Questions and Answers
What is assessing apical and radial pulse?
Counting of the pulse at the apex of the heart and at the radial artery simultaneously to assess the apical-radial pulse rate.
Which of the following factors contribute to an irregular pulse? (Select all that apply)
How should two providers verify irregular pulses?
They should assess the pulses while in a sitting position.
What is a major health problem resulting from a pulse deficit?
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What should the nurse do when a pulse deficit is suspected?
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Which action should the nurse perform after identifying a pulse deficit?
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How does poorly controlled pain affect physiological changes?
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What is neuropathic pain?
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Based on the following information, what is the pulse deficit? Oral temperature-36.8°C, Radial Pulse-112 weak, thready, Apical pulse-117 regular, Respirations-24 regular, Blood Pressure-104/56 right arm-102/50 left arm.
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Which of the following is an early manifestation of decreased cardiac output?
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Study Notes
Assessing Apical & Radial Pulse
- The apical-radial pulse rate is determined by counting pulses at the heart's apex and the radial artery simultaneously.
- A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating not all heartbeats reach peripheral arteries or are too weak to detect.
Factors for Irregular Pulse
- Orthopnea: Shortness of breath when lying flat, requiring elevation for sleep.
- Palpitations: Rapid, strong, and irregular heartbeat sensations.
- Dyspnea: Difficulty breathing during normal activities or any position.
- Additional symptoms include fatigue and chest pain.
Verifying Irregular Pulses
- Both providers should assess pulses in a sitting position.
- A difference of more than two beats between radial and apical indicates cardiac deficit.
- Look for signs of decreased cardiac output:
- Edema: Swelling due to fluid leakage into tissues.
- Syncope: Loss of consciousness from inadequate brain blood flow.
- Dizziness and cyanosis: Bluish discoloration of skin.
Major Health Problem from Pulse Deficit
- Bradycardia, activity intolerance, decreased cardiac output, and impaired tissue perfusion can result from a pulse deficit.
Actions for Suspected Pulse Deficit
- Measure the radial pulse for one minute, then the apical pulse for one minute to confirm findings.
- Alternatively, the radial pulse may be measured while another health care provider counts the apical.
Post-Identification of Pulse Deficit
- Assess the patient for signs of decreased cardiac output after identifying a pulse deficit.
- This may include monitoring other vital signs and symptoms.
Impact of Poorly Controlled Pain
- Acute pain induces physiological stress:
- Cardiac effects: Tachycardia, elevated blood pressure, and increased myocardial oxygen demand.
- Pulmonary effects: Hypoventilation and atelectasis.
- Gastrointestinal issues: Nausea and vomiting.
- Renal complications: Oliguria and urinary retention.
- Musculoskeletal effects: Spasms and stiffness.
- Endocrine alterations: Increased adrenergic activity.
- Central nervous system impacts: Fear and anxiety, leading to diminished quality of life.
Understanding Neuropathic Pain
- Neuropathic pain arises from lesions or diseases affecting the somatosensory nervous system.
- It represents abnormal pain processing from nerve injuries and can persist long after healing.
- Common causes: Diabetes mellitus, herpes zoster, HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and chemotherapy.
Calculating Pulse Deficit Example
- Given clinical data:
- Radial pulse: 112 (weak, thready)
- Apical pulse: 117 (regular)
- Calculated pulse deficit: 5 beats.
Early Manifestation of Decreased Cardiac Output
- Early signs include fatigue, substernal pain, cyanosis of nail beds, and shortness of breath, with fatigue being a prominent early indicator.
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Description
This quiz focuses on key concepts related to assessing the apical and radial pulses, including what a pulse deficit indicates. It's an essential review for nursing students preparing for exams in cardiovascular assessments.
