Vital Signs (Pulse) PDF

KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER Vit...

KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER Vital Signs: Pulse Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Vital Signs - Pulse Pulse: is a wave of blood created by contraction of the left ventricle of the heart. Compliance of the arteries is their ability to contract and expand. 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, 65 mL * 70 beats per minute = 4.55 L per minute. When an adult is resting, the heart pumps about 5 liters of blood each minute. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  A peripheral pulse: is a pulse located away from the heart, for example, in the foot or wrist. The apical pulse: is a central pulse;, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Factors Affecting Pulse Age Stress Sex Position Exercise Pathology Fever Medications Hypovolemia/dehydra tion Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Pulse Sites Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  1C Carotid 1E Popliteal 1F Tibial 1G Pedal (dorsalis pedis) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Characteristics of the Pulse Rate Rhythm Volume Arterial wall elasticity Bilateral equality Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  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. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Pulse Rate and Rhythm Rate – Tachycardia: heart rate over 100 beats/min in – Bradycardia: heart rate less than 60 beats/min Rhythm – Pattern of beats and intervals between beats A pulse with an irregular rhythm: – Dysrhythmia – Arrhythmia Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Characteristics of the Pulse Volume – Strength or amplitude – The force of blood with each beat. Usually, is the same with each beat. – Range from absent to bounding Arterial wall elasticity – Expansibility or deformity Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Characteristics of the Pulse Presence or absence of bilateral equality – Compare corresponding pulse – If distal pulse is palpable, more proximal pulses will be also Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Delegation of Pulse Measurement Pulse – Radial or brachial pulse may be delegated to AP; AP report abnormal pulses – Nurse interprets abnormal rates or rhythms, determines response – AP generally not responsible for apical or one person apical-radial pulses Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Documentation of Pulse Document in client’s record Use graphic sheet Pulse rate, rhythm, volume Variation in pulse rate Abnormal skin color and temperature Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. 4 A. Stethoscope with both a bell and diaphragm. B. Close-up of a diaphragm and a bell. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. 5 Taking an apical pulse using the flat disc of the stethoscope. Note how the amplifier is held against the chest. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Measuring Apical Pulse Clients with irregular or unavailable peripheral pulse, clients with cardiovascular, pulmonary, renal disease Done prior to administering medications that affect heart rate Also used for newborns, infants, and children up to 2-3 years old Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Documentation of Apical Pulse Document in client’s record Pulse rate and rhythm Variation in pulse rate Abnormal skin color and temperature Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Apical-Radial Pulse Locate apical and radial sites Normally, the apical and radial rates are identical. Any discrepancy between the two pulse rates is called a pulse deficit and needs to be reported promptly. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Apical-Radial Pulse An apical-radial pulse can be taken by two nurses or one nurse. (two-nurse technique may be more accurate) Two-nurse method: – Decide on starting time – Nurse counting radial says “start” – Both count for 60 seconds – Nurse counting radial says “stop” Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Documentation of Apical-Radial Pulse Document in client’s record Apical and radial (AR) pulse rates, rhythms, volume, and any pulse deficit Variation in pulse rate Pallor, cyanosis, or dyspnea Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.