Purpose

• The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery. A pulse is felt every time the heart beats.
• The temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis (pedal) pulses are felt on each side of the body. The radial pulse is used most often. It is easy to reach and find. The person is not exposed.
• The pulse rate is the number of heartbeats or pulses felt or heard in 1 minute.
  • The pulse rate is affected by many factors, including activity, drugs, and pain.
  • The adult pulse rate is between 60 and 100 beats per minute. A rate of less than 60 or more than 100 is abnormal. Report abnormal pulses at once.
• The pulse rhythm should be regular. That is, pulses are felt in a pattern. The same interval occurs between beats. An irregular pulse occurs when the beats are not evenly spaced or beats are skipped.
• Force relates to pulse strength. A forceful pulse is easy to feel. It is described as strong, full, or bounding. Hard-to-feel pulses are termed weak, thready, or feeble.
• You will take radial and apical pulses. You must count, report, and record accurately.
• The radial pulse is used for routine vital signs. Place the first two or three fingertips against the radial artery. The radial artery is on the thumb side of the wrist. Count the pulse for 30 seconds. Then multiply the number by 2. This gives the number of beats per minute. If the pulse is irregular, count it for 1 minute. In some agencies, all radial pulses are taken for 1 minute. Follow agency policy.

Equipment

Roll cursor over items to see labels. For the purposes of clearly depicting the equipment, a barrier is not shown in this photo. When providing care, a barrier should always be placed on the surface before placing the equipment.

Watch with a second hand

Delegation

• Follow delegation guidelines. Before taking a radial pulse, obtain this information from the nurse and care plan:
  • What pulse to take for each person—radial or apical
  • When to take the pulse
  • What other vital signs to measure
  • How long to count the pulse—30 seconds or 1 minute
  • If the nurse has concerns about certain patients or residents
  • What observations to report and record
  • When to report the pulse rate
  • What patient or resident concerns to report at once

Preparation

• Observe quality-of-life measures.
• Review the information under Delegation and Safety and Comfort.
• Practice hand hygiene.
• Identify the person. Check the ID bracelet against the assignment sheet. Also call the person by name.
• Provide for privacy.

Safety

• Use your first two or three fingertips to take a pulse. Do not use your thumb. The thumb has a pulse. You could mistake the pulse in your thumb for the person’s pulse. Reporting and recording the wrong pulse can harm the person.

Comfort

• Support the exposed wrist in a non-compromised position for comfort.

Follow-up Care

• Provide for comfort.
• Place the call light within reach.
• Unscreen the person.
• Complete a safety check of the room.
• Practice hand hygiene.

Reporting/Recording

• Report and record your observations, including:
  • The pulse site
  • The pulse rate—report at once a pulse rate less than 60 (bradycardia) or more than 100 (tachycardia) beats per minute
  • If the pulse is regular or irregular
  • Pulse force—strong, full, bounding, weak, thready, or feeble