Pulse

The pulse is a wave of blood created by contraction of the left ventricle of the heart. Generally,
the pulse wave represents the stroke volume output or the amount of blood that enters the
arteries with each ventricular contraction. Compliance of the arteries is their ability to contract
and expand. When an individual’s arteries lose their distensibility, as can happen with the age,
greater pressure is required to pump the blood into the arteries.

Cardiac output is the volume of blood pumped into the arteries by the heart and equals
the result of the stroke volume (SV) times the heart rate (HR) per minute. For example. 65mL c
70 beats per minute = 4.55 L per minute. When an adult is resting, the heart pumps about 5
liters of blood each minute.

In a healthy individual, the pulse reflects the heartbeat; that is, the pulse rate is the same as the
rate of the ventricular contractions of the heart. However, in some conditions, the heartbeat and
pulse rates can differ. For example, a client's heart may produce very weak pulse waves that
are not detectable in a pulse far from the heart. In these instances, the should assess both the
heartbeat (apical pulse) and the peripheral pulse. A peripheral pulse is a pulse located away
from the heart, for example, in the foot or wrist, The apical pulse, in Contrast, is a central pulse;
that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse
(PMI).

Factors Affecting the Pulse

The rate of the pulse is expressed in beats per minute (beats/min). Consider each of the
following factors when assessing a client's pulse:

 Age. As age increases, the average pulse rate gradually decreases. See Table 28.2 for
specific variations in pulse rates from birth to adulthood.

 Sex. After puberty, the average male's pulse rate is slightly lower than the female's.

 Exercise. The pulse rate normally increases with activity. The rate of increase in the
professional athlete is often less than in the average individual because of greater
cardiac size, strength, and efficiency

 Fever. The pulse rate increases (a) in response to the lowered blood pressure that
results from peripheral vasodilation associated with elevated body temperature and (b)
because of the increased metabolic rate.

 Medications. Some medications decrease the pulse rate, and Others increase it. For
example, cardiotonics (e.g., digitalis preparations) decrease the heart rate, whereas
epinephrine increases it,
  Hypovolemia or dehydration. Loss of fluid from the vascular system increases the
pulse rate. The loss of circulating volume results in an adjustment of the heart rate to
increase blood pressure as the body compensates for the lost blood volume.
o
 Stress. In response to stress, sympathetic nervous stimulation increases the over-all
activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear
and Anxiety as well as acute pain stimulate the sympathetic system
Position. In applying sitting and standing, blood usually pools in dependent vessels of
the venous system. Pooling usually in the transient decrease in the venous gland return
to the heart and is subsequent reduction in blood pressure and increase in heart rate.
 Pathology. Certain diseases such as some heart conditions or those that impair
oxygenation can alter the resting pulse rate.

TABLE 28.2 VARIATIONS IN PULSE AND RESPIRATION BY AGE

Age Pulse Average Respirations Average

(and Ranges) (and Ranges)

Newborn 130 (80 – 180) 35 (30 - 60)

1 Year 120 (80 - 140) 30 (20 – 40)

5 – 8 Years 100 (75 – 120) 20 (15 – 25)

10 Years 70 (50 – 90) 19 (15 – 25)

Teen 75 (50 - 90) 18 (15 - 20)

Adult 80 (60 – 100) 16 (12 - 20)

Older Adult 70 (60 – 100) 16 (15 – 20)

Pulse sites

A pulse is commonly measured in nine sites (Figure 28.13).

Figure 28.13

1. Temporal, where the temporal artery passes over the temporal bone of the head. The
site is superior (above) and lateral to (away from the midline of) the eye.

2. Carotid, at the side of the neck where the carotid artery runs between trachea and the
sternocleidomastoid muscle.

Clinical Alert: Never press both carotid at the same time because this can cause a reflex drop in blood
pressure or pulse rate.
 3. Apical, at the apex of the heart. In an adult this s located on the left side of the chest
about 8 cm (3 in.) to the left of the sternum (breastbone at the fifth intercoastal space
(area between the ribs). In older adults, the apex maybe further left if the conditions are
present that have leave enlarge heart. Before 4 years of age, the apex is left on the
midclavicular line (MCL); between 4 and 6 years, it is at the MCL (Figure 28.14) for a
child 7 to 9 years of age, the apical pulse is located at the fourth or fifth intercoastal
space.

4. Brachial is at the inner aspects of the biceps muscles of the arm or medially in the
antecubital space.

5. Radial, runs along the radial bone, on the thumb side of the inner aspect of the wrist.

6. Femoral, where the femoral artery passes along side of the inguinal ligament.

7. Popliteal, where the popliteal artery passes behind the knee.

8. Posterior tibial, on the medial surface of the angle where the posterior tibial artery
passes behind the medial malleolus.

9. Dorsalis pedis, where the dorsalis pedis artery passes over the bone of the foot on an
imaginary line drawn from the middle of the angle to the space between the big and the
second toes.

Table 28.3 Reasons for using specific pulse sites

Pulse Site Reasons for Use

Radial Readily accessible

Temporal Used when radial pulse is not accessible

Carotid Used during cardiac arrest or shock in adults

Used to determine circulation to the brain

Apical Routinely used for infants and children up to 3 years of age

Used to determine discrepancies with radial pulse

Used in conjunction with some medication

Brachial Used to measure blood pressure

Used during cardiac arrest for infants

Femoral Used in case of cardiac arrest or shock

Used to determine circulation to a leg

 Popliteal Used to determine circulation to a lower leg

Posterior Tibial Used to determine circulation to the foot

Dorsalis Pedis Used to determine circulation to the foot

The radial site is most commonly used in adults. It is easily found in most people and readily
accessible. Some reasons for use of each site are given in Table 28.3

Assessing the Pulse

A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The middle

three fingertips are used for palpating all pulse sites except the apex of the heart. A stethoscope
is used for assessing apical pulses. A Doppler ultrasound stethoscope (DUS; Figure 28.15)

Figure 28.15

Is used for pulses that are difficult to assess. The DUS has a headset with earpieces similar to
standard stethoscope earpieces or as speaker, and an ultrasound transducer. The DUS detects
movement of red blood cells through a blood vessel. In contrast to the conventional
stethoscope, it eliminates environmental sounds, thus, is useful in noisy settings.

A pulse is normally palpated by applying moderate pressure with the three middle
fingers of the hand. The pads on the most distal aspects of the finger are the most sensitive
areas for detecting a pulse. With excessive pressure, one can obliterate a pulse, whereas with
too little pressure one may not be able to detect it. Before the nurse the resting pulse, the client
should assume a comfortable position. The nurse should also be aware of the following:

 Any medication that could affect the heart rate

  Whether the client has been physically active. If so, wait 10 to 15 minutes until the client
has rested and the pulse has slowed to its usual rate.

 Any baseline data about the normal heart rate for the client. For example, a physically fit
athlete may have a resting heart rate below 60 beats/min.

 Whether the client should assume a particular position (e.g., sitting). In some clients, the
rate changes with the position because of changes in blood flow volume and autonomic
nervous system activity.

When assessing the pulse, the nurse collects the following data: the rate, rhythm, volume,
arterial wall elasticity, and presence or absence of bilateral equality. An excessively fast heart
rate (e.g., over 100 beats/ min in an adult) is referred to as tachycardia. A heart rate in an adult
of less than 60 beats/ min is called bradycardia. If a client has either tachycardia or
bradycardia, the apical pulse should be assessed.

The pulse rhythm is the pattern of the beats and the intervals between the beats. Equal
time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as
a dysrhythmia or arrhythmia. It may consist of random, irregular beats or predictable pattern
of irregular beats (documented as “regularly irregular”). When a dysrhythmia is detected, the
apical pulse should be assessed. An electrocardiogram (ECG or EKG) is necessary to define
the dysrhythmia further.

Pulse volume, also called the pulse strength or amplitude, refers to the force of blood
with each beat. Usually, the pulse volume is the same with each beat. Usually, the pulse volume
is the same with each beat. It can range from absent to bounding. A normal pulse can be felt
with moderate pressure of the fingers and can be obliterated with greater pressure. A forceful or
full blood volume that is obliterated only with difficulty is called a full or bounding pulse. A pulse
that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or
thready.

The elasticity of the arterial wall reflects its expansibility or its deformities. A healthy,
normal artery feels straight, smooth, soft, and pliable. Older adults often have inelastic arteries
that feel twisted (tortuous) and irregular on palpation.

When assessing a peripheral pulse to determine the adequacy of blood flow to a

particular area of the body (perfusion), the nurse should also asses the corresponding pulse on
the other side of the body. The second assessment gives the nurse data with which to compare
the pulses. For example, when assessing the blood flow to pulses. For example, when
assessing the blood flow to the right foot, the nurse assesses the right dorsalis pedis pulse and
then the left dorsalis pedis pulse. If the client’s right and left pulses are the same volume and
elasticity, the client’s dorsalis pedis pulses are bilaterally equal. The pulse rate does not need to
be counted when assessing for perfusion and equality.

When a peripheral pulse is located, it indicates that pulses more proximal to that
location, will also be present. For example, if the dorsalis pedis, the most distal pulse of the
lower extremity, cannot be felt, the nurse next palpates for the posterior tibial pulse. If it is not
felt, the popliteal pulse must be assessed. If the popliteal pulse is found, it is not necessary to
assess the femoral pulse since it must also be present in order for the more distal pulse to exist.

Assessing a Peripheral Pulse

PURPOSES

 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

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

ASSESSMENT
Assess
 Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations),
fatigue, pallor, cyanosis (blush discoloration of skin and mucous membranes),
palpitations, syncope (dizziness and fainting), or impaired peripheral tissue, perfusion
(as evidenced by skin discoloration and cool temperature)

PLANNING
Measurement of the clients radial or brachial pulse can be assigned to AP, or be performed by
family members or caregivers in nonhospital settings. Reports of abnormal pulse rates or
rhythms require reassessment by the nurse, who also determines appropriate action if the
abnormality is confirmed. AP are generally not delegated these techniques due to skill required
in location and interpreting peripheral pulses other than the radial or brachial artery and in using
Doppler ultrasound devices.

IMPLEMENTATION

Preparation

If using a DUS, check that the equipment is functioning normally.

Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what you are going to do why it is necessary, and
how to participate. Discuss how the results will be used in planning further care or
treatments.

2. Perform hand hygiene and observe appropriate infection prevention procedures.

3. Provide for client privacy.

4. Select the pulse point. Normally, the radial pulse is taken, unless it cannot be reached or
circulation to another body area is to be assessed.

5. Assist the client to a comfortable resting position. When the radial pulse is assessed,
with the palm facing downward, the client’s arm can rest alongside the body or the
forearm can rest at a 90-degree angle across the chest. For the client who can sit the
forearm can rest across the thigh, with the palm of the hand facing downward or inward.

6. Palpate and count the pulse. Place two or three middle fingertips lightly and squarely
over the pulse point. Rationale: Using the thumb is contraindicated because the nurse’s
thumb has a pulse that could be mistaken for the client’s pulse.

 Count for 15 seconds and multiply by 4. Record the pulse in beats per minute on your
worksheet. If taking a client’s pulse for the first time, when obtaining baseline data, or if
the pulse is irregular pulse is found, also take the apical pulse.

7. Assess the pulse rhythm and volume.

 Assess the pulse rhythm by noting the pattern of the intervals between the beats. A
normal pulse has equal time periods between betas. If this is an initial assessment,
assess for 1 minute.

 Assess the pulse volume. A normal pulse can be felt with moderate pressure, and the
pressure is equal with each beat. A forceful pulse volume is full; an easily obliterated
pulse is weak. Record the rhythm and volume on your worksheet.

8. Document the pulse rate, rhythm and volume and your actions in the client record (see
Figure 1 in Skill 28.1) Also record pertinent related data such as variation in pulse rate
compared to normal for the client and abnormal skin color and skin temperature.
Figure 1. A, Radial

Figure 1. B, Brachial
Figure 1. C, Carotid

Figure 1. D, Femoral
 Figure 1. E, Popliteal

Figure 1. F, Posterior Tibial

Figure 1. G. Dorsalis Pedis

Variation: Using a DUS

  If used, plug the stethoscope headset into one of the two output jacks located next to the
volume control, DUS units may have two jacks so that a second individual can listen to
the signals.

 Apply transmission gel either to the probe at the narrow end of the plastic case housing
the transducer, or to the client’s skin. Rationale: Ultrasound beams do not travel well
through air. The gel makes an airtight seal, which then promotes optimal ultrasound
wave transmission.

 Press the “on” button.

 Hold the probe against the skin over the pulse site. Use light pressure, and keep the
probe in contact with the skin. Rationale: Too much pressure can stop the blood flow
and obliterate the signal.

Figure 2. Using a DUS to assess the dorsalis pedis

Apical Pulse Assessment

Assessment of the apical pulse is indicated for clients whose peripheral pulse is indicated for
clients whose peripheral pulse is irregular or unavailable and for clients with known
cardiovascular, pulmonary, and renal diseases. It is commonly assessed prior to administering
medications that affect heart rate. The apical site is also used to assess the pulse for newborns,
infants, and children up to 2 to 3 years old.

Assessing and Apical Pulse

PURPOSES

 To obtain the heart rate of an adult with an irregular peripheral pulse

 To establish baseline data for subsequent evaluation

 To determine whether the cardiac rate is within normal range and the rhythm is regular
  To monitor clients with cardiac, pulmonary, or renal disease and those receiving
medications to improve heart action

ASESSMENT
Assess
 Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations),
fatigue, weakness, pallor, cyanosis (bluish discoloration of skin and mucous
membranes), palpitations, syncope (dizziness or fainting), or impaired peripheral tissue
perfusion as evidenced by skin discoloration and cool temperature.

 Factors that may alter pulse rate (e.g., emotional status , activity level, and the
medications that affect heart rate such as digoxin, beta-blockers, or calcium channel
blockers).

PLANNING
Due to the degree of skill and knowledge required, AP are generally not responsible for
assessing apical pulses.

Equipment

 Clock, timer, or watch with a sweep second hand or digital second indicator

 Stethoscope

 Antiseptic wipes

 If using DUS; the transducer probe, the stethoscope headset transmission gel, and
tissues or wipes

IMPLEMENTATION

Preparation

If using a DUS, check that the equipment is functioning normally.

Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what are going to do, why it is necessary, and how
to participate. Discuss how the results will be used in planning further care or treatments.

2. Perform hand hygiene and observe appropriate infection prevention procedures.

3. Provide for client privacy.

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

Expose the area of the chest over the apex of the heart.
5. Locate the apical impulse. This is the point over the apex of the heart where the apical
pulse can be most clearly heard.

 Palpate the angle of Louis (the angle between the manubrium, the top of the
sternum, and the body of the sternum) It is palpated just below the suprasternal
notch and is felt as a prominence (see Figure 28.14)

Figure 28.14 Location of the apical pulse for a child under 4 years, a child 4 to 6
years, and an adult

 Slide your index finger just to the left of the sternum, and palpate the second
intercostal space (1)

(1) Second Intercostal space

Clinical Alert!
  Place your middle or next finger in the third intercostal space, and continue
palpating downward until you locate the fifth intercostal space (2)

(2) Third Intercostal space

 Move your index finger laterally along the fifth intercostal space toward the MCL.
(3)

Auscultate and count heartbeats.

 Use antiseptic wipes to clean the earpieces and diaphragm of the stethoscope.
Rationale: The diaphragm needs to be cleaned and disinfected on a regular
basis. Both earpieces and diaphragms have been shown to harbor pathogenic
bacteria.

 Warm the diaphragm of the stethoscope by holding it in the palm of the hand for
a moment. Rationale: The metal of the diaphragm is usually cold and can startle
the client when placed immediately on the chest.

 Insert the earpieces of the stethoscope into your ears in the direction of the ear
canals, or slightly forward. Rationale: This position facilitates hearing.

 Tap your finger lightly on the diaphragm. Rationale: This ensures it is active side
of the head. If necessary, rotate the head to select the diaphragm side to select
the diaphragm side. (4)
 Stethoscope with both a bell and a diaphragm

 Place the diaphragm of the stethoscope over the apical pulse and listen for
the normal S1 and S2 heart sounds, which are heard as “lub-dub”. (5)
Rationale: The two heart sounds are produced by closure of the heart
valves. The S1 heart sound (lub) occurs when the atrioventricular valves
close after the ventricles have been sufficiently filled. The S2 heart sound
(dub) occurs when the semilunar valves close after the ventricles empty.

6. Auscultate and count heartbeats

Auscultate and count heartbeats Rationale

Use antiseptic wipes to clean the earpieces The diaphragm needs to be cleaned and
and diaphragm of the stethoscope. disinfected on a regular basis. Both earpieces
and diaphragms have been shown to harbor
pathogenic bacteria (Bansal, Sarath, Bhan,
Gupta, & Purwar, 2019).

Warm the diaphragm of the stethoscope by The metal of the diaphragm is usually cold
holding it in the palm of the hand for a and can startle the client when placed
moment. immediately on the chest.

Insert the earpieces of the stethoscope into This position facilitates hearing.
your ears in the direction of the ear canals, or
slightly forward.

Tap your finger lightly on the diaphragm. This ensures it is the active side of the head.
If necessary, rotate the head select the
diaphragm side.

Place the diaphragm of the stethoscope over The heartbeat is normally loudest over the
the apical impulse and listen for the normal apex of the heart. Each lub-dub counted as
S1 and S2 heart sounds, which are heard as one heartbeat.
“lub-dub” is counted as one heartbeat.
The two heart sounds are produced by
closure of the heart valves. The S1 heart
sound (lub) occurs when the atrioventricular
valves close after the ventricles have been
sufficiently filled. The S2 heart sound (dub)
occurs when the semilunar valves close after
the ventricles empty.

If the rhythm is regular, count the heartbeats A 60-second count provide a more accurate
for 30 seconds and multiply by 2. If the assessment of an irregular pulse then a 30-
rhythm is irregular or for giving certain second count.
medications such as digoxin, count the beats
for 60 seconds.

7. Assess the rhythm and the strength of the heartbeat.

 Assess the rhythm of the heartbeat by noting the pattern of intervals between
the beats. A normal pulse has equal time periods between beats.

 Assess the strength (volume) of the heartbeat. Normally, the heartbeats are
equal in strength and can be described as strong or weak.

8. Document the pulse rate and rhythm, and actions in the client record. Also record
pertinent related data such as variation in pulse rate compared to normal for the client
and abnormal skin color and skin temperature.

LIFESPAN CONSIDERATIONS: Pulse

INFANTS

 Use the apical pulse for the heart rate of newborns, infants, and children 2 to 3 years
old to establish baseline data for subsequent evaluation, to determine whether the
cardiac rate is within normal range, and to determine if the rhythm is regular.
  Place a baby in a supine position, and offer a pacifier if the baby is crying or restless.
Crying and physical activity will increase the pulse rate. For this reason, take the
resting apical pulse rate of infants and small children prior to other uncomfortable
procedures so that the rate is not artificially elevated by the discomfort.

 Locate the apical pulse in the left fourth intercostal space, lateral to the midclavicular
line during infancy.

 Brachial, popliteal, and femoral pulses may be palpated. Due other distal pulses may
be hard to feel.

 Newborn infants may have heart murmurs that are not pathologic, but reflect
functional incomplete closure of fetal heart structures (ductus arteriosus or foramen
ovale).

CHILDREN

 To take a peripheral pulse, position the child comfortably in the adult’s arms or have
the adult remain close by. This may decrease anxiety and yield more accurate
results.

 To assess the apical pulse, assist a young child to a comfortable supine or sitting
position.

 Demonstrate the procedure to the child using a stuffed animal or doll, and allow the
child to handle the stethoscope before beginning the procedure. This will decrease
anxiety and promote cooperation.

 The apex of the heart is normally located in the left fourth intercostal space in young
children and in the fifth intercostal space in children 7 years of age and over,
between the MCL and the anterior axillary line.

 Count the pulse prior to other uncomfortable procedures so that the rate is not
artificially elevated by the discomfort.

OLDER ADULTS

 If the client has severe hand or arm tremors, the radial pulse may be difficult to
count.

 Cardiac changes in older adults, such as decrease in cardiac output, sclerotic,

changes to heart valves, and dysrhythmias, may suggest that obtaining an apical
pulse will be more accurate that a peripheral pulse.

 Older adults often have decreased peripheral circulation. To detect these, pedal
pulses should also be checked for regulatory, volume, and symmetry.

 The pulse returns to baseline after exercise more slowly than with other age groups.
APICAL-RADIAL PULSE ASSESMENT

An apical-radial pulse may need to be assessed for clients with certain

cardiovascular disorders. Normally, the apical and radial rates are identical. An apical pulse rate
greater than a radial pulse rate can indicate that the thrust of the blood from the heart is too
weak for the wave to be felt at the peripheral pulse site, or it can indicate that vascular disease
is preventing impulses from being transmitted. Any discrepancy between the two pulse rates is
called a pulse deficit and needs to be reported promptly. In no instance is the radial pulse
greater than the apical pulse.

Assessing an Apical-Radial Pulse

PURPOSE

 To determine adequacy of peripheral circulation or presence of pulse deficit

ASSESSMENT

 Clinical signs of hypovolemic shock (hypertension, pallor, cyanosis, and cold, clammy
skin)

PLANNING

AP are generally not responsible for assessing apical-radial pulses using the one-nurse
technique. AP or any healthcare provider who is trained to assess a radial pulse may perform
the radial pulse count using the two-nurse technique.

Assessing an Apical-Radial Pulse

PURPOSE

 To determine adequacy of peripheral circulation or presence of pulse deficit

ASSESSMENT

 Clinical signs of hypovolemic shock (hypertension, pallor, cyanosis, and cold, clammy
skin)

PLANNING

AP are generally not responsible for assessing apical-radial pulses using the one-nurse
technique. AP or any healthcare provider who is trained to assess a radial pulse may perform
the radial pulse count using the two-nurse technique.
Equipment

 Clock, timer, or watch with a sweep second hand or digital seconds indicator.

 Stethoscope

 Antiseptic wipes

IMPLEMENTATION

Preparation

If using the two-nurse technique, ensure that the other nurse is available at this time.

Performance

1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what you are going to do, why it is necessary,
and how to participate. Discuss how the results will be used in planning further care
or treatments.

2. Perform hand hygiene and observe appropriate infection prevention procedures.

3. Provide for client privacy.

4. Position the client appropriately. Assist the client to a comfortable supine or sitting
position. Expose the area of the chest over the apex of the heart. If previous
measurements were taken, use the same position. Rationale: This ensures an
accurate comparative measurement.

5. Locate the apical and radial pulse sites. In the two-nurse technique, one nurse
locates the apical impulse by palpation or with the stethoscope while the other nurse
palpates the radial pulse site.

6. Count the apical and radial pulse rates.

Apical-Radial pulse check with two nurse
Apical-Radial pulse check with one nurse