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Assessing Peripheral Pulse

This document provides guidelines for assessing a patient's peripheral pulse, including the purposes and equipment needed. It describes the 13 step procedure for taking a pulse, including introducing yourself, washing hands, selecting a pulse point, counting the pulse, and documenting findings. Key aspects of a normal pulse are also defined such as a rate within normal limits, equal rhythm and volume, and ability to feel it with moderate pressure.

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kuroko senpai
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77 views

Assessing Peripheral Pulse

This document provides guidelines for assessing a patient's peripheral pulse, including the purposes and equipment needed. It describes the 13 step procedure for taking a pulse, including introducing yourself, washing hands, selecting a pulse point, counting the pulse, and documenting findings. Key aspects of a normal pulse are also defined such as a rate within normal limits, equal rhythm and volume, and ability to feel it with moderate pressure.

Uploaded by

kuroko senpai
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MABINI COLLEGES

Daet, Camarines Norte


College of Nursing and Midwifery

Assessing Peripheral Pulse


PURPOSES :

1. To establish baseline data for subsequent evaluation


2. To identify whether the pulse rate is within normal range
3. To determine the pulse volume and whether the pulse rhythm is regular
4. To determine the equality of corresponding peripheral pulses on each side of
the body
5. To monitor and assess changes in the client’s health status
6. To monitor clients at risk for pulse alterations (e.g., those with a history of
heart disease or experiencing cardiac arrhythmias, hemorrhage, acute pain,
infusion of large volumes of fluids, or fever)
7. To evaluate blood perfusion to the extremities

Equipment :

Clock or watch with a sweep second hand or digital seconds indicator

PROCEDURE Rationale
1. Introduce self and verify the client’s identity
using agency protocol. Explain to the client
what you are going to do, why it is necessary,
and how he or she can participate. Discuss
how the results will be used in planning
further care or treatments
2. Perform hand hygiene and observe
appropriate infection prevention procedures
3. Provide for client privacy
4. Select the pulse point. Normally, the radial
pulse is taken, unless it cannot be exposed or
circulation to another body area is to be
assessed.
5. Assist the client to a comfortable resting
position.
 When the radial pulse is assessed,
with the palm facing downward, the
client’s arm can rest alongside the
body or the forearm can rest at a 90-
degree angle across the chest.
 For the client who can sit, the
forearm can rest across the thigh,
with the palm of the hand facing
downward or inward
6. Palpate and count the pulse. Place two or Using the thumb is contraindicated
three middle fingertips lightly and squarely because the nurse’s thumb has a pulse
over the pulse point. that could be mistaken for the client’s
pulse
7. Assess the pulse rhythm and volume. Assess A normal pulse has equal time periods
the pulse rhythm by noting the pattern of the between beats. If this is an initial
intervals between the beats.. assessment, assess for 1 minute.

8. Assess the pulse volume. • A normal pulse can be felt with


moderate pressure, and the pressure is
equal with each beat. A forceful pulse
volume is full; an easily obliterated
pulse is weak. Record the rhythm and
volume on your worksheet
. Adjust the volume if necessary. Distinguish
9. Count for 15 seconds and multiply by 4. artery sounds from vein sounds. The artery
Record the pulse in beats per minute on your sound (signal) is distinctively pulsating and has
worksheet. If taking a client’s pulse for the a pumping quality. The venous sound is
first time, when obtaining baseline data, or if intermittent and varies with respirations. Both
the pulse is irregular, count for a full minute. artery and vein sounds are heard
If an irregular pulse is found, also take the simultaneously through the DUS because major
apical pulse arteries and veins are situated close together
throughout the body. If arterial sounds cannot
be easily heard, reposition the probe. If you
cannot hear any pulse, move the probe to
several different locations in the same area
before determining that no pulse is present.
• After assessing the pulse, remove all gel from
the probe to prevent damage to the surface.
Clean the transducer with water-based solution
10. Document the pulse rate, rhythm, and
volume and your actions in the client record
(see Figure ❶ in Skill 29-1).
11. Also record in the nurse’s notes pertinent
related data such as variation in pulse rate
compared to normal for the client and
abnormal skin color and skin temperature
12. Variation: Using a DUS Alcohol or other disinfectants may damage
• If used, plug the stethoscope headset into the face of the transducer. •
one of the two output jacks located next to Remove all gel from the client
the volume control.
 DUS units may have two jacks so that a
second person can listen to the signals.
13. EVALUATION • If assessing peripheral pulses,
• Compare the pulse rate to baseline data or evaluate equality, rate, and volume in
normal range for age of client. corresponding extremities.
• Relate pulse rate and volume to other vital • Conduct appropriate follow-up such
signs; relate pulse rhythm and volume to as notifying the primary care provider
baseline data and health status or giving medication

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