of significance in the diagnosis of temporal arteritis
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11
Q

What is the location / use and assessment criteria for the carotid site?

A
  • Along medial edge of sternocleidomastoid muscle in neck
  • During physiological shock or cardiac arrest, when other sites are not palpable
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12
Q

What is the location / use and assessment criteria for the apical pulse site?

A
  • Fourth to fifth intercostal space at left midclavicular line
  • Auscultation is performed to obtain apical pulse
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13
Q

What is the location / use and assessment criteria for the brachial pulse site?

A
  • Groove between biceps and triceps muscles at antecubital fossa
  • Provides status of circulation to lower arm; to auscultate blood pressure
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14
Q

What is the location / use and assessment criteria for the radial pulse site?

A
  • Radial or thumb side of forearm at wrist
  • Common site to assess peripheral pulse and status of circulation to hand
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15
Q

What is the location / use and assessment criteria for the ulnar pulse site?

A
  • Ulnar side of forearm at wrist
  • Assess status of circulation to hand; also to perform Allen’s test (test for patency of radial artery)
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16
Q

What is the location / use and assessment criteria for the femoral pulse site?

A
  • Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine
  • Appropriate location to assess pulse during physiological shock or cardiac arrest when other pulses are not palpable; to assess status of circulation to leg
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17
Q

What is the location / use and assessment criteria for the popliteal pulse site?

A
  • Behind knee in popliteal fossa
  • Assess status of circulation to lower leg
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18
Q

What is the location / use and assessment criteria for the posterior tibial pulse site?

A
  • Inner side of ankle, below medial malleolus
  • Assess status of circulation to foot
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19
Q

What is the location / use and assessment criteria for the dorsalis pedis pulse site?

A
  • Along top of foot, between extension tendons of the great toe and next toe
  • Assess status of circulation to foot
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20
Q

What are the delegation considerations when delegating pulse measurement to UCPs?

A
  • Inform UCP about patient’s history or risk for irregular pulse
  • Inform UCP about frequency of pulse measurement for the patient
  • Provide UCP with patient’s usual pulse values
  • Instruct UCP on abnormalities that should be reported
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21
Q

What equipment is needed to assess radial and apical pulses?

A
  • Stethoscope (for apical pulse only)
  • Watch or clock with second hand/digital display
  • Pen and vital sign flow sheet or documentation record
  • Alcohol swab
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22
Q

What is the first step in assessing radial or apical pulse?

A
  • Identify patient using at least two person specifics (e.g., name and date of birth or name and medical record number) according to employer policy
  • Ensures correct patient and complies with safety standards
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23
Q

What should be determined before assessing radial or apical pulse?

A
  • Determine need to assess radial or apical pulse using clinical judgment
  • Note risk factors for alterations in apical pulse (e.g., cardiac conditions, pain, tests/procedures, fluid shifts)
  • Assess for signs/symptoms of altered stroke volume and cardiac output
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24
Q

What factors should be assessed that can influence heart rate and rhythm?

A
  • Age, exercise, position changes, fluid balance, medications, temperature, sympathetic nervous system stimulation
  • Enables accurate evaluation of pulse alterations
25
Q

How can previous baseline pulse rate help?

A
  • Determine previous baseline apical rate (if available) from patient’s record, otherwise note baseline radial rate
  • Allows comparison to assess change in patient’s condition
26
Q

What should be done before taking the patient’s pulse?

A
  • Explain procedure to patient
  • If patient was active, wait 5-10 minutes before taking pulse
  • Encourage patient to relax and not speak
  • Allows objective measurement at rest
27
Q

Why is hand hygiene important?

A
  • Perform hand hygiene
  • Reduces transmission of microorganisms between patient and nurse
28
Q

How can privacy and comfort be promoted?

A
  • If necessary, draw curtain around bed or close room door
  • Maintains patient’s privacy, minimizes embarrassment, promotes comfort
29
Q

What position should the patient be in to assess the radial pulse?

A
  • Assist patient to assume a supine or sitting position
  • These positions enable easy access to pulse sites
30
Q

How should the patient’s arm be positioned for a radial pulse check?

A
  • If supine, place forearm straight alongside body, across lower chest, or upper abdomen with wrist extended
  • If sitting, bend elbow 90 degrees and support lower arm on chair/your arm, with wrist slightly flexed and palm down
  • Relaxed arm position and slight wrist flexion promotes artery exposure
31
Q

Where should you place your fingers to palpate the radial pulse?

A
  • Place tips of first two or middle three fingers over groove along radial/thumb side of inner wrist
  • Fingertips are most sensitive to palpate arterial pulsation, avoiding thumb pulse
32
Q

How should pressure be applied to palpate the radial pulse?

A
  • Lightly compress fingertips against radius, obliterating pulse initially
  • Then relax pressure so pulse becomes easily palpable
  • Moderate pressure allows accurate assessment, avoiding occlusion
33
Q

How is pulse strength determined?

A
  • Note thrust of vessel against fingertips as bounding (4+), full/increased (3+), normal (2+), diminished/barely palpable (1+), or absent (0)
  • Strength reflects blood volume ejected per contraction
  • Accurate description aids communication, though subjective
34
Q

How do you count the radial pulse rate?

A
  • After feeling regular pulse, look at watch and count when second hand reaches a number
  • Count “one” for first palpated beat, then “two”, etc.
  • Ensures accurate rate after establishing pulse
35
Q

How do you count a regular radial pulse rate?

A
  • If pulse is regular, count rate for 30 seconds and multiply total by 2
  • A 30-second count is accurate for rapid, slow, or regular heart rates
36
Q

How do you count an irregular radial pulse rate?

A
  • If pulse is irregular, count rate for 1 minute (60 seconds)
  • Assess frequency and pattern of irregularity
  • Compare bilateral radial pulses
  • Inefficient heart contraction fails to transmit pulse wave, causing irregularity
  • Longer count ensures accurate rate
37
Q

What is the critical decision point if pulse is irregular?

A
  • Assess apical or radial pulse to detect a pulse deficit
  • Count apical heart rate while colleague counts radial rate simultaneously
  • Begin apical count out loud to synchronize assessments
  • If pulse counts differ by more than two, a pulse deficit exists
  • Pulse deficit can indicate altered cardiac output
38
Q

What should be done before assessing the apical pulse?

A
  • Perform hand hygiene
  • Clean earpieces and diaphragm of stethoscope with alcohol swab
  • Reduces transmission of microorganisms between patients and when sharing equipment
39
Q

What patient position is needed to assess the apical pulse?

A
  • Assist patient to supine or sitting position
  • Move aside bed linen and gown to expose sternum and left chest
  • Exposes chest wall to select auscultation site
40
Q

How do you locate the point of maximal impulse (PMI/apical impulse)?

A
  • Find angle of Louis below suprasternal notch, palpating bony prominence
  • Slip fingers down each side to find 2nd intercostal space
  • Move fingers down left side of sternum to 5th intercostal space
  • Go laterally to left midclavicular line
  • Light tap 1-2cm from PMI reflects apex of heart
41
Q

Why use anatomical landmarks to find the PMI?

A
  • Allows correct stethoscope placement over apex of heart
  • Enhances ability to clearly hear heart sounds
  • For large breasts, ask patient to move breast aside
  • If unable to palpate PMI, reposition patient on left side
  • With severe cardiac disease, PMI may be left of midclavicular line or 6th intercostal space
42
Q

How do you locate the anatomical landmarks to find the point of maximal impulse (PMI)?

A
  • Find the angle of Louis below the suprasternal notch by palpating the bony prominence
  • Slide fingers down each side to locate the second intercostal space
  • Move fingers down the left side of the sternum to the fifth intercostal space
  • Go laterally to the left midclavicular line
  • The PMI is located within 1-2 cm of a light tap felt in this area
43
Q

Why should you warm the stethoscope diaphragm before use?

A
  • Place the diaphragm in your palm for 5-10 seconds
  • Warming the metal/plastic diaphragm avoids startling the patient and promotes comfort
44
Q

Where should you place the stethoscope diaphragm to auscultate heart sounds?

A
  • Place diaphragm over the PMI at the fifth intercostal space, left midclavicular line
  • Auscultate for normal S1 and S2 heart sounds (“lub-dub”)
  • Allow tubing to extend straight without kinks to avoid sound distortion
  • S1 and S2 are high-pitched and best heard with the diaphragm
45
Q

How do you count the apical pulse rate when it is regular?

A
  • When S1 and S2 are heard regularly, look at watch and count when second hand reaches a number
  • Start counting “one” for the first auscultated sound, then “two”, etc.
  • If rate is regular, count for 30 seconds and multiply by 2
46
Q

What is the critical decision point if the heart rate is irregular or patient is on cardiac medications?

A
  • If heart rate is irregular or patient is receiving cardiac medications, count for 1 full minute (60 seconds)
  • An irregular rate is more accurately assessed over a longer interval
47
Q

How do you count and describe an irregular apical pulse rate?

A
  • Count for 1 full minute (60 seconds)
  • Describe pattern of irregularity (S1 and S2 occurring early/late, skipped beats)
  • If on digoxin, hold medication if apical rate is less than 60 bpm
  • Regular dysrhythmia may indicate inefficient heart contraction and altered output
48
Q

What should be done after assessing the apical pulse?

A
  • Replace patient’s gown and bed linen
  • Assist patient to a comfortable position
  • Clean stethoscope with alcohol swab as needed
  • Perform hand hygiene
49
Q

What comparisons should be made after assessing heart rate?

A
  • Compare current rate to previous baseline or acceptable range for age
  • Compare peripheral (radial) rate to apical rate, noting any discrepancy
  • Compare radial pulses between arms for equality
  • Correlate rate with blood pressure and related signs/symptoms
50
Q

What interventions are needed for a weak or thready radial pulse?

A
  • Assess and compare both radial pulses for local obstruction decreasing blood flow
  • Perform complete assessment of all pulses
  • Observe for signs of decreased tissue perfusion like pallor and cool skin
  • Measure apical and radial pulses simultaneously to check for pulse deficit
51
Q

What should be done if the apical pulse is greater than 100 bpm (tachycardia)?

A
  • Assess for fever, anxiety, pain, recent exercise, hypotension, low oxygenation, or dehydration as potential causes
  • Measure all vital signs
  • Assess for decreased cardiac output signs like chest pain, dizziness, cyanosis, fatigue, orthopnea
52
Q

What interventions are needed for an apical pulse less than 60 bpm (bradycardia)?

A
  • Check if patient is on digoxin or cardiac meds that could alter heart rate
  • May need to withhold meds until provider evaluates dosage adjustment
  • Assess for signs of decreased cardiac output
53
Q

How should heart rate findings be documented?

A
  • Record heart rate with assessment site in nurses’ notes or vital signs flowsheet
  • Document rate in narrative notes after administering specific therapies
  • Report any abnormal findings to nurse in charge or provider
54
Q

What should be considered for assessing apical pulse in the community?

A
  • Assess home environment to determine a quiet room for auscultating apical rate
55
Q

What are the normal heart rate ranges for different age groups?

A

0-28 days: 104-162 bpm
1-3 months: 104-162 bpm
4-11 months: 109-159 bpm
1-3 years: 89-139 bpm
4-6 years: 71-128 bpm
7-11 years: 60-114 bpm
Over 12 years: 50-104 bpm

56
Q

When should the diaphragm be used?

A

The diaphragm transmits high-pitched sounds like lung, heart, and bowel sounds. It should be positioned firmly against the skin.

57
Q

When should the bell be used?

A

The bell transmits low-pitched sounds like heart and vascular sounds. It should be rested lightly on the skin

58
Q

How can you test which side of the chestpiece is functioning?

A

Tap lightly on the diaphragm to determine which side is transmitting sound properly.

59
Q

How should a stethoscope be cared for?

A

Earpieces should be removed and cleaned regularly per manufacturer instructions. The bell, diaphragm, and tubing should be cleaned routinely with alcohol, soap and water to prevent microorganism transmission. Each nurse should have their own stethoscope if possible.

Nursing 20G - Vital Signs (19 decks)

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