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Systematic examination of the pulse remains an essential part of clinical practice. Palpating the pulse is a skill that can take time to learn. Initially, an experienced person could assist you by feeling the pulse simultaneously, for example on the opposite arm. The aim of pulse assessment is to ascertain the heart rate, as well as to assess the pulse rate, rhythm and strength (sometimes referred to as amplitude, quality, volume or character). In clinical practice, taking the pulse is used to assess the effects of disease and response to therapy such as medication. It is important to establish the baseline pulse of patients in order to monitor any changes. Assessing the pulse should form part of a holistic assessment that also considers other factors such as blood pressure, the colour and temperature of the skin—for example, whether the skin at the extremities is warm and pink or cold and clammy—and the respiratory rate. (See also clinicalskills.net procedure, “Cardiovascular assessment.) In practice, it is also possible to take the heart rate by auscultating with a stethoscope over the left ventricle (listening directly to the heart), which is also called monitoring the apex beat. This method is useful for establishing the ventricular rate, e.g. in patients with atrial fibrillation who may have a lower radial pulse rate than apex beat (a pulse deficit) because the rapid contractions of the heart’s left ventricle are too weak to create a pulse wave that is detectable at the radial artery. Another method of recording pulse rate is by using an electronic device, such as a pulse oximeter attached to a finger. However, taking a manual pulse remains the gold standard when assessing patients who have a potential to deteriorate because it allows for the additional assessment of heart rhythm, strength and peripheral temperature. Pulse assessment is integrated in the NEWS2 scoring system (RCP, 2017). It is important to assess the regularity of the pulse by feeling the radial or brachial pulse before measuring blood pressure (NICE, 2019), and to cross-check electronic data by auscultation or palpation of the pulse (RCN, 2017). When a patient is undergoing continuous ECG monitoring, it may still be necessary to manually feel for a pulse. For example, in pulseless electrical activity (PEA), the monitor displays electrical activity normally associated with cardiac output but no pulse is palpable in the peripheries (Resuscitation Council [UK], 2015). The radial artery at the wrist is easily accessible and therefore the radial pulse is frequently used for initial measurement. Other clinically important pulses include the carotid, femoral and brachial pulses. See pages 4 and 5 for a review of the different sites used. This procedure outlines how to take the radial pulse and related cardiovascular observations. It then explains how to find commonly used pulse sites and describes the main heart rhythms that may be felt when assessing the pulse. Page 1 of 6 Observations Adults Assessing the pulse Edited by Edda Hensler, Senior Lecturer in Nursing, University of Brighton ©2020 Clinical Skills Limited. All rights reserved The cardiac cycle and the pulse wave Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person. Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution. Factors affecting the pulse Many factors can alter the pulse (heart) rate, including anxiety, pain and fever (which may raise it), or certain medications, such as beta-blockers and digoxin (which may lower it). Pulse rate may also vary with age, sex, exercise, cardiac disease, positioning (i.e., the difference between lying and standing), stress, hormones and electrolytes (Obrey, 2010). It is important either to try to eliminate these factors or take them into account when assessing the pulse. Check previous pulse rate measurements, so that you can assess the trend and pattern of the pulse. Age Infant (resting) Child 1–2 years Child 2–5 years Child 5–12 years Adolescent to adult (RCN, 2017; ALSG, 2016) Heart rate 110–170 100–160 80–150 65–135 60–110 The cardiac cycle refers to the sequence of events in the heart from the beginning of one heart beat to the next, which includes systole (contraction) and diastole (relaxation). The alternating expansion and recoil of an artery that occurs with each beat of the left ventricle creates a pressure wave that travels through the entire arterial system (Marieb, 2015). This wave is felt as a pulse in any artery that lies close to the surface of the body (Lister et al., 2020). It is strongest in the arteries close to the heart (such as the aorta), then becomes weaker in the arterioles and disappears in the capillaries altogether. Propanolol 40mg film-coated tablets Propanolol hydrochloride Each film-coated tablet containe 40mg Propanolol hydrochloride. Contans lactose. See the package leaflet for further information. 40 mg 28 tablets Digoxin 6.25 micrograms Tablets Oral Use 28 Tablets 6.25 mcg
6

Edited by Edda Hensler, Senior Lecturer in Nursing ...

Jan 01, 2022

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Page 1: Edited by Edda Hensler, Senior Lecturer in Nursing ...

Systematic examination of the pulse remains an essential part of clinical practice. Palpating the pulse is a skill that can take time to learn. Initially, an experienced person could assist you by feeling the pulse simultaneously, for example on the opposite arm.

The aim of pulse assessment is to ascertain the heart rate, as well as to assess the pulse rate, rhythm and strength (sometimes referred to as amplitude, quality, volume or character). In clinical practice, taking the pulse is used to assess the effects of disease and response to therapy such as medication. It is important to establish the baseline pulse of patients in order to monitor any changes. Assessing the pulse should form part of a holistic assessment that also considers other factors such as blood pressure, the colour and temperature of the skin—for example, whether the skin at the extremities is warm and pink or cold and clammy—and the respiratory rate. (See also clinicalskills.net procedure, “Cardiovascular assessment.)

In practice, it is also possible to take the heart rate by auscultating with a stethoscope over the left ventricle (listening directly to the heart), which is also called monitoring the apex beat. This method is useful for establishing the ventricular rate, e.g. in patients with atrial fibrillation who may have a lower radial pulse rate than apex beat (a pulse deficit) because the rapid contractions of the heart’s left ventricle are too weak to create a pulse wave

that is detectable at the radial artery. Another method of recording pulse rate is by using an electronic device, such as a pulse oximeter attached to a finger. However, taking a manual pulse remains the gold standard when assessing patients who have a potential to deteriorate because it allows for the additional assessment of heart rhythm, strength and peripheral temperature.

Pulse assessment is integrated in the NEWS2 scoring system (RCP, 2017). It is important to assess the regularity of the pulse by feeling the radial or brachial pulse before measuring blood pressure (NICE, 2019), and to cross-check electronic data by auscultation or palpation of the pulse (RCN, 2017). When a patient is undergoing continuous ECG monitoring, it may still be necessary to manually feel for a pulse. For example, in pulseless electrical activity (PEA), the monitor displays electrical activity normally associated with cardiac output but no pulse is palpable in the peripheries (Resuscitation Council [UK], 2015).

The radial artery at the wrist is easily accessible and therefore the radial pulse is frequently used for initial measurement. Other clinically important pulses include the carotid, femoral and brachial pulses. See pages 4 and 5 for a review of the different sites used. This procedure outlines how to take the radial pulse and related cardiovascular observations. It then explains how to find commonly used pulse sites and describes the main heart rhythms that may be felt when assessing the pulse.

Page 1 of 6

ObservationsAdults

Assessing the pulseEdited by Edda Hensler, Senior Lecturer in Nursing, University of Brighton

©2020 Clinical Skills Limited. All rights reserved

The cardiac cycle and the pulse wave

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Factors affecting the pulse

Many factors can alter the pulse (heart) rate, including anxiety, pain and fever (which may raise it), or certain medications, such as beta-blockers and digoxin (which may lower it). Pulse rate may also vary with age, sex, exercise, cardiac disease, positioning (i.e., the difference between lying and standing), stress, hormones and electrolytes (Obrey, 2010). It is important either to try to eliminate these factors or take them into account when assessing the pulse. Check previous pulse rate measurements, so that you can assess the trend and pattern of the pulse.

Age

Infant (resting)

Child 1–2 years

Child 2–5 years

Child 5–12 years

Adolescent to adult

(RCN, 2017; ALSG, 2016)

Heart rate

110–170

100–160

80–150

65–135

60–110

The cardiac cycle refers to the sequence of events in the heart from the beginning of one heart beat to the next, which includes systole (contraction) and diastole (relaxation). The alternating expansion and recoil of an artery that occurs with each beat of the left ventricle creates a pressure wave that travels through the entire arterial system (Marieb, 2015). This wave is felt as a pulse in any artery that lies close to the surface of the body (Lister et al., 2020). It is strongest in the arteries close to the heart (such as the aorta), then becomes weaker in the arterioles and disappears in the capillaries altogether.

Propanolol 40mgfilm-coated tablets

Propanolol hydrochlorideEach film-coated tablet containe 40mg Propanolol hydrochloride.Contans lactose.See the package leaflet for further information.

40 mg

28 tablets

Digoxin6.25 micrograms TabletsOral Use

28 Tablets

6.25 mcg

Page 2: Edited by Edda Hensler, Senior Lecturer in Nursing ...

Observations

Adults

Assessing the pulse Page 2

The patient Decontaminate your hands

Explain the procedure and gain the patient’s consent. Before assessing the pulse, let the person rest, ideally for 20 minutes, as taking the pulse after strenuous activity can lead to raised readings (Lister et al., 2020; Rawlings-Anderson & Hunter, 2008). Create a calm environment and be both reassuring and confident in your manner. Where possible, ask the patient not to talk while you palpate the pulse, to minimise distraction during the assessment.

Decontaminate your hands using an alcohol-based sanitiser or by washing with soap and water and drying thoroughly.

Assess the limb Capillary refill test

You can carry out a capillary refill test to give an indication of the status of the circulation. Press firmly on the nail bed for 5 seconds. When you release the pressure, note how long it takes to flush red. If it takes longer than 2 seconds, this may indicate poor circulation or vasoconstriction, or other factors such as hypothermia.

Always use a reliable timer to take the pulse. This may be a watch with a second hand or a digital counter. Support the patient’s arm with a pillow.

As part of your holistic assessment of the patient, consider other signs of poor circulation. Bluish lips (cyanosis of the lips) can indicate poor tissue perfusion caused by a respiratory condition, usually long-standing, or a severe compromise of the cardiovascular system. Look at the skin—does the patient show pallor (pale colour)? This, too, can indicate a compromised circulation and requires further assessment and advice.

It is important to observe the limb when taking the pulse. Consider the colour of the extremities. Nail beds that are pale or have a bluish colouration (in the absence of nail polish) indicate possible poor circulation or tissue oxygenation.

Colour of lips and skin Prepare timer

Page 2 of 6

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Page 3: Edited by Edda Hensler, Senior Lecturer in Nursing ...

160180

200

220

240

260

280300

140120

100

80

60

40

20

0

0472

mm Hg

≥220201-219181-200161-180141-160121-140111-120101-11091-10081-9071-8061-7051-60

≤50≥131

121-140111-120101-11091-10081-9071-8061-7051-6041-5031-40

≤30

CPulseBeats/min

AlertConfusion

VPU

DConsciousnessScore for NEWonset of confusion(no score if chronic)

103

A

Description

Full, bounding

Normal/strong

Weak, diminished, thready

Absent/non-palpable

Grading

3+

2+

1+

0

(Lapum et al., 2018)

Observations

Adults

Assessing the pulse Page 3

Explain your findings to the patient

Palpate artery and assess pulse rhythm and rate Quality or character of the pulse

Document the pulse rate on the NEWS2 chart (RCP, 2017). If the pulse rhythm and strength are abnormal, you should document this in the patient's notes and escalate as necessary to senior nursing or medical staff.

Decontaminate your hands. Explain your findings to the patient in terms they can understand.

Page 3 of 6

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Pulse quality and character are terms that describe the strength (or force) of the pulse, and reflect the volume of blood, cardiac output and the elasticity of the arterial wall (Lapum et al., 2018). A strong and bounding pulse may indicate high blood pressure while a faint pulse may mean the patient is hypovolaemic. It takes practice to feel differences in pulse amplitude, e.g., between the flexible artery of a young, healthy adult and the hard artery of a patient with atherosclerosis.

To take the pulse manually, the healthcare professional lightly compresses the radial artery and counts the number of beats in a minute. If the rhythm of the pulse is regular and the rate seems normal, you can count the rate for 30 seconds and multiply by two to obtain the rate per minute. If the rate is unusually fast or slow or is irrregular, you must count it for 60 seconds (Bickley & Szilagyi, 2013). Students who are learning to take a pulse should record the pulse for a full minute.

If you cannot feel a pulse at the radial site, it is important to assess the patient for possible causes such as poor perfusion, hypovolaemia, obstruction (e.g., by a blood clot) and abnormal heart rhythms (Lister et al., 2020). Refer any concerns to senior nursing or medical staff.

If you are undertaking a full assessment of all the pulses, notably in each limb and the femoral area, compare the strength of each. Are any pulses weaker than others? This could indicate an obstruction in that area, which may affect the circulation.

Documentation

To take the pulse manually, the healthcare professional lightly compresses the artery (usually in the wrist) and counts the number of beats in a minute. If the rhythm of the pulse is regular and the rate seems normal, you can count the rate for 30 seconds and multiply by two to obtain the rate per minute. If the rate is unusually fast or slow, you should count it for 60 seconds (Bickley & Szilagyi, 2013).

green text to become caption for page 3, pic 2

Unable to feel the pulse? Compare pulses

Page 4: Edited by Edda Hensler, Senior Lecturer in Nursing ...

ARTERY

Temporal artery

Carotid artery

Brachial artery

Radial artery

Ulnar artery

Femoral artery

Popliteal artery

Posterior tibial artery

Dorsalis pedis artery

ARTERY

IND

EX L

INE

Brachial pulse: (a)

Carotid pulse

Healthcare professionals often use the femoral pulse to assess the cardiac output during cardiac arrest. It is generally easier to find and palpate than the carotid pulse. It is also useful for assessing blood flow to the lower limbs. As a central pulse, it offers greater clarity on the character and volume of the pulse.

When measuring blood pressure manually, you must palpate the brachial pulse to ascertain its location before positioning the diaphragm of the stethoscope in order to hear the Korotkoff sounds. If there is an arrow on the cuff, this must line up with the brachial artery. (See clinicalskills.net procedures on measuring blood pressure.)

The apical pulse is located at the apex of the heart on the left ventricle. Use a stethoscope to listen to the heart rate: the pulse rate is usually consistent with the apex beat. This method is also useful for measuring the rate of ventricular contraction in patients with atrial fibrillation (Jevon, 2010). (The apical pulse is often used in neonates and children as it can be difficult to find and record the pulse at other sites in children [RCN, 2017]; see also clinicalskills.net procedures on “Cardiovascular examination” and “Assessing pulse in children”.)

There are many points in the body where it is possible to palpate the pulse. The radial artery is the most commonly used for routine observations, but other pulses may be utilised to assess the circulation in various parts of the body, depending on the reason for taking the pulse. The following illustrations provide detail on each of the pulse sites, starting with the central pulses, followed by pulses of the limbs.

Femoral pulse

Observations

Adults

Assessing the pulse Page 4

Apical pulse

Page 4 of 6

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

To palpate the radial pulse, turn the limb palm side up and use your fingers to lightly compress the radial artery, by placing your fingertips about 2.5 cm along from the base of the thumb, down from the fold of the wrist. Do not use your thumb, as this has a pulse of its own (Marieb, 2015). The pulse is easily accessible here, offering a good guide to the heart and its regularity. As the radial pulse is some distance from the heart, its use to assess the character of the pulse and its volume can be limited.

Carotid pulses are found at each side of the neck, next to the larynx. Apply light compression to one carotid artery at a time to prevent a reduction in blood supply to the brain (Obrey, 2010). Only those trained and experienced in the assessment of sick patients should assess the carotid pulse. The public, and healthcare professionals not used to palpating this pulse, should use other signs to assess whether there is a circulation, such as an unresponsive patient and the absence of breathing (Resuscitation Council [UK], 2015).

Pulse points

Page 5: Edited by Edda Hensler, Senior Lecturer in Nursing ...

Observations

Adults

Assessing the pulse Page 5

Dorsalis pedis pulse Posterior tibial pulse

Radial pulse

Popliteal pulse

It is advisable to assess these pulses in strong light, so that you can assess the colour of the feet. Feet that are mottled or bluish will cause concern because this may indicate a poor blood supply and ischaemia in the lower limbs; in this case, inform the medical team immediately.

Page 5 of 6

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

To palpate the radial pulse, turn the arm palm side up and use your fingers to lightly compress the radial artery until the pulse is felt. Do not use your thumb, as this has a pulse of its own (Marieb, 2015). The pulse is easily accessible here, offering a good guide to the heart and its regularity. As the radial pulse is some distance from the heart, its use to assess the character of the pulse and its volume can be limited.

Brachial artery

Radial artery

Ulnar artery

Ulnar pulse

The brachial pulse site may offer more detail about the volume and character of the pulse. This pulse may need some practice to find. The brachial artery lies close to the tendon that can be felt when the arm is bent. Depending on the patient's anatomy and arm circumference, you may need to vary the position across the elbow and/or press harder to be able to feel the pulse. It may help if the arm is straight and supported with a pillow.

The popliteal, dorsalis pedis and posterior tibial pulses all take some time to locate and palpate. These pulses are invaluable for assessing the circulation to the lower limbs, e.g., if poor circulation in this area is a concern or following vascular surgery. If it is impossible to feel them, you can use a Doppler to hear the blood flow.

It is unusual to use the ulnar artery for assessing the pulse as it can be difficult to palpate. However, healthcare professionals typically palpate the ulnar artery to assess blood flow to the hand before inserting an arterial line into the radial artery. (See clinicalskills.net series on “Care of an arterial line”.)

(b) Finding the brachial pulse

Page 6: Edited by Edda Hensler, Senior Lecturer in Nursing ...

S =systole

D = diastole

mm

Hg

100

Time sec 0 3 4 5 6 7 8 9 10D

S S S S S S S S S S S S

D D D D D D D D D D D21

Observations

Adults

Assessing the pulse Page 6Normal sinus rhythm

Sinus arrhythmia

Tachycardia

The illustrations here help you consider the rhythm of the pulse. Take the pulse for 60 seconds to assess the rhythm. If the patient is in sinus rhythm, the electrical impulse originates in the sinoatrial node, the natural pacemaker of the heart, and the pulse should be regular and steady. This diagram, and the ones below, provide a visual representation of the pattern of the pulse and should not be confused with the ECG, which shows electrical activity.

Sinus arrhythmia is a slight elevation and decrease in pulse rate that coincides with respiration, and is normal in younger people (Soos & McComb, 2019).

Bradycardia

Irregular pulse: atrial fibrillation and ectopic beats

Absence of pulse: ventricular fibrillation

Generally, bradycardia is defined as a heart rate slower than 60 beats/minute (Resuscitation Council [UK], 2015; Bickley & Szilagy, 2013; Riley, 2007), although some texts use a figure of 50 beats/minute. For some, a slow heart rate may be normal and healthy, such as in a young, athletic person in whom the heart muscle has been trained to circulate an adequate blood volume with fewer beats. It is important to assess the patient to ascertain their baseline and the effect of a slow pulse, such as feeling unwell or dizzy, a drop in blood pressure or chest pain. A pulse below 40 beats/minute would be cause for concern in most patients. (Normal pulse shown as a beige line.)

The most common cause of an irregular pulse is atrial fibrillation (AF), a long-term arrhythma caused by continuous disorganised electrical activity in the atria. In AF, the characteristically irregular pulse occurs because the electrical activity in the atria varies, so the atrioventricular node conducts electrical impulses intermittently to the ventricles, producing irregular ventricular contractions. Assess the patient to determine whether this rhythm is normal for them. If the patient has symptoms such as dizziness, chest pain or a drop in blood pressure, seek immediate assistance. An irregular pulse may also occur when normal sinus rhythm is interrupted by ventricular extrasystoles (ectopics), which are premature beats occurring from within the ventricles.

In ventricular fibrillation (VF), shown above, the ventricles are not conducting in a strong, steady fashion, so there is no pulse. The result is cardiac arrest: the patient requires immediate defibrillation.

Page 6 of 6

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

A rapid heart rate through the normal conduction pathway is known as sinus tachycardia. However, a fast pulse rate can also be initiated by an electrical impulse outside of the sinoatrial node, and the tachycardia is denoted by the origin of the impulse, e.g. ventricular tachycardia (VT) or atrial fibrillation. Sinus tachycardia is said to occur with pulse rates above approximately 100 beats/minute (Bickley & Szilagyi, 2013). (Normal pulse shown as a beige line.) Assess the patient for possible complications of tachycardia, such as shortness of breath or a drop in blood pressure.