Lesson 3: Assessing the Pulse
Pulse, is a wave of blood created by contraction of the left ventricle of the
heart.
A pulse is commonly assessed by palpation (feeling) or auscultation (hearing).
Terminologies
Tachycardia is a rate greater than 100 beats/min.
Bradycardia. a heart rate in an adult of less than 60 beats/min.
Pulse rhythm is the pattern of the beats and the intervals between the beats.
Dysrhythmia or Arrhythmia A pulse with an irregular rhythm
Pulse volume, also called the pulse strength or amplitude - refers to the force
of blood with each beat.
Purpose
To establish baseline data for subsequent evaluation
To identify whether the pulse rate is within normal range
To determine the pulse volume and whether the pulse rhythm is regular
Lesson 3: Assessing the Pulse 1
To monitor and assess changes in the client’s health status
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)
Procedure (Based on Checklist)
1. Assessment
note for clinical signs of cardiovascular alterations
recall the factors that may alter pulse rate
identify which site is most appropriate of pulse site based
on the purpose and in relation to client’s condition/ age
(note: assessment of factors that can affect both the pulse /
heart and respiratory rate can be done at the same time.)
Factors affecting the pulse:
Age
Sex
Exercise
Fever
Medications
Hypovolemia/Dehydration
Stress
Position
Pathology
2. Assemble the equipment/materials needed and ensure that they are
functioning normally.
Clock or watch with a sweep second hand or digital seconds indicator
Lesson 3: Assessing the Pulse 2
Clean gloves, if appropriate
Stethoscope (if necessary)
Pen, small notebook, VS flowsheet, EMR
3. Select pulse point.
Identify and locate all the nine pulse sites.
Normally, the radial pulse is taken, unless it cannot be exposed or
circulation to another body area is to be assessed.
Lesson 3: Assessing the Pulse 3
4. Assist the client to a complete resting position. Move the client’s
clothing to expose only the site chosen.
Lesson 3: Assessing the Pulse 4
When the radial pulse is assessed, if the client is lying supine, the forearm
can
rest alongside the client’s body or the forearm can rest at a 90- degree
angle
across the chest with the palm facing downward.
For the client who can sit, the forearm can rest across the abdomen with
the palm of the hand facing downward or inward.
• (Note: this comfortable position of the client’s forearm can
rest across the
abdomen, will be used as the student nurse measure and
immediately proceed
with assessment of the client’s respiratory rate without the
need of informing
the client)
5. Palpate and count pulse.
Place the tips of the first two or three middle fingers of your hand over the
groove along radial or thumb side of client’s inner wrist
Slightly extend the wrist with palm down until you note the strongest pulse
Lightly compress against radius, obliterate pulse initially and then relax
pressure
so pulse becomes easily palpable
After you feel the pulse regularly, look at your watch’s second hand and
begin
to count the rate. Note and count for one full minute (60 seconds)
Lesson 3: Assessing the Pulse 5
Lesson 3: Assessing the Pulse 6
Variations in Pulse and Respiration by Age
6. Assess the pulse rhythm by noting the pattern of the
intervals between the beats.
A normal pulse has equal time periods between beats.
Lesson 3: Assessing the Pulse 7
If there’s an irregular pulse is found, compare radial pulses bilaterally and
also take the apical pulse, using a stethoscope.
7. Determine the strength (volume/amplitude) of pulse.
Note its grade (+4, +3, +2, +1, 0) and explain its meaning/rationale
Pulse Amplitude
• 0 - ( ABSENT PULSE) PULSE CANNOT BE FELT EVEN WITH THE
APPLICATION OF EXTREME PRESSURE.
• 1+ - (THREAD PULSE) PULSE IS VERY DIFFICULT TO FEEL AND APPLYING
SLIGHT PRESSURE CAUSES PULSE TO
DISAPPEAR
• 2+ ( WEAK PULSE) PULSE IS STRINGER THAN A THREAD PULSE BUT
APPLYING LIGHT PRESSURE CAUSES
PULSE TO DISAPPEAR.
• 3+ ( NORMAL PULSE) PULSE IS EASILY FELT AND REQUIRES MODERATE
PRESSURE TO MAKE IT DISAPPEAR
• 4+ ( BOUNDING PULSE ) PULSE IS STRONG AND DOES NOT DISAPPEAR
WITH MODERATE PRESSURE.
Lesson 3: Assessing the Pulse 8
Lesson 3: Assessing the Pulse 9
