Measuring Pulse and Respiration - Medical Simulation Center PDF

Measuring Pulse Pulse The Pulse occurs when the left ventricle of the heart contracts and sends blood into the arteries. This process creates a pulse wave that the nurse can palpate (feel). A person’s heartbeat changes throughout the day to meet the circulatory needs of the body....

Measuring Pulse Pulse The Pulse occurs when the left ventricle of the heart contracts and sends blood into the arteries. This process creates a pulse wave that the nurse can palpate (feel). A person’s heartbeat changes throughout the day to meet the circulatory needs of the body. 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. Purpose or Objective : 1 - To monitor the patient condition. 2 - To detect any abnormality in characteristics of pulse. 3 – To obtain base line data during the patient admission. 4 – To detect the presence of arrhythmia or inadequate circulation or other change in patient condition. 5 – To estimate the dose of some medication. Pulse sites 1-Temporal 2-Carotid 3-Apical 4-Radial 5-Femoral 6-Brachial 7-Popliteal 8-Dorsalis Pedis (Pedal) 9-POSTERIOR TIBIAL Pulse Sites Pulse Sites HOW TO MEASURE? Measured in beats per minute. Pulse norms are 60 - 100 beats per minute. Pulses between 90 - 100 are in a gray area - high normal. Faster than 100 – tachycardia. Slower than 60 – bradycardia. QUALITY / Characteristics OF PULSE: ❑ Rhythm: regular or irregular. ❑ Rate: Within the normal limits. ❑ Strength (Pulse volume): Strong, bounding, thready. Factors affecting Pulse Rate: ❑ Activity. ❑ Pain. ❑ Fever. ❑ Significant blood loss ❑ Emotions such as anger, fear, agitation or excitement can cause the pulse rate to increase. ❑ Sleep. ❑ Some medications. ❑ Conditions such as depression can cause the pulse rate to decrease. Equipment Watch with a second hand Stethoscope (Apical) Alcohol swab Gloves (PPE as needed) Measuring Person's Radial Pulse Measuring Person's Radial Pulse Measuring Person's Radial Pulse Measuring Person's Radial Pulse ATTITUDE Maintains professionalism all throughout the procedure. Establishes rapport with the person. *Preserves person's dignity. Provides privacy for the person all throughout the procedure. *Provides comfort and safety for the person.  Normal Resting Pulse Rates ❑ In well-trained athletes, the normal resting pulse rate may be between 40 and 60 beats/min. Observations Into Action! ❑ The following may be signs of a medical problem and should be reported to the nurse right away: A pulse rate that is less than 60 beats/min ( Bradycardia) or greater than 100 beats/min (Tachycardia). A pulse that is irregular. A weak (thready) or bounding pulse Apical pulse: ❑ The Apical pulse: When evaluating an apical pulse, you place a stethoscope over the apex of the heart and count each pulse beat by listening to it rather than feeling it. ❑ The apical pulse is evaluated when the person has a very weak or irregular pulse that is difficult to detect at the radial artery, and when the person has certain heart conditions. ❑ The apical method is also used for infants and young children ❑ Place diaphragm of stethoscope over the Apex at fifth intercostal space and auscultate the normal heart sounds (“lub-dub”). Ensuring accuracy when evaluating the pulse: ❑ To ensure accuracy when measuring a person’s pulse, evaluate factors that could increase the person’s pulse rate before beginning. For example, if the person has just come back from physical therapy or undergone a painful procedure, or if the person is emotionally upset, it might be best to give the person time to rest and relax before checking the pulse. ❑ When you are taking a radial pulse, make sure the person’s arm is resting comfortably on the bed (or on her lap if she is seated). Avoid placing your thumb over the person’s radial artery (when taking a radial pulse) or holding the diaphragm of the stethoscope with your thumb (when taking an apical pulse) because your thumb has its own pulse, which you might confuse for the person’s pulse. Respiration Introduction to Respirations ❑ Respirations: Is the process of breathing. When we breathe, we take oxygen into the body and expel carbon dioxide (a waste product) from the body. Both of these functions are vital to life. ❑ The process of respiration consists of: Inhalation or inspiration is the intake of air into the lungs. Exhalation or expiration is the breathing out or the movement of gases from the lungs to the atmosphere. Respiration ❑ Definition: Respiration is the act of breathing air into the lungs (inhalation) and exhaling air out of the lungs (exhalation). ❑ One inhalation and one exhalation equal one respiration. ❑ This is a complex process that involves the intake of oxygen and the output of carbon dioxide. Purposes of Respiratory assessment ❑ Collect baseline data for comparison and follow-up. ❑ Monitor abnormalities of respirations. ❑ Monitor respirations before or after medications that influences respirations. ❑ Detect some diseases. Factors affecting Respiratory Rate: ❑ The same factors that can increase the pulse rate also can increase the respiratory rate (for example, exercise, fever, pain, significant blood loss, and emotions such as anger, fear, agitation or excitement). ❑ The same factors that decrease the pulse rate can decrease the respiratory rate (for example, sleep, certain medications, and certain conditions such as depression). ❑ In adults, the normal respiratory rate is between 15 and 20 breaths/min. ❑ In infants and children, the normal respiratory rate is faster. Characteristics of Respirations: ❑ The respiratory rate: This is the number of respirations that occur in 1 minute. You count respirations by observing the person’s chest rise (inhalation or taking the breath in) and fall (exhalation or letting the breath out). One inhalation plus one exhalation equals one respiration. ❑ The respiratory rhythm: This is the regularity with which the person breathes. In normal breathing, the breaths are evenly spaced. ❑ The respiratory depth: A person’s respirations may be described as deep or shallow. Normally, a person breathes quietly and easily. The breaths seem effortless and are evenly spaced. Both sides of the chest rise and fall equally. Observations Into Action! ❑ Difficult, irregular or noisy breathing is considered abnormal. Report the following signs of abnormal breathing to the nurse right away: ❖ A respiratory rate that is greater than 20 breaths/min or less than 15 breaths/min. ❖ A respiratory rhythm that is irregular. ❖ Respirations that are shallow or deep. ❖ Respirations that are strained or difficult (dyspnea). ❖ Respirations that do not cause both sides of the chest to rise and fall together ❑ Dyspnea (DOF) is the medical term for breathing that is difficult or seems like it takes a lot of effort. Ensuring accuracy when evaluating Respirations: ❑ Respiration is the one vital function that we can control to a certain extent. ❑ We also have the ability to interrupt the normal pattern of breathing, by holding our breath. Because just knowing that you are evaluating her breathing can cause a person’s breathing to change, it is best to evaluate respirations without the person being aware that you are doing it. ❑ Usually, you evaluate a person’s respirations after evaluating her pulse. If you keep your fingers on the person’s wrist (as if you are still checking the pulse), the person may not be aware that you are evaluating her respirations, which can lead to a more accurate evaluation. Count the person’s respirations for 1 full minute, counting one rise and one fall of the chest for each respiration. Measuring Person's Respiratory Rate Measuring Person's Respiratory Rate Measuring Person's Respiratory Rate ATTITUDE Maintains professionalism all throughout the procedure. Establishes rapport with the person. *Preserves person's dignity. Provides privacy for the person all throughout the procedure. *Provides comfort and safety for the person.