Skill 02[1]..Pulse.pdf

SKILL 2

Pulse

EQUIPMENT

Stethoscope (for apical pulse)

Watch with a second hand

GENERAL GUIDELINES FOR VITAL SIGNS

1. Check record for baseline and factors (age, illness, med-

ications, etc.) influencing vital signs. Provides parame-

ters and helps in device and site selection.

2. Gather equipment, including paper and pen, for record-

ing vital signs. Promotes organization and efficiency.

3. Wash hands. Reduces transmission of microorganisms.

4. Prepare child and family in a quiet and nonthreatening

manner. Enhances cooperation and participation;

reduces anxiety and fear, which can affect readings.

NOTE: Infants and young children may be quiet and

more cooperative if vitals signs are obtained while

child is sitting on caregiver’s lap.

APICAL PULSE

PROCEDURE

Apical pulse should be the first vital sign assessed. Other

assessment procedures may be upsetting, leading to

increased heart rate and crying, which makes hearing apical

pulse difficult .

An apical pulse should be taken on neonates, infants,

and young children (under 2 years of age) and on all children

with cardiac problems or receiving digitalis preparations.

Radial pulse is unreliable in neonates and infants due to their

small size and normally rapid heart rate. Radial pulse is

unreliable in children with cardiac problems or receiving

digitalis preparations due to possibly irregular heart rhythm.

1. Steps 1–4 of General Guidelines.

2. Cleanse earpieces and diaphragm of stethoscope with an

alcohol wipe. Reduces transmission of microorganisms

from practitioner to practitioner and from client to

client.

3. Warm stethoscope in hand for 5–10 seconds. Prevents

client from being startled by cold bell; promotes client

comfort.

4. Raise client’s gown to expose sternum and left chest.

Allows for proper placement of stethoscope.

5. Place stethoscope over point of maximal impulse (PMI).

Enhances ability to clearly hear heart sounds.

a. For infant, PMI is at 3rd to 4th intercostal space near

the sternum. (Figure 6)

FIGURE 6 Place stethoscope over point of

maximum impulse to count heart rate.

b. For older child, PMI is at 5th left intercostal space in

the midclavicular line.

6. Count pulse for one full minute. Each “lub-dub” sound

is one beat. Assess apical pulse for rate, rhythm, and any

abnormal heart sounds. If an irregular rhythm, deter-

mine if there is a regular pattern to the irregularity.

Counting for less than one minute may lead to inaccu-

rate heart rate, especially in neonates, infants, and

young children where arrhythmia is normal or in chil-

dren with cardiac problems or receiving digitalis prepa-

rations.

7. If appropriate, evaluate for pulse deficit between the

apical pulse and peripheral pulse by simultaneously tak-

ing the apical and radial pulse. For the inexperienced

nurse this may be more accurately accomplished by

using two nurses, one to count the apical pulse and one

to count the radial pulse. Both nurses should use the

same watch when performing this procedure.

8. Wash hands. Reduces transmission of microorganisms.

continued

SKILL 2

Pulse

continued

RADIAL PULSE

DOCUMENTATION

1. Pulse rate and site.

2. Rhythm, and, if applicable, number and character of

irregular beats.

3. Sites, character, and quality of peripheral pulses. Note if

bilateral equality and if deficits exist between upper and

lower extremities.

4. Who notified if concerned about findings.

PROCEDURE

A radial pulse is reliable in children over 2 years of age

except as specified under apical pulse above. Some agency

policies require apical pulses on all children regardless of

age or condition. Be familiar with the policy of your agency.

1. Steps 1–4 of General Guidelines.

2. Place index and middle finger along child’s radial artery.

Fingertips are sensitive to touch. Use of thumb might

lead to nurse feeling own pulse.

3. Apply gentle pressure, enough to feel the pulsating

artery. Too firm a pressure obliterates the pulse. Too gen-

tle a pressure does not allow one to feel the pulse.

4. Count pulse rate for 30 seconds and multiply by two to

get the rate per minute. If there are any abnormalities in

the pulse, count the rate for one full minute. Ensures

sufficient time to count irregular beats.

5. Assess the pulse for rate, rhythm, amplitude (strength),

and elasticity of vessel (distention of vessel).

6. Wash hands. Reduces transmission of microorganisms.

ASSESSMENT OF PERIPHERAL

PULSES

PROCEDURE

1. Steps 1–4 of General Guidelines.

2. Assess peripheral pulses by placing index and middle

finger against pulse site and applying gentle pressure.

Pulse sites to be assessed generally include brachial,

radial, femoral, popliteal, posterior tibial, and dorsalis

pedis (pedal). See steps 2 and 3 of radial pulse proce-

dure.

3. Assess equality of pulses (amplitude and elasticity of

vessel) bilaterally, i.e., right side compared to left side.

Assess for any pulse deficit between upper and lower

extremities.

4. Wash hands. Reduces transmission of microorganisms.

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