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Assessing Pulse Rate

The document is a checklist for assessing pulse rate, detailing procedures and criteria for evaluation. It includes steps for assessing both radial and apical pulses, emphasizing the importance of client communication, hygiene, and documentation. Scoring ranges from 0 to 4, indicating the level of proficiency demonstrated by the assessor.

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froilangarcia331
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11 views

Assessing Pulse Rate

The document is a checklist for assessing pulse rate, detailing procedures and criteria for evaluation. It includes steps for assessing both radial and apical pulses, emphasizing the importance of client communication, hygiene, and documentation. Scoring ranges from 0 to 4, indicating the level of proficiency demonstrated by the assessor.

Uploaded by

froilangarcia331
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: __________________________ Date: ____________ Section/Group: __________

Assessing Pulse Rate


CHECKLIST
Legend:
0 - Procedure was not performed.
1 - Procedure was performed but needs significant improvement.
2 - Procedure was performed satisfactorily, meeting basic expectations.
3 - Procedure was performed very satisfactorily, demonstrating consistent competence and
attention to detail.
4 - Procedure was performed with exceptional proficiency, showcasing outstanding skill,
precision, and expertise beyond expectations.

PROCEDURES 0 1 2 3 4
Assessment
- Assess:
• Clinical signs of cardiovascular alterations such as dyspnea (difficult
respirations), fatigue, pallor, cyanosis (bluish discoloration of skin and
mucous membranes), palpitations, syncope (dizziness or fainting), or
impaired peripheral tissue perfusion (as evidenced by skin discoloration
and cool temperature)
• Factors that may alter pulse rate (e.g., emotional status and activity
level)
• Which site is most appropriate for assessment based on the purpose
Assemble Equipment
• Clock timer or watch with a sweep second hand or digital seconds
indicator.
• If using a DUS: transducer probe, stethoscope headset (some models),
transmission gel, and tissues or wipes
1. Prior to performing the procedure, 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 to 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 reached or circulation to another body area is to be assessed.
5. Assist the client in 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 three middle fingertips
lightly and squarely over the pulse point
7. Assess the pulse rhythm and volume
8. Document the pulse rate, rhythm, and volume and your actions in the
client record note: 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.
Taking Apical Pulse
1. Perform step 1-3
4. Position the client appropriately in a comfortable supine position or in
a sitting position. Expose the area of the chest over the apex of the
heart.
5. Locate the apical impulse. This is the point over the apex of the heart
where the apical pulse can be most clearly heard.
• Palpate the angle of Louis (the angle between the manubrium, the top
of the sternum, and the body of the sternum). It is palpated just below
the suprasternal notch and is felt as a prominence.
• Slide your index finger just to the left of the sternum and palpate the
second intercostal space.
• Place your middle or next finger in the third intercostal space and
continue palpating downward until you locate the fifth intercostal
space.
• Move your index finger laterally along the fifth intercostal space
toward the MCL.
• Normally, the apical impulse is palpable at or just medial to the MCL.
6. Auscultate and count heartbeats.
• Use antiseptic wipes to clean the earpieces and diaphragm of the
stethoscope.
• Warm the diaphragm of the stethoscope by holding it in the palm for a
moment.
• Insert the earpieces of the stethoscope into your ears in the direction
of the ear canals, or slightly forward.
• Tap your finger lightly on the diaphragm.
• Place the diaphragm of the stethoscope over the apical impulse and
listen for the normal S1 and S2 heart sounds, which are heard as “lub-
dub.”
7. Assess the rhythm and the strength of the heartbeat.
• Assess the rhythm of the heartbeat by noting the pattern of intervals
between the beats. A normal pulse has equal periods between beats.
• Assess the strength (volume) of the heartbeat. Normally, the
heartbeats are equal in strength and can be described as strong or weak.
8. Document the pulse rate and rhythm, and nursing actions in the client
record.
note: Also record pertinent related data such as variation in pulse rate
compared to normal for the client and abnormal skin color and skin
temperature.
For the next items, evaluate the students in general according to the criteria. (4
as the highest score)
0 1 2 3 4
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions.
Proper reporting was observed.

Student’s Signature: ____________________

Evaluator’s Signature: ____________________

Comments:
_______________________________________________________________________________
____________________________________________________________.

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