12) Character Of The Pulse Flashcards
What characteristics are assessed when palpating the radial pulse?
Rate, rhythm, strength, and bilateral equality
What characteristics are assessed when auscultating the apical pulse?
Rate and rhythm only
What should be done before measuring a pulse?
- Review the patient’s baseline heart rate for comparison
- Some practitioners measure baseline rates in lying, sitting, and standing positions
How does a change in position affect heart rate?
- Changing from lying to sitting/standing temporarily increases heart rate
- Due to alterations in blood volume and sympathetic nervous system activity
What factors influence heart rate?
- Various factors like age, medications, exercise, emotions, temperature, etc.
- A single factor or combination can cause significant changes
What should be done if an abnormal peripheral pulse rate is detected?
- Assess the apical pulse rate by auscultating heart sounds
- Provides a more accurate assessment of cardiac contractions
What factors increase heart rate?
- Short-term exercise
- Fever and heat
- Anxiety (increases sympathetic stimulation)
- Acute pain (increases sympathetic stimulation)
- Positive chronotropic medications like epinephrine
- Cholinergic blocking agents like atropine
- Loss of blood (increases sympathetic stimulation)
- Standing up from sitting position
- Diseases causing poor oxygenation like asthma, COPD
What factors decrease heart rate?
- Long-term exercise (conditions the heart for lower resting rate)
- Hypothermia
- Relaxation
- Unrelieved severe pain (increases parasympathetic stimulation)
- Negative chronotropic medications like digitalis, beta-blockers, calcium channel blockers
- Lying down
How should the nurse identify heart sounds?
- S1 is the first heart sound, low-pitched and dull (“lub”)
- S2 is the second heart sound, higher pitched and shorter (“dub”)
- Each “lub-dub” set counts as one heartbeat
How does the nurse count the heart rate?
- Using the diaphragm or bell of the stethoscope
- Count the number of “lub-dub” sets in 1 minute
What is the normal heart rate range in adults?
- Between 60 and 100 beats per minute
What is tachycardia?
- Fast heart rate, more than 100 beats per minute in adults
- If resting rate is over 120 bpm, may indicate underlying problem
What is bradycardia?
- Slow heart rate, less than 60 beats per minute in adults
- Can occur from heart block or medications like beta-blockers
- Often seen in athletes at rest
What is a pulse deficit?
- Inefficient heart contraction that fails to transmit pulse wave peripherally
- Detected by two people simultaneously assessing apical and radial rates
- Difference between the two rates is the pulse deficit
- Associated with abnormal rhythms
What is a normal pulse rhythm?
- Regular interval between each pulse/heartbeat
- Pulse should be regular under normal circumstances
What indicates an abnormal heart rhythm (dysrhythmia)?
- Interval interrupted by an early, late, or missed beat
- Threatens adequate cardiac output if occurs repetitively
How is dysrhythmia identified?
- Palpating interruption in successive pulse waves
- Auscultating interruption between heart sounds
What should the nurse do if dysrhythmia is present?
- Assess regularity of its occurrence
- Auscultate apical rate for one full minute
How are dysrhythmias described?
- “Regularly irregular” (next pulse can be predicted)
- “Irregularly irregular” (next pulse cannot be predicted)
What tests may be ordered to document/investigate dysrhythmia?
- Electrocardiogram (records 12-second electrical activity)
- Holter monitor (records 24-hour electrical activity)
- Telemetry (continuous electrical monitoring)
What does the strength of a pulse reflect?
- Volume of blood ejected against arterial wall with each contraction
- Condition of arterial vascular system leading to pulse site
How can pulse strength be simply described?
- Absent
- Present
- Bounding
What is the 0-4 grading scale for pulse strength?
0 = Absent
1+ = Diminished
2+ = Normal
3+ = Full/Increased
4+ = Bounding
Why should pulses on both sides be assessed?
- To compare characteristics
- One side may be unequal or absent in disease states like thrombosis
Which pulses should not be measured simultaneously?
- Carotid pulses
- Excessive pressure may occlude brain blood supply or trigger reflexes altering cardiac output
What does pulse assessment help determine?
- General state of cardiovascular health
- Body’s response to other system imbalances
What are defining characteristics of many nursing diagnoses?
- Tachycardia
- Bradycardia
- Dysrhythmia
What are some nursing diagnoses related to abnormal pulse?
- Activity intolerance
- Anxiety
- Decreased cardiac output
- Deficient/excess fluid volume
- Impaired gas exchange
- Hyperthermia
- Hypothermia
- Acute pain
- Ineffective tissue perfusion
How are nursing interventions determined?
- Based on the specific nursing diagnosis identified
- And its related factors
Give an example of a nursing diagnosis and intervention related to pulse.
- Diagnosis: Activity intolerance (abnormal heart rate, exertional dyspnea, fatigue)
- Intervention: Increase daily exercises (if related factor is inactivity after illness)
How are patient outcomes evaluated related to pulse?
- By assessing heart rate, rhythm, strength, and equality
- After each nursing intervention
