NURS 1090 Vital Signs: Pulse Measurement

Questions and Answers

What is the primary difference between pulse rate and heart rate?

Pulse rate includes both heartbeats and blood flow, while heart rate is only concerned with heartbeats.

Pulse rate refers to the heart's contraction, while heart rate measures blood flow.

Pulse rate measures the number of times blood can be felt at an artery, while heart rate measures heartbeats. (correct)

There is no significant difference; both terms are interchangeable.

What defines stroke volume?

The total volume of blood pumped in one minute by the heart.

The volume of blood present in the arteries at any time.

The amount of blood ejected with each heartbeat. (correct)

The frequency of heartbeats in one minute.

In what situation should pulse assessments be prioritized according to nursing judgment?

Routine checks at predetermined intervals regardless of patient condition.

Whenever the patient reports feeling fatigued.

When there is an alteration in patient status or pulse character. (correct)

Only during medical emergencies as directed by a physician.

What physiological event is associated with pulse creation?

Distension of the aorta following each stroke volume ejection. Signup and view all the answers

Cardiac Output is calculated as which of the following?

Heart Rate multiplied by Stroke Volume. Signup and view all the answers

Where should the femoral pulse be palpated?

At midline of the fold of the groin Signup and view all the answers

What is the purpose of assessing peripheral lower extremity pulses?

To assess circulation in lower extremities Signup and view all the answers

What additional equipment is used to assess the apical pulse?

Stethoscope Signup and view all the answers

Which anatomical landmark corresponds to the aortic auscultory site?

2nd intercostal space, right sternal border Signup and view all the answers

What type of sounds is best assessed with the diaphragm of a stethoscope?

High pitched sounds Signup and view all the answers

Where is the apical pulse typically located?

5th intercostal space, mid-clavicular line Signup and view all the answers

What characterizes the S1 heart sound?

Low pitched, associated with closure of mitral and tricuspid valves Signup and view all the answers

How should one assess the quality of a pulse?

By evaluating strength, equality, and rhythm Signup and view all the answers

What does a bounding pulse indicate?

Full and very easy to palpate, hard to obliterate Signup and view all the answers

What is the purpose of using a Doppler device in pulse assessment?

To amplify and hear inaudible pulses Signup and view all the answers

What is the normal pulse rate range for adult patients?

60-100 beats per minute Signup and view all the answers

Which pulse rate condition indicates tachycardia?

Rate greater than 100 beats per minute Signup and view all the answers

What are common causes of bradycardia?

Medications and long-term exercise Signup and view all the answers

Which pulse site is most commonly used for routine vital signs?

Radial pulse Signup and view all the answers

In older adults, what physiological change may affect the assessment of pulse?

Decreased elasticity and increased atherosclerosis Signup and view all the answers

What is the correct approach for counting an irregular radial pulse?

Count for 60 seconds Signup and view all the answers

Which pulse site is suggested for emergency situations?

Carotid pulse Signup and view all the answers

What should be avoided when locating the radial pulse?

Using the thumb Signup and view all the answers

Study Notes

Vital Signs: Pulse Measurement

Pulse Definition: Palpable blood flow sensed at various body points.
Key Terms:
- Pulse Rate: Number of pulse sensations per minute.
- Heart Rate: Number of heartbeats per minute.
- Stroke Volume: Blood ejected per ventricular contraction (60-70 ml).
- Cardiac Output: Blood volume pumped per minute (Heart Rate x Stroke Volume).

Physiology and Regulation

Each ejection of stroke volume distends aorta walls, creating a pulse wave.
The pulse wave travels to peripheral arteries, allowing pulse palpation over bony or muscular areas.

When to Assess Pulses

Based on physician's orders and nursing judgment.
Consider alterations in pulse rate, patient status, and influencing factors such as activity, pathology, medications, and prior readings.

Adult Pulse Rate Variables

Normal pulse rate: 60-100 beats per minute.
Tachycardia: Rate > 100, caused by factors like emotions, exercise, fever.
Bradycardia: Rate < 60, associated with medications and physical conditioning.

Pulse Variations in Older Adults

Normal pulse rate: 60-100 but may be irregular due to health conditions.
Palpation may be difficult due to decreased elasticity and atherosclerosis.
Slower sympathetic nervous response affects pulse reactivity.

Pulse Sites

Radial and Apical: Most common for routine checks.
Carotid: Used in emergencies; easily accessible.
Brachial: Ideal for blood pressure readings, especially in infants.
Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis: Assess peripheral pulses in lower extremities.

Assessing Pulses: Radial

Use 2-3 fingertips to locate the pulse, apply moderate pressure, avoid using the thumb.
Count for 30 seconds if the rhythm is regular or for 60 seconds if irregular.

Assessing Pulses: Other Sites

Brachial: Located on the ulnar side of the arm at the antecubital space.
Carotid: Palpate at the medial edge of the sternocleidomastoid muscle; do one side at a time.
Femoral: Found at the midline of the groin fold.

Apical Pulse Assessment

Auscultate using a stethoscope positioned correctly to listen for heartbeats.
Diaphragm of the stethoscope is for high-pitched sounds; bell for low-pitched sounds.

Anatomical Landmarks for Auscultation

Aortic: 2nd intercostal space, right sternal border.
Pulmonic: 2nd intercostal space, left sternal border.
Tricuspid: 4th or 5th intercostal space, left sternal border.
Mitral: 5th intercostal space, left mid-clavicular line.

Heart Sounds

S1 ("Lub"): Low-pitched sound from closure of mitral/tricuspid valves; best heard at the apex.
S2 ("Dub"): High-pitched sound from closure of pulmonic/aortic valves; best heard at the base.

Counting an Apical Pulse

Use a clean stethoscope; ensure warmth and cleanliness.
Locate the heart's apex; count for a full 60 seconds, noting rhythm and strength.

Assessing Quality of Pulses

Strength: Reflects pulse force or intensity.
- Normal: Full, moderate pressure required.
- Bounding: Forceful, hard to obliterate.
- Weak/"Thready": Easy to obliterate, poor circulation.
Equality: Assess if pulse strength/rate is equal bilaterally.

Using a Doppler

An electronic device amplifying pulse sounds, helpful for inaudible pulses.
Apply gel for optimal contact; movement over the pulse area produces a swooshing sound indicating the pulse is audible.

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Description

This quiz focuses on the measurement of apical and radial pulse as part of vital signs in nursing. You will learn definitions, terms, and physiological concepts related to pulse rate, heart rate, stroke volume, and cardiac output. Prepare to test your understanding of these essential health metrics.