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ASSESSING PULSE RATE

EQUIPMENTS:
Watch with a second hand
Stethoscope
Action
1. RADIAL PULSE
a. Inform client of the site(s) at which
you will measure pulse.
b. Flex clients elbow and place lower
part of arm across chest.

c. Support clients wrist by grasping


outer aspect with thumb.
d. Place your index and middle finger on
inner aspect of clients wrist over the
radial artery and apply light but firm
pressure until pulse is palpated.
e. Identify pulse rhythm.

Rationale
a. Encourages participation and allays
anxiety.

b. Maintains wrist in full extension and


exposes artery for palpation. Placing
clients hand over chest will facilitate
later respiratory assessment without
undue attention to your action.
c. Stabilizes wrist and allows for
pressure to be exerted.
d. Fingertips are sensitive, facilitating
palpation of pulsating pulse. The CG may
feel own pulse if palpating with thumb.
Applying light pressure prevents
occlusion of blood flow and pulsation.

f. Determine pulse volume.

e. Palpate pulse until rhythm is


determined.
Describe as regular or irregular.

g. Count pulse rate by using second


hand on a watch:
For an irregular rhythm, count
number of beats for a full minute,
noting number of irregular beats.

f. Quality of pulse strength is an


indication of stroke volume. Describe as
normal, weak, strong, or bounding.

2. APICAL PULSE
a. Raise clients gown to expose sternum
and left side of chest.
b. Cleanse earpiece and diaphragm of
stethoscope with an alcohol swab.
c. Put stethoscope around your neck.

g. An irregular rhythm requires a full


minute of assessment to identify the
number of inefficient cardiac
contractions that fail to transmit a
pulsation, referred to as a skipped or
irregular beat.
a. Allows access to clients chest for
proper placement of stethoscope.
b. Decreases transmission of
microorganisms from one practitioner to
another (earpiece) and from one client to
another (diaphragm).

d. Apex of heart:
With client lying on left side, locate
suprasternal notch.
Palpate second intercostal space to left
of sternum.

Identification of landmarks facilitates


correct placement of the stethoscope at

Place index finger in intercostal space,


counting downward until fifth intercostal
space is located.
Move index finger along fourth
intercostals space left of the sternal
border and to the fifth intercostal space,
left of the midclavicular line to palpate
the point of maximal impulse (PMI)

the fifth intercostal space in order to


hear point of maximal impulse.

Ensures correct placement of


stethoscope.

Keep index finger of nondominant


hand on the PMI.
e. Inform client that you are going to
listen to his heart. Instruct client to
remain silent.
f. With dominant hand, put earpiece of
the stethoscope in your ears and grasp
diaphragm of the stethoscope in palm of
your hand for 5 to 10 seconds.

e. Elicits client support. Stethoscope


amplifies noise.
f. Dominant hand facilitates
psychomotor dexterity for placement of
earpiece with one hand. Heat warms
metal or plastic diaphragm and prevents
startling client.

g. Place diaphragm of stethoscope over


the PMI and auscultate for sounds S1
and S2 to hear lub-dub sound.
h. Note regularity of rhythm.

i. Start to count while looking at second


hand of watch. Count lub-dub sound as
one beat:
For a regular rhythm, count rate for
60 seconds.

h. Establishment of a rhythm pattern


determines length of time to count the
heartbeats to ensure accurate
measurement.
i. Ensures sufficient time to count
irregular beats.

For an irregular rhythm, count rate for


a full minute, noting number of irregular
beats.
j. Share your findings with client.

j. Supports client participation in care.

k. Record by site the rate, rhythm, and,


if applicable, number of irregular beats.

k. Record rate and characteristics at


bedside to ensure accurate
documentation.

ASSESSING RESPIRATIONS
Equipment
Watch with a second hand
Action
1. Before replacing clients gown from
auscultating heart sounds, assess

Rationale
1. Facilitates observation of chest wall
and abdominal movements.

respirations.
2. Place your hand over clients wrist
and observe one complete respiratory
cycle.
3. Start to count with first inspiration
while looking at second hand sweep of
watch. Count a full minute.
4. Observe depth of respirations by
degree of chest wall movement and
rhythm of cycle (regular or interrupted).
5. Replace clients gown.
6. Record rate and character of
respirations.

2. Hand rises and falls with inspiration


and expiration.
3. Respiratory rate is one complete cycle
(inspiration and expiration).
4. Reveals volume of air movement into
and out of the lungs. Describe as
shallow, normal, or deep.
5. Prevents embarrassment and chilling.
6. Record rate and characteristics at
bedside to ensure accurate
documentation

ASSESSING BLOOD PRESSURE


EQUIPMENT
Alcohol swabs
Sphygmomanometer with proper size cuf
Stethoscope
ACTION
RATIONALE
1. Determine which extremity is most
1. Cuf inflation can temporarily
appropriate for reading. Do not take a
interrupt blood flow and compromise
pressure reading on an injured or painful circulation in an extremity already
extremity or one in which an intravenous impaired or a vein receiving intravenous
line is running.
fluids.
2. Select a cuf size that completely
2. Provides equalization of pressure on
encircles upper arm without overlapping. the artery to ensure accurate
measurement.
3. Move clothing away from upper
3. Ensures accurate measurement.
aspect of arm.
4. Position arm at heart level, extend
4. Blood pressure increases when arm is
elbow with palm turned upward.
below level of heart and decreases when
arm is above level of heart.
5. Make sure cuf is fully deflated and
5. Equipment must function properly to
pump valve moves freely.
obtain an accurate reading.
6. Locate brachial artery in the
6. Designates placement of stethoscope.
antecubital space.
7. Apply cuf snugly and smoothly over
7. Ensures even pressure distribution
upper arm, 2.5 cm (1 in.) above
over brachial artery. Prevents tubing
antecubital space with center of cuf
from being constricted and allows
over brachial artery.
visualization of aneroid manometer dial.
8. Insert earpiece of stethoscope in ears 8. Enhances sound transmission from
with a forward tilt, ensuring diaphragm
chestpiece to ears.
hangs freely.
9. Relocate brachial pulse with your
9. Sound heard best directly over artery;
nondominant hand and place bell or
decreases muffled sounds that cause
diaphragm chestpiece directly over
inaccurate reading. Bell chestpiece is
pulse. Chestpiece should be in direct
more sensitive to low-frequency sound
contact with skin and not touch cuf.
that occurs with pressure release.
10. With dominant hand, turn valve
10. Prevents air leak during inflation.
clockwise to close. Compress pump to
inflate cuf.
11. Slowly turn valve counterclockwise
11. Maintains constant release of
so that mercury falls at a rate of 23 mm pressure to ensure hearing first systolic

Hg per second.
Listen for five phases of Korotkofs
sounds while
noting manometer reading:
A faint, clear tapping sound appears
and increases in intensity (phase I).
Swishing sound (phase II).
Intense sound (phase III).
Abrupt, distinctive muffled sounds
(phase IV).
Sound disappears (phase V).
14. Deflate cuf rapidly and completely.
15. Remove cuf or wait 2 minutes
before taking a second reading.
16. Inform client of reading.
17. Record reading.
18. Lower bed, raise side rails, place call
light in easy reach.
19. Put all equipment in proper place.
20. Wash hands.

sound. Identify manometer readings for


each of the five phases.

Identify two consecutive tapping


sounds to confirm systolic reading.

Phase IV is the best indicator of


diastolic pressure in children.
Phase V is the best index of diastolic
blood pressure in clients over age 13.
14. Prevents arterial occlusion and client
discomfort of numbness or tingling.
15. Releases trapped blood in the
vessels.
16. Promotes client participation in care.
17. Ensures accuracy.
18. Promotes client safety.

21. Document measurements in clients


medical record on appropriate form,
usually vital signs flow sheet.
22. Compare data with clients baseline
and normal range for age group.

19. Fosters maintenance of equipment.


20. Prevents transmission of
microorganisms.
21. Vital sign measurements are usually
charted on the graphic section of the
vital signs form.
22. Provides for comparative data
analysis.

23. If any measurements are abnormal,


measure again and report abnormal
findings to instructor or charge nurse.

23. Reporting abnormal measurements


alerts staf to possible problems
requiring intervention.