ST Vital Signs Pulse Assessment - Tagged PDF

VITAL SIGNS MEASUREMENT OF APICAL AND RADIAL PULSE NURS 1090  PULSE Definition: palpable bounding of blood flow noted at various points on the body Terms Pulse rate: number of pulsing sensations occurring in one minute Heart rate: number of times t...

VITAL SIGNS MEASUREMENT OF APICAL AND RADIAL PULSE NURS 1090  PULSE Definition: palpable bounding of blood flow noted at various points on the body Terms Pulse rate: number of pulsing sensations occurring in one minute Heart rate: number of times the heart beats in one minute Stroke volume: amount of blood ejected with each ventricular contraction (60-70 ml) Cardiac Output: volume of blood pumped during one minute (HR x SV)  PHYSIOLOGY AND REGULATION With each stroke volume ejection, the walls of aorta distend Pulse wave created that travels to distal arteries When pulse wave reaches a peripheral artery, you are able to feel the pulse over a bony or muscle area Palpable bounding  Physician’s order Nursing judgment based on WHEN Alteration in rate or character of SHOULD pulse PULSES BE Alterations in manifestations Alteration in patient status ASSESSED Influencing factors ? Activity, pathology, medication Last pulse reading Method of last measurement (radial/apical)  PULSE RATE VARIABLES ADULT PATIENTS Age Normal rate 60-100 Tachycardia : Rate > 100 Emotion, exercise, fever, hemorrhage, drugs, hypoxia, cardiac pathology Bradycardia: Rate < 60 Medications, long term exercise and physical conditioning, heart block  PULSE VARIATIONS: OLDER ADULTS Normal older adult pulse rate 60-100 May be irregular due to underlying medical conditions Difficulty with palpating pulse due to decreased elasticity and atherosclerosis Decreased sympathetic nervous system response Takes longer for pulse to increase and longer to return to baseline with outside stressors such as exercise  PULSE SITES Radial and Apical Most common for routine vital signs Carotid Suggested for emergency situations; easily found Brachial For taking blood pressures Best for infants and young children Femoral, popliteal, posterior tibial, dorsalis pedis (pedal) To assess peripheral pulses in lower extremities ASSESSING PULSES  RADIAL PULSE Locate the pulse with fingertips (middle 2-3 fingers) using moderate pressure Don’t use thumb Be sure you feel pulse before you start to count If radial pulse rhythm is regular, count for 30 seconds; multiply x 2 If it is irregular, count for 60 seconds “one full minute”  PULSE SITES: RADIAL Most common site Moderate pressure with 2 or 3 middle fingertips  PULSE SITES: BRACHIAL Ulnar (outer aspect)side of arm At the antecubital space (at the crease of elbow)  PULSE SITES: CAROTID Along medial edge of sternocleidomastoid muscle Only palpate one side at a time **Not a part of regular vital sign assessment.  PULSE SITES: FEMORAL At midline of fold of groin Remember medical asepsis and privacy Wear gloves May need to press deeply Done by advanced practitioner  PULSE SITES: PERIPHERAL LOWER EXTREMITY These are done to assess circulation in lower extremities Popliteal Dorsalis Pedis Posterior Tibial  PULSE SITES: APICAL Stethoscope used to count pulse at this site  APICAL PULSE Stethoscope used to auscultate Earpieces positioned toward face Tubing should be flexible and 12-18” in length Chest piece: Diaphragm- for high pitched sounds such as heart, abdomen, lungs Bell-low pitched sounds such as aortic  ANATOMICAL LANDMARKS Sternal Angle (Angle of Louis) 2nd ribs Intercostal spaces Mid-clavicular line  AUSCULTORY SITES Aortic (2ICS-RSB) 2nd intercostal space, right sternal border Pulmonic (2ICS-LSB) 2nd intercostal space, left sternal border Tricuspid (4/5ICS-LSB) 4th or 5th intercostal space, left sternal border Mitral (5ICS-MCL) 5th intercostal space, left midclavicular line. Apex; Apical Pulse; Point of Maximum Impulse (PMI)  APICAL PULSE 5th intercostal space, Mid-clavicular line  HEART SOUNDS S1 “Lub” Low pitched sound and dull Closure of mitral and tricuspid valves Heard best at apex of heart S2 “Dub” Shorter and higher pitched than S1 Closure of pulmonic and aortic valves Heard best at base of heart (aortic area)  HOW TO COUNT AN APICAL PULSE Use clean, warm stethoscope Locate ideal position on chest (apex) Don’t start to count until you are sure you hear it Count for a full 60 seconds Each set of lub-dub is one heartbeat Note rhythm, rate and strength Regular, irregular, bounding, weak, etc. Document as “beats per minute”  ASSESSING QUALITY OF PULSES Strength Force or intensity Amplitude or volume Normal Full, easy to palpate with moderate pressure, not easily obliterated Bounding (forceful) Full, very easy to palpate, hard to obliterate Weak or “thready” Easy to obliterate, difficult to palpate Often with rapid, poor circulation Equality Are both sides equal in strength/rate  USING A DOPPLER Electronic device that amplifies pulse sound Used to hear inaudible pulses Use gel for ease of movement and transmission of sounds Transducer moved over pulse area Swooshing sound heard  indicates pulse