ATI: Pulse

The pulse is the rhythmic dilation of the arteries and pulsation of blood flow occurring with each contraction of the left ventricle.

1. Physiology and Regulation

  1. Sinoatrial (SA) Node

    • Known as the intrinsic pacemaker of the heart.

    • Located in the right atrium.

    • Generates electrical impulses that travel to the atrioventricular (AV) node to trigger heart muscle contraction.

  2. Influencing Factors

    • Increases Pulse: Exercise, elevated body temperature, anxiety, caffeine, nicotine, and certain medications.

    • Decreases Pulse: Physical fitness (well-conditioned heart), underactive thyroid gland (hypothyroidism), and specific medications.

2. Pulse Rate Classifications (Adults)

  • Tachycardia: A pulse rate greater than 100/min

    • Manifestations: Racing heart sensations or no symptoms at all.

    • Nursing Interventions: Encourage relaxation (yoga, meditation), perform the Valsalva maneuver (bearing down to stimulate the vagus nerve/parasympathetic system), and smoking cessation education.

  • Bradycardia: A pulse rate less than 60/min60/min.

    • Manifestations: Dizziness, fatigue, chest pain, or shortness of breath (common in unfit individuals; expected in athletes).

    • Nursing Interventions: Change positions slowly to prevent orthostatic issues and monitor for systemic perfusion.

3. Pulse Assessment Techniques

  • Apical Pulse

    • Location (Adults/Kids >7>7): 5th5th intercostal space (ICS) at the left midclavicular line.

    • Location (Kids <7<7): 4th4th intercostal space to the left of the sternum.

    • Method: Auscultate for 11 full minute if the rhythm is irregular.

  • Heart Sounds

    • S1S1 (Lub): Closure of mitral and tricuspid valves; low-pitched; best heard with the bell.

    • S2S2 (Dub): Closure of aortic and pulmonic valves; high-pitched; best heard with the diaphragm.

  • Peripheral Pulses

    • Sites: Temporal, carotid, brachial, radial (most common), femoral, popliteal, posterior tibial, and dorsalis pedis.

    • Pulse Strength Rating Scale:

    • 00: Absent/nonpalpable

    • +1+1: Weak/diminished

    • +2+2: Normal (expected)

    • +3+3: Increased/strong

    • +4+4: Bounding

4. Special Considerations

  • Pulse Deficit: The difference between the apical pulse and a peripheral (radial) pulse.

    • Calculation: Apical Rate−Radial Rate=Pulse DeficitApical Rate−Radial Rate=Pulse Deficit.

    • Requires two nurses to assess simultaneously.

  • Doppler Ultrasound Stethoscope (DUS): Used when peripheral pulses are nonpalpable or circulation is severely impaired.

5. NCLEX-Style Prep (Unit Test)

  1. A nurse finds a client's radial pulse to be irregular. Which action should the nurse take next?

    • Answer: Auscultate the apical pulse for 11 full minute to confirm the irregularity.

  2. A client has an apical pulse of 108/min108/min and a radial pulse of 88/min88/min. What is the pulse deficit?

    • Calculation: 108−88=20/min108−88=20/min.

  3. Which pulse site is located on the top of the foot?

    • Answer: Dorsalis pedis.

  4. A nurse is teaching a client the Valsalva maneuver to manage tachycardia. What instruction should be given?

    • Instruction: "Bear down as if you are having a bowel movement to stimulate your nervous system."

  5. At which location should the nurse palpate the pulse of an adult client's apex?

    • Answer: Left 5th5th intercostal space at the midclavicular line.