Radial pulse 2 - lecture PDF

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Skills Assessing Radial Pulse Extended Text ALERT

OVERVIEW The ejection of blood from the heart distends the walls of the aorta. Because of the force of the blood exiting the heart, aortic distention creates a pulse wave that travels rapidly toward the extremities. When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow. The number of pulsing sensations occurring in 1 minute is the pulse rate. Assessing the patient’s peripheral pulse sites offers valuable data for determining the integrity of the cardiovascular system. An abnormally slow, rapid, or irregular pulse indicates the inability of the heart to deliver adequate blood to the body; a pulse deficit may be present. The 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 and 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 distributed by the pulse. For example, assessment of the right femoral pulse determines whether blood flow to the right leg is adequate. 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. You can assess any artery for pulse rate, but the radial and carotid arteries are commonly used because they are easy to palpate. When a patient’s condition suddenly worsens, the carotid site is recommended for finding a pulse quickly. Assessment of other peripheral pulse sites such as the brachial or femoral artery is unnecessary when routinely obtaining vital signs. Other peripheral pulses are assessed when a complete physical is conducted or when the radial artery is not available for assessment because of surgery, trauma, or impaired blood flow.

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PATIENT AND FAMILY EDUCATION • Patients taking certain prescribed cardiotonic or antidysrhythmic medications need to learn to assess their own pulse rates to detect side effects of medications. Patients undergoing cardiac rehabilitation need to learn to assess their own pulse rates to determine their response to exercise. • Teach patients taking heart medications or starting a prescribed exercise regimen how to monitor carotid pulse rate.

ASSESSMENT AND PREPARATION • Determine the need to assess the radial pulse: • Note any risk factors for pulse alterations, such as history of heart disease, cardiac dysrhythmia, onset of sudden chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of a large volume of intravenous (IV) fluid, internal or external hemorrhage, or administration of medications that alter cardiac function. • Assess for signs and symptoms of altered cardiac function, such as the presence of dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin.

• Assess for signs and symptoms of peripheral vascular disease, such as pale, cool extremities; thin, shiny skin with decreased hair growth; and thickened nails. • Assess for factors that affect radial pulse rate and rhythm, such as age, exercise, position changes, fluid balance, medication, temperature, and sympathetic stimulation, such as from caffeine or nicotine. • Determine the previous baseline pulse rate (if available) from the patient’s record. • If the patient has been active, wait 5 to 10 minutes before assessing pulse. If the patient has been smoking or ingesting caffeine wait 15 minutes before assessing pulse.

DELEGATION Do not delegate the skill of assessing radial pulse to nursing assistive personnel (NAP) when the patient’s condition is unstable or when you must evaluate the patient’s response to medication or another treatment. Before delegating this skill under other circumstances, be sure to inform NAP of the following: • The appropriate site for checking the pulse rate, frequency of measurement, and factors related to the patient’s history (e.g., risk for abnormally slow, rapid, or irregular pulse). • The patient’s usual pulse rate and the need to report significant changes to you. • Report any specific abnormalities immediately.

PROCEDURE 1. Verify the health care provider’s orders. 2. Gather the necessary equipment and supplies. 3. Perform hand hygiene. 4. Introduce yourself to the patient and family, if present. 5. Identify the patient using two patient identifiers. 6. Explain the procedure to the patient and ensure that he or she agrees to treatment. 7. Assess for factors that can affect pulse rate and rhythm, such as medical history, disease processes, age, exercise, and medications. Use gloves if you will be in contact with bodily fluids or if the patient is in protective precautions. 8. Help the patient into a supine or sitting position. If the patient is supine, place the forearm along the side, with the wrist extended straight, or place the patient’s forearm across the chest or upper abdomen. 9. If the patient is sitting, bend the elbow 90 degrees and support the lower arm on the chair or on your arm. Slightly extend or flex the wrist, with the palm down. 10. Place your first two or middle three fingertips over the groove along the thumb side of the patient’s inner wrist. Slightly extend or flex the wrist, with palm down, until you note the strongest pulse. 11. Press against the radius, obliterating the pulse at first and then relaxing the pressure until the pulse is readily palpable. 12. Rate the strength of the pulse, determining whether the thrust of the vessel against your fingertips is bounding; full or strong; barely palpable or diminished; or absent, not palpable. 13. Note the regularity of the rate and rhythm. Once you can feel the pulse consistently, look at your watch. When the second hand reaches a number on the dial (or when the digital display reaches a round number), start taking the pulse, counting the first beat you feel as “one.” a. For a regular pulse, count the rate for 30 seconds and multiply the total by 2. The pulse rate normally ranges from 60 to 100 beats per minute. b. For an irregular pulse, count the pulse rate for a full 60 seconds. Note the frequency and pattern of the irregularity, and compare the radial pulses bilaterally. Assess for a pulse deficit. 14. Help the patient into a comfortable position, and place toiletries and personal items within reach. 15. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 16. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. 17. Dispose of used supplies and equipment. Leave the patient’s room tidy. 18. Remove and dispose of gloves, if used. Perform hand hygiene. 19. Discuss your findings with the patient as needed. 20. As part of your follow-up, compare the patient’s pulse rate and character with the baseline and with the acceptable range for the patient’s age. 21. Document and report the patient’s response and expected or unexpected outcomes.

MONITORING AND CARE • When assessing the pulse for the first time, establish the radial pulse as the baseline and compare it with the acceptable range for the patient’s age.

• During subsequent assessments, compare the pulse rate and character with the patient’s baseline and with the acceptable range for the patient's age. • Report any pulse abnormalities to the nurse in charge or to the health care provider.

EXPECTED OUTCOMES • Radial pulse is palpable, within normal range for the patient's age. • Rhythm is regular. • Radial pulse is strong, firm, and regular.

UNEXPECTED OUTCOMES • • • •

Pulse is weak, difficult to palpate, or absent. Pulse rate for an adult is greater than 100 bpm (tachycardia). Pulse rate for an adult is less than 60 bpm (bradycardia). Pulse is irregular.

DOCUMENTATION Documentation Guidelines: • Record the pulse rate and site assessed. • Document measurement of the pulse rate after administration of specific therapies. Report abnormal findings to the nurse in charge or to the health care provider.

Sample Documentation: 2300 Right radial pulse 112, weak, thready. Left radial pulse 114, weak, thready. Respirations 24, regular. Temperature 36.8° C tympanic. Blood pressure 104/56 right arm, supine. Reports dizziness. Denies dyspnea, nausea, or pain. Skin pale. Physician notified. Orders received. –S. Lipinski, RN 5/1/19

PEDIATRIC CONSIDERATIONS • Radial artery is difficult to assess in an infant. Apical, femoral, or brachial pulse is best site for assessing pediatric heart rate and rhythm until 2 years of age. • Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration. • Breath holding in a child affects pulse rate.

GERONTOLOGICAL CONSIDERATIONS • Older adults have a reduced heart rate with exercise because of a decreased responsiveness to catecholamines. • It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate. • Peripheral vascular disease is more common among older adults, making radial pulse assessment difficult.

HOME CARE CONSIDERATIONS • Patients taking certain prescribed cardiac medications should learn to assess their own pulse rates to detect side effects of medications.

REFERENCES 1. Ball, J.W. and others. (Eds.). (2019). Chapter 6: Vital signs and pain assessment. In Seidel’s guide to physical examination: An interprofessional approach (9th ed., pp. 74-87). St. Louis: Elsevier. 2. Hockenberry, M.J., Wilson, D. (Eds.). (2015). Communication, physical, and developmental assessment. In Wong's nursing care of infants and children (10th ed., pp. 91-151). St. Louis: Mosby....