LEC 9.2: Pulse | Vitals

Pulse

Wave of blood created by contraction of Left Ventricle

Left Ventricle

Pulse is created by the contraction of what part of the heart?

Stroke Volume Output

What the pulse wave generally represents which is the amount of blood that enters the arteries with each ventricular contraction

Cardiac Output

Volume of blood that comes out into the arteries by the heart and equals the result of the Stroke Volume x Heart Rate per minute

Pulse Rate = Rate of Ventricular Contraction

In a healthy individual what is the relationship between pulse rate and the rate of ventricular contraction?

1. Apical Pulse

2. Peripheral Pulse

Clients heart produces very weak pulse waves that are not detectable in a pulse far from the heart, like peripheral pulse cells. So what should the nurse assess?

Apical Pulse

Central pulse that is located at the apex of the heart

Point of Maximal Impulse (PMI)

What is the apex of the heart referred to as?

Beats per minute (bpm)

What is rate of pulse expressed in?

1. Age

2. Sex

3. Exercise

4. Fever

5. Medicaitons

6. Hypovolemia or Dehydration

7. Stress

8. Position

9. Pathology

Factors Affecting the Pulse

Age

(Factor affecting the pulse)

• Changes in pulse rate are usually associated with natural aging process, physical fitness, and overall health

• As __ increases, average pulse rate gradually decreases

Sex

(Factor affecting the pulse)

• After puberty, the average male’s pulse rate is lower than that of the females

• Hormonal influences

Exercise

(Factor affecting the pulse)

• Pulse rate normally increases with activity but rate of increase in professional athlete is often less than that of the average individual due to greater cardiac size, strength, efficiency

Fever

(Factor affecting the pulse)

• Pulse rate increases in response to lowered BP that results from peripheral vasodilation related to elevated body temperature and due to increased metabolic rate

Medications

(Factor affecting the pulse)

• Some decrease the pulse rate

  • Cardiotonics

  • Digitalis Preparations

• Others increase it

  • Epinephrine

Hypovolemia/Dehydration

(Factor affecting the pulse)

• Loss of fluid form vascular system increases pulse rate

• Loss of circulating volume results in adjustment of heart rate to increase blood pressure as body compensates for the blood volume that is lost

Stress

(Factor affecting the pulse)

• Sympathetic nervous stimulation increases the overall activity of the heart and rate, force of the heart

• Fear and anxiety stimulate sympathetic system

Position

(Factor affecting the pulse)

• Sometimes when clients sit up or stand up, blood usually pulls independent vessels in our venous system —> resulting in transient decrease in venous blood return to heart and increase heart rate because of reduction in BP

Pathology

(Factor affecting the pulse)

• Certain diseases or heart conditions that could impair oxygenation that can alter the resting pulse rate of the patient

1. Temporal

2. Carotid

3. Apical

4. Brachial

5. Radial

6. Femoral

7. Popliteal

8. Posterior Tibial

9. Dorsalis Pedis

Locations to Assess Pulse

Temporal

(Location to Assess Pulse)

• Where temporal artery passes over temporal bone of head

• Superior and lateral from midline o

Carotid

(Location to Assess Pulse)

• Side of the neck where ___ artery runs between trachea and sternocleidomastoid muscle

• Do not press too hard or may stimulate Vagus nerve which can lead to drop in heart rate —> bradycardia —> dizziness, fainting

• Should not be palpated at the same time

Apical

(Location to Assess Pulse)

• At apex of the heart

• In an adult, located at left side of chain about 3 inches to left of sternum at 5th intercostal space

• In older adults, apex may be further in the left if conditions are present, like enlarged heart

• Before 4 years of age, apex is on the left of the midclavicular line

• Between 4-6 years, at midclavicular line

• 7-9 years, located at 4th or 5th intercostal space

3 inches to left of sternum at 5th intercostal space

In an adult, where is the apex of the heart located (apical pulse site)?

Further in the left of sternum if conditions are present, like enlarged heart

In an older adult, where is the apex of the heart located (apical pulse site)?

Left of the midclavicular line

In a child before 4 years old, where is the apex of the heart located (apical pulse site)?

At midclavicular line

In a child 4-6 years old, where is the apex of the heart located (apical pulse site)?

Located at 4th or 5th intercostal space

In a child before 7-9 years old, where is the apex of the heart located (apical pulse site)?

Brachial

(Location to Assess Pulse)

• At the inner aspects of the biceps of the arm or medially in the antecubital space

Radial

(Location to Assess Pulse)

• Thumb side of wrist

Femoral

(Location to Assess Pulse)

• Alongside inguinal ligament

Popliteal

(Location to Assess Pulse)

• __ artery passes behind the knee

Posterior Tibial

(Location to Assess Pulse)

• On the medial surface of the ankle where the ___ artery passes behind the medial malleolus

• Middle of the ankle

Dorsalis Pedis

(Location to Assess Pulse)

• __ artery passes over the bones of the foot on an imaginary line drawn from the middle of the ankle to the space between the big and second toes

1. Palpation (feeling)

2. Auscultation (hearing)

How is pulse assessed?

Pads of the three middle fingers, moderate pressure

What is used for palpating all pulse sites, except for one?

Apical

What pulse site should NOT be palpated?

Auscultation via stethoscope

What is used to assess the apical pulse?

Doppler Ultrasound Stethoscope (DUS)

What stethoscope is used when there is a difficulty in pulse assessment?

Has a headset with ear pieces similar to standard stethoscopes’ ear pieces or speaker or ultrasound transducer

Detects movement of RBCs through a blood vessel

Eliminates environmental sounds, so very useful for noisy setting

1. Medications

2. Activities

3. Baseline Data

4. Position

What needs to be assessed prior to obtaining the pulse?

Medications

(One of the factors that needs to be assessed prior to obtaining the pulse)

• There are certain ___ that can affect HR

Activities

(One of the factors that needs to be assessed prior to obtaining the pulse)

• If patient/client has been physically ___, we have to wait 10-15 minutes until the client has rested and pulse has slowed to its usual rate

Baseline Data

(One of the factors that needs to be assessed prior to obtaining the pulse)

• For example, those physically fit athletes may have low resting pulse rate

Position

(One of the factors that needs to be assessed prior to obtaining the pulse)

• Sitting or change in certain __ due to change in blood flow or volume of autonomic nervous system activity

1. Rate

2. Rhythm

3. Volume

4. Arterial Wall Elasticity

5. Presence or Absence of Bilateral Equality

What also need to be taken note of when assessing pulse?

Tachycardia

• Excessively fast heart rate over 100 bpm in adult px

Bradycardia

• Heart rate less than 60 bpm in adult px

Pulse Rhythm

• Pattern of the beats and the intervals between beats

Dysrhythmia/Arrhythmia

• Pulse of an irregular rhythm

Apical pulse should be assessed and ECG/EKG should be necessary to define dysrhythmia further

What should be done if Dysrhythmia/Arrhythmia is noted?

Pulse Volume/Strength/Amplitude

• Refers to force of blood with each beat

Peripheral Pulse Assessment

Refers to evaluating the pulses in the limbs to assess blood flow circulation and heart function

Typically checked to evaluate strength, rhythm, and rate of blood flow in the extremities

Can help identify problems like peripheral artery diseases, circulatory issues, or even heart conditions

1. To establish baseline data

2. To identify if it is normal

3. To determine the equality of corresponding peripheral pulses on each side of the body

What are the purposes of assessing Peripheral Pulse?

Apical Pulse Assessment

Indicated for clients whose peripheral pulse is irregular, unavailable

Also for those with known cardiovascular, pulmonary, and renal diseases

Commonly assessed prior to administering medications that affect the heart rate of the client

Also used to assess pulse for newborns, infants, or children up to 2-3 years old

1. Indicated for clients whose peripheral pulse is irregular or unavailable

2. Prior to administering certain medications

3. Clients with known cardiovascular, pulmonary, and renal diseases

4. To assess the pulse for newborns, infants, and children up to 2-3 years old

What are the purposes of assessing apical pulse?

False

True or False: Apical pulse assessment may be delegated to nursing aids.

1. Assess for clinical signs for cardiovascular alterations

2. Do not delegate apical pulse assessment to nursing aid

3. Need clock, timer, or watch; stethoscope, antiseptic wipes

4. Locate it: Position the client appropriately in a comfortable supine position or in a sitting position

5. Expose the area of the chest so the apex of the heart is exposed

6. Locate apical impulse, point over the apex of the heart where the apical pulse may be clearly heard

7. Palpate the angle of Bluey, angle between manubrium, top of sternum, and body of the sternum

   1. Palpated below suprasternal notch and felt as a prominence

8. Slide index finger to left of sternum and palpate second intercostal space

9. Place middle or next finger into next spaces until 5th intercostal space is located

10. Move index finger laterally along 5th intercostal space toward midclavicular line (medial to midclavicular line)

11. Need to know how to document pulse rate, rhythm, nursing actions, related data (variations, discolorations, abnormal temperatures)

How do we assess Apical Pulse?

1. dyspnea

2. difficult respirations

3. fatigue

4. weakness

5. pallor

6. cyanosis

7. palpitations

8. syncope

9. dizziness

10. fainting

11. impaired peripheral tissue perfusion

12. skin discoloration

13. cold temperature

What signs of cardiovascular alteration does the nurse have to assess for prior to taking the apical pulse?

Diaphragm

Larger, flat circular side of stethoscope

High-pitched sounds like:

• Normal Heart sounds

• S1 & S2

• Lung sounds (crackles, wheezes, breath sounds)

• Bowel sounds

What sounds does the diaphragm pick up?

Bell

Smaller, concave bowl-shaped side of stethoscope

Low-pitched sounds like:

• Heart murmurs

• Abnormal heart sounds

• S3 & S4 heart sounds

• Gallops

• Vascular sounds like bruits or venous hums

What sounds does the bell pick up?

Sample documentation of apical pulse assessment

Apical-Radial Pulse Assessment

May need to be assessed for clients with certain CV disorders

Either…

• Thrust of blood from the heart is too weak for the waves to be left at the peripheral pulse site OR

• Vascular disease is preventing impulses from being transmitted

What does an apical pulse greater than radial pulse?

1. Two-Nurse Technique

2. One-Nurse Technique

What are the techniques to conduct Apical-Radial Pulse Assessment?

Two-Nurse Technique

One nurse locates the apical impulse by palpation or with the stethoscope while the other nurse palpates the radial pulse site

If a clock or timer is not visible, nurse that is taking the radial pulse needs to have a watch, while the nurse taking the radial pulse decides when to begin and say and “start”

Ensures simultaneous counts are begun

Each nurse counts pulse for 60 seconds — nurse taking radial pulse says “stop”

One-Nurse Technique

Feel the radial pulse at the same time as listening to the apical pulse

Assess apical pulse for 60 seconds than radial pulse for 60 seconds - difference is the pulse deficit

Pulse Deficit

What is the difference between the 60 second-reading of the apical and radial pulses called?

Cardiac Glycoside/Digitalis Glycoside

Increase cardiac contractility which increases cardiac output, so as a result perfusion to the kidneys is increased, increasing the production of urine

Decrease heart rate by prolonging cardiac conduction

Digoxin

What is commonly used to used for clinical management of heart failure (atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia)?

• Atrial fibrillation

• Atrial flutter

• Paroxysmal atrial tachycardia

What conditions can Digoxin treat?

1 minute

How long should the apical pulse be taken before administering the dose?

60 bpm

What is the normal apical pulse?

Dose should not be administered and pulse should be retaken in 1 hour

If the apical pulse is less than 60 bpm or another specific parameter is set by the healthcare provider, what should be done?

Call the prescriber

If pulse remains less than 60 after an hour or patient reports dizziness initially, what should be done?