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    Assessing Pulse Rate

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    Jan Jamison Zulueta
    This document provides instructions for assessing a patient's pulse rate, respirations, and blood pressure. It describes the necessary equipment, steps to perform each assessment, and the rationale for each step. For pulse rate, it describes assessing the radial and apical pulses, including identifying rhythm and counting rate. For respirations, it describes observing chest movement, placing a hand on the wrist, and counting rate for a minute. For blood pressure, it provides detailed instructions for using a sphygmomanometer and stethoscope to identify the five phases of Korotkoff sounds and determine systolic and diastolic pressure.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Assessing Pulse Rate

    Uploaded by

    Jan Jamison Zulueta
    1K views4 pages
    This document provides instructions for assessing a patient's pulse rate, respirations, and blood pressure. It describes the necessary equipment, steps to perform each assessment, and the rationale for each step. For pulse rate, it describes assessing the radial and apical pulses, including identifying rhythm and counting rate. For respirations, it describes observing chest movement, placing a hand on the wrist, and counting rate for a minute. For blood pressure, it provides detailed instructions for using a sphygmomanometer and stethoscope to identify the five phases of Korotkoff sounds and determine systolic and diastolic pressure.

    Original Description:

    ASSESSING PULSE RATE RLE

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    This document provides instructions for assessing a patient's pulse rate, respirations, and blood pressure. It describes the necessary equipment, steps to perform each assessment, and the rationale for each step. For pulse rate, it describes assessing the radial and apical pulses, including identifying rhythm and counting rate. For respirations, it describes observing chest movement, placing a hand on the wrist, and counting rate for a minute. For blood pressure, it provides detailed instructions for using a sphygmomanometer and stethoscope to identify the five phases of Korotkoff sounds and determine systolic and diastolic pressure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views4 pages

    Assessing Pulse Rate

    Uploaded by

    Jan Jamison Zulueta
    This document provides instructions for assessing a patient's pulse rate, respirations, and blood pressure. It describes the necessary equipment, steps to perform each assessment, and the rationale for each step. For pulse rate, it describes assessing the radial and apical pulses, including identifying rhythm and counting rate. For respirations, it describes observing chest movement, placing a hand on the wrist, and counting rate for a minute. For blood pressure, it provides detailed instructions for using a sphygmomanometer and stethoscope to identify the five phases of Korotkoff sounds and determine systolic and diastolic pressure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The key takeaways are the proper procedures and techniques for assessing a patient's pulse rate, apical pulse, and blood pressure.

    The steps to assess pulse rate are to inform the client, flex the elbow, grasp the wrist, palpate the radial artery, identify the rhythm and volume, and count the rate using a watch for one minute.

    The steps to assess apical pulse are to expose the chest, clean the stethoscope, locate landmarks on the chest, palpate the point of maximal impulse, inform the client, auscultate over the impulse, note the rhythm, and count the rate.

    ASSESSING PULSE RATE

    EQUIPMENTS:
    Watch with a second hand
    Stethoscope
    Action
    1. RADIAL PULSE
    a. Inform client of the site(s) at which
    you will measure pulse.
    b. Flex clients elbow and place lower
    part of arm across chest.

    c. Support clients wrist by grasping


    outer aspect with thumb.
    d. Place your index and middle finger on
    inner aspect of clients wrist over the
    radial artery and apply light but firm
    pressure until pulse is palpated.
    e. Identify pulse rhythm.

    Rationale
    a. Encourages participation and allays
    anxiety.

    b. Maintains wrist in full extension and


    exposes artery for palpation. Placing
    clients hand over chest will facilitate
    later respiratory assessment without
    undue attention to your action.
    c. Stabilizes wrist and allows for
    pressure to be exerted.
    d. Fingertips are sensitive, facilitating
    palpation of pulsating pulse. The CG may
    feel own pulse if palpating with thumb.
    Applying light pressure prevents
    occlusion of blood flow and pulsation.

    f. Determine pulse volume.

    e. Palpate pulse until rhythm is


    determined.
    Describe as regular or irregular.

    g. Count pulse rate by using second


    hand on a watch:
    For an irregular rhythm, count
    number of beats for a full minute,
    noting number of irregular beats.

    f. Quality of pulse strength is an


    indication of stroke volume. Describe as
    normal, weak, strong, or bounding.

    2. APICAL PULSE
    a. Raise clients gown to expose sternum
    and left side of chest.
    b. Cleanse earpiece and diaphragm of
    stethoscope with an alcohol swab.
    c. Put stethoscope around your neck.

    g. An irregular rhythm requires a full


    minute of assessment to identify the
    number of inefficient cardiac
    contractions that fail to transmit a
    pulsation, referred to as a skipped or
    irregular beat.
    a. Allows access to clients chest for
    proper placement of stethoscope.
    b. Decreases transmission of
    microorganisms from one practitioner to
    another (earpiece) and from one client to
    another (diaphragm).

    d. Apex of heart:
    With client lying on left side, locate
    suprasternal notch.
    Palpate second intercostal space to left
    of sternum.

    Identification of landmarks facilitates


    correct placement of the stethoscope at

    Place index finger in intercostal space,


    counting downward until fifth intercostal
    space is located.
    Move index finger along fourth
    intercostals space left of the sternal
    border and to the fifth intercostal space,
    left of the midclavicular line to palpate
    the point of maximal impulse (PMI)

    the fifth intercostal space in order to


    hear point of maximal impulse.

    Ensures correct placement of


    stethoscope.

    Keep index finger of nondominant


    hand on the PMI.
    e. Inform client that you are going to
    listen to his heart. Instruct client to
    remain silent.
    f. With dominant hand, put earpiece of
    the stethoscope in your ears and grasp
    diaphragm of the stethoscope in palm of
    your hand for 5 to 10 seconds.

    e. Elicits client support. Stethoscope


    amplifies noise.
    f. Dominant hand facilitates
    psychomotor dexterity for placement of
    earpiece with one hand. Heat warms
    metal or plastic diaphragm and prevents
    startling client.

    g. Place diaphragm of stethoscope over


    the PMI and auscultate for sounds S1
    and S2 to hear lub-dub sound.
    h. Note regularity of rhythm.

    i. Start to count while looking at second


    hand of watch. Count lub-dub sound as
    one beat:
    For a regular rhythm, count rate for
    60 seconds.

    h. Establishment of a rhythm pattern


    determines length of time to count the
    heartbeats to ensure accurate
    measurement.
    i. Ensures sufficient time to count
    irregular beats.

    For an irregular rhythm, count rate for


    a full minute, noting number of irregular
    beats.
    j. Share your findings with client.

    j. Supports client participation in care.

    k. Record by site the rate, rhythm, and,


    if applicable, number of irregular beats.

    k. Record rate and characteristics at


    bedside to ensure accurate
    documentation.

    ASSESSING RESPIRATIONS
    Equipment
    Watch with a second hand
    Action
    1. Before replacing clients gown from
    auscultating heart sounds, assess

    Rationale
    1. Facilitates observation of chest wall
    and abdominal movements.

    respirations.
    2. Place your hand over clients wrist
    and observe one complete respiratory
    cycle.
    3. Start to count with first inspiration
    while looking at second hand sweep of
    watch. Count a full minute.
    4. Observe depth of respirations by
    degree of chest wall movement and
    rhythm of cycle (regular or interrupted).
    5. Replace clients gown.
    6. Record rate and character of
    respirations.

    2. Hand rises and falls with inspiration


    and expiration.
    3. Respiratory rate is one complete cycle
    (inspiration and expiration).
    4. Reveals volume of air movement into
    and out of the lungs. Describe as
    shallow, normal, or deep.
    5. Prevents embarrassment and chilling.
    6. Record rate and characteristics at
    bedside to ensure accurate
    documentation

    ASSESSING BLOOD PRESSURE


    EQUIPMENT
    Alcohol swabs
    Sphygmomanometer with proper size cuf
    Stethoscope
    ACTION
    RATIONALE
    1. Determine which extremity is most
    1. Cuf inflation can temporarily
    appropriate for reading. Do not take a
    interrupt blood flow and compromise
    pressure reading on an injured or painful circulation in an extremity already
    extremity or one in which an intravenous impaired or a vein receiving intravenous
    line is running.
    fluids.
    2. Select a cuf size that completely
    2. Provides equalization of pressure on
    encircles upper arm without overlapping. the artery to ensure accurate
    measurement.
    3. Move clothing away from upper
    3. Ensures accurate measurement.
    aspect of arm.
    4. Position arm at heart level, extend
    4. Blood pressure increases when arm is
    elbow with palm turned upward.
    below level of heart and decreases when
    arm is above level of heart.
    5. Make sure cuf is fully deflated and
    5. Equipment must function properly to
    pump valve moves freely.
    obtain an accurate reading.
    6. Locate brachial artery in the
    6. Designates placement of stethoscope.
    antecubital space.
    7. Apply cuf snugly and smoothly over
    7. Ensures even pressure distribution
    upper arm, 2.5 cm (1 in.) above
    over brachial artery. Prevents tubing
    antecubital space with center of cuf
    from being constricted and allows
    over brachial artery.
    visualization of aneroid manometer dial.
    8. Insert earpiece of stethoscope in ears 8. Enhances sound transmission from
    with a forward tilt, ensuring diaphragm
    chestpiece to ears.
    hangs freely.
    9. Relocate brachial pulse with your
    9. Sound heard best directly over artery;
    nondominant hand and place bell or
    decreases muffled sounds that cause
    diaphragm chestpiece directly over
    inaccurate reading. Bell chestpiece is
    pulse. Chestpiece should be in direct
    more sensitive to low-frequency sound
    contact with skin and not touch cuf.
    that occurs with pressure release.
    10. With dominant hand, turn valve
    10. Prevents air leak during inflation.
    clockwise to close. Compress pump to
    inflate cuf.
    11. Slowly turn valve counterclockwise
    11. Maintains constant release of
    so that mercury falls at a rate of 23 mm pressure to ensure hearing first systolic

    Hg per second.
    Listen for five phases of Korotkofs
    sounds while
    noting manometer reading:
    A faint, clear tapping sound appears
    and increases in intensity (phase I).
    Swishing sound (phase II).
    Intense sound (phase III).
    Abrupt, distinctive muffled sounds
    (phase IV).
    Sound disappears (phase V).
    14. Deflate cuf rapidly and completely.
    15. Remove cuf or wait 2 minutes
    before taking a second reading.
    16. Inform client of reading.
    17. Record reading.
    18. Lower bed, raise side rails, place call
    light in easy reach.
    19. Put all equipment in proper place.
    20. Wash hands.

    sound. Identify manometer readings for


    each of the five phases.

    Identify two consecutive tapping


    sounds to confirm systolic reading.

    Phase IV is the best indicator of


    diastolic pressure in children.
    Phase V is the best index of diastolic
    blood pressure in clients over age 13.
    14. Prevents arterial occlusion and client
    discomfort of numbness or tingling.
    15. Releases trapped blood in the
    vessels.
    16. Promotes client participation in care.
    17. Ensures accuracy.
    18. Promotes client safety.

    21. Document measurements in clients


    medical record on appropriate form,
    usually vital signs flow sheet.
    22. Compare data with clients baseline
    and normal range for age group.

    19. Fosters maintenance of equipment.


    20. Prevents transmission of
    microorganisms.
    21. Vital sign measurements are usually
    charted on the graphic section of the
    vital signs form.
    22. Provides for comparative data
    analysis.

    23. If any measurements are abnormal,


    measure again and report abnormal
    findings to instructor or charge nurse.

    23. Reporting abnormal measurements


    alerts staf to possible problems
    requiring intervention.

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