PULSE

The pulse is a wave of blood created by contraction of the left ventricle of the heart.
Generally, the pulse wave represents the stroke volume output or the amount of blood that enters the
arteries with each ventricular contraction. Compliance of the arteries is their ability to contract and
expand. When a person’s arteries lose their distensibility, as can happen with age, greater pressure is
required to pump the blood into the arteries.
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 3 70 beats per
minute 5 4.55 L per minute. When an adult is resting, the heart pumps about 5 liters of blood each
minute.
In a healthy person, the pulse reflects the heartbeat; that is, the pulse rate is the same as the
rate of the ventricular contractions of the heart. However, in some types of cardiovascular disease, the
heartbeat and pulse rates can differ. For example, a client’s heart may produce very weak or small
pulse waves that are not detectable in a peripheral pulse far from the heart. In these instances, the
nurse should assess the heartbeat and the peripheral pulse. A peripheral pulse is a pulse located away
from the heart, for example, in the foot or wrist. The apical pulse, in contrast, is a central pulse; that
is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI).

Factors Affecting the Pulse

The rate of the pulse is expressed in beats per minute (beats/min). A pulse rate varies according to
a number of factors. The nurse should consider each of the following factors when assessing a client’s
pulse:
 Age. As age increases, the pulse rate gradually decreases overall. See Table 29–2 for specific
variations in pulse rates from birth to adulthood.
 Sex. After puberty, the average male’s pulse rate is slightly lower than the female’s.
 Exercise. The pulse rate normally increases with activity. The rate of increase in the
professional athlete is often less than in the average person because of greater cardiac size,
strength, and efficiency.
 Fever. The pulse rate increases (a) in response to the lowered blood pressure that results from
peripheral vasodilation associated with elevated body temperature and (b) because of the
increased metabolic rate.
 Medications. Some medications decrease the pulse rate, and others increase it. For example,
cardiotonics (e.g., digitalis
 reparations) decrease the heart rate, whereas epinephrine increases it.
 Hypovolemia/dehydration. Loss of blood from the vascular system increases the pulse rate. In
adults, the loss of circulating volume results in an adjustment of the heart rate to increase
blood pressure as the body compensates for the lost blood volume.
 Stress. In response to stress, sympathetic nervous stimulation increases the overall activity of
the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as
well as the perception of severe pain stimulate the sympathetic system.
 Position. When a person is sitting or standing, blood usually pools in dependent vessels of the
venous system. Pooling results in a transient decrease in the venous blood return to the heart
and a subsequent reduction in blood pressure and increase in heart rate.
 Pathology. Certain diseases such as some heart conditions or those that impair oxygenation
can alter the resting pulse rate.
Pulse Sites
A pulse may be measured in nine sites (Figure 29–13 •):
1. Temporal, where the temporal artery passes over the temporal bone of the head. The site is
superior (above) and lateral to (away from the midline of) the eye
2. . Carotid, at the side of the neck where the carotid artery runs between the trachea and the
sternocleidomastoid muscle.
3. Apical, at the apex of the heart. In an adult, this is located on the left side of the chest, about 8
cm (3 in.) to the left of the sternum (breastbone) at the fifth intercostal space (area between
the ribs). In older adults, the apex may be further left if conditions are present that have led to
an enlarged heart. Before 4 years of age, the apex is left of the midclavicular line (MCL);
between 4 and 6 years, it is at the MCL (Figure 29–14 •). For a child 7 to 9 years of age, the
apical pulse is located at the fourth or fifth intercostal space.
4. Brachial, at the inner aspect of the biceps muscle of the arm or medially in the antecubital
space.
5. Radial, where the radial artery runs along the radial bone, on the thumb side of the inner
aspect of the wrist. 6. Femoral, where the femoral artery passes alongside the inguinal
ligament.
6. Popliteal, where the popliteal artery passes behind the knee.
7. Posterior tibial, on the medial surface of the ankle where the posterior tibial artery passes
behind the medial malleolus.
8. Dorsalis pedis, where the dorsalis pedis artery passes over the bones of the foot, on an
imaginary line drawn from the middle of the ankle to the space between the big and second
toes.

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
Pulse Site Reasons for Use
1. Radial Readily-accessible
2. Temporal Used when radial pulse is not accessible
3. Carotid Used during cardiac arrest/shock in adults Used to determine circulation to
the brain
4. Apical Routinely used for infants and children up to 3 years of age Used to determine
discrepancies with radial pulse Used in conjunction with some medications
5. Brachial Used to measure blood pressure Used during cardiac arrest for infants
6. Femoral Used in cases of cardiac arrest/shock Used to determine circulation to a leg
7. Popliteal Used to determine circulation to the lower leg
8. Posterior tibial Used to determine circulation to the foot
9. Dorsalis pedis Used to determine circulation to the foot Reasons for Using Specific
Pulse Site T
assessing apical pulses. A Doppler ultrasound stethoscope (DUS; Figure 29–15 •) is used
for pulses that are difficult to assess. The DUS headset has earpieces similar to standard
stethoscope earpieces, but it has a long cord attached to a volume-controlled audio unit and
an ultrasound transducer. The DUS detects movement of red blood cells through a blood
vessel. In contrast to the conventional stethoscope, it eliminates environmental sounds.
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. With excessive pressure, one can obliterate a pulse, whereas with too
little pressure one may not be able to detect it. Before the nurse assesses the resting pulse,
the client should assume a comfortable position. The nurse should also be aware of the
following:
 Any medication that could affect the heart rate.
 Whether the client has been physically active. If so, wait 10 to 15 minutes until the
client has rested and the pulse has slowed to its usual rate.
 Any baseline data about the normal heart rate for the client. For example, a
physically fit athlete may have a resting heart rate below 60 beats/min.
 Whether the client should assume a particular position (e.g., sitting). In some clients,
the rate changes with the position because of changes in blood flow volume and
autonomic nervous system activity
When assessing the pulse, the nurse collects the following data: the rate, rhythm,
volume, arterial wall elasticity, and presence or absence of bilateral equality. An excessively
fast heart rate (e.g., over 100 beats/min in an adult) is referred to as tachycardia. A heart
rate in an adult of less than 60 beats/min is called bradycardia. If a client has either
tachycardia or bradycardia, the apical pulse should be assessed.
The pulse rhythm is the pattern of the beats and the intervals between the beats.
Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is
referred to as a dysrhythmia or arrhythmia. It may consist of random, irregular beats or a
predictable pattern of irregular beats (documented as “regularly irregular”). When a
dysrhythmia is detected, the apical pulse should be assessed. An electrocardiogram (ECG) is
necessary to define the dysrhythmia further.
Pulse volume, also called the pulse strength or amplitude, refers to the force of
blood with each beat. Usually, the pulse volume is the same with each beat. It can range
from absent to bounding. A normal pulse can be felt with moderate pressure of the fingers
and can beobliterated with greater pressure. A forceful or full blood volume that is
obliterated only with difficulty is called a full or bounding pulse. A pulse that is readily
obliterated with pressure from the fingers is referred to as weak, feeble, or thready.
The elasticity of the arterial wall reflects its expansibility or its deformities. A healthy,
normal artery feels straight, smooth, soft, and pliable. Older adults often have inelastic
arteries that feel twisted (tortuous) and irregular on palpation.
When assessing a peripheral pulse to determine the adequacy of blood flow to a
particular area of the body (perfusion), the nurse should also assess the corresponding pulse
on the other side of the body. The second assessment gives the nurse data with which to
compare the pulses. For example, when assessing the blood flow to the right foot, the nurse
assesses the right dorsalis pedis pulse and then the left dorsalis pedis pulse. If the client’s
right and left pulses are the  same volume and elasticity, the client’s dorsalis pedis pulses
are bilaterally equal. The pulse rate does not need to be counted when assessing for
perfusion and equality.
When a peripheral pulse is located, it indicates that pulses more proximal to that
location will also be present. For example, if the dorsalis pedis, the most distal pulse of the
lower extremity, cannot be felt, the nurse next palpates for the posterior tibial pulse. If it is
not felt, the popliteal pulse must be assessed. If the popliteal pulse is found, it is not
necessary to assess the femoral pulse since it must also be present in order for the more
distal pulse to exist.

Assessing a Peripheral Pulse

PURPOSES
 To establish baseline data for subsequent evaluation
 To identify whether the pulse rate is within normal range
 To determine the pulse volume and whether the pulse rhythm is regular
 To determine the equality of corresponding peripheral pulses on each side of the
body
 To monitor and assess changes in the client’s health status
 To monitor clients at risk for pulse alterations (e.g., those with a history of heart
disease or experiencing cardiac arrhythmias, hemorrhage, acute pain, infusion of
large volumes of fluids, or fever)
 To evaluate blood perfusion to the extremities

ASSESSMENT
Assess
 Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations),
fatigue, pallor, cyanosis (bluish discoloration of skin and mucous membranes),
palpitations, syncope (fainting), or impaired peripheral tissue perfusion (as
evidenced by skin discoloration and cool temperature)
 Factors that may alter pulse rate (e.g., emotional status and activity level)
 Which site is most appropriate for assessment based on the purpose

PLANNING
DELEGATION
Measurement of the client’s radial or brachial pulse can be delegated to UAP, or be performed by
family members/caregivers in nonhospital settings. Reports of abnormal pulse rates or rhythms
require reassessment by the nurse, who also determines appropriate action if the abnormality is
confirmed. UAP are generally not delegated these techniques due to the skill required in locating
and interpreting peripheral pulses other than the radial or brachial artery and in using Doppler
ultrasound devices

INTERPROFESSIONAL PRACTICE
Assessing a peripheral pulse may be within the scope of practice for many health care
providers. For example, in addition to nurses, both physical therapists and respiratory
therapists may check the client’s pulse before, during, and after treatment. Although these
therapists may verbally communicate their findings and plan to the health care team
members, the nurse must also know where to locate their documentation in the client’s
medical record.

Assessing a Peripheral Pulse—continued

IMPLEMENTATION
Preparation
If using a DUS, check that the equipment is functioning normally.
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity
using agency protocol. Explain to the client what you are going to do, why it is
necessary, and how he or she can participate. Discuss how the results will be used in
planning further care or treatments
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Provide for client privacy.
4. Select the pulse point. Normally, the radial pulse is taken, unless it cannot be
exposed or circulation to another body area is to be assessed.
5. Assist the client to a comfortable resting position. When the radial pulse is assessed,
with the palm facing downward, the client’s arm can rest alongside the body or the
forearm can rest at a 90-degree angle across the chest. For the client who can sit, the
forearm can rest across the thigh, with the palm of the hand facing downward or
inward.
6. Palpate and count the pulse. Place two or three middle fingertips lightly and squarely
over the pulse point.
❶ Rationale: Using the thumb is contraindicated because the nurse’s thumb has a
pulse that could be mistaken for the client’s pulse.
 Count for 15 seconds and multiply by 4. Record the pulse in beats per minute
on your worksheet. If taking a client’s pulse for the first time, when obtaining
baseline data, or if the pulse is irregular, count for a full minute. If an irregular
pulse is found, also take the apical pulse.
7. Assess the pulse rhythm and volume.
 Assess the pulse rhythm by noting the pattern of the intervals between the
beats. A normal pulse has equal time periods between beats. If this is an
initial assessment, assess for 1 minute.
 Assess the pulse volume. A normal pulse can be felt with moderate pressure,
and the pressure is equal with each beat. A forceful pulse volume is full; an
easily obliterated pulse is weak. Record the rhythm and volume on your
worksheet.
8. Document the pulse rate, rhythm, and volume and your actions in the client record
(see Figure ❶ in Skill 29-1). Also record in the nurse’s notes pertinent related data
such as variation in pulse rate compared to normal for the client and abnormal skin
color and skin temperature.
Variation: Using a DUS
 If used, plug the stethoscope headset into one of the two output jacks located next
to the volume control. DUS units may have two jacks so that a second person can
listen to the signals.
 Apply transmission gel either to the probe at the narrow end of the plastic case
housing the transducer, or to the client’s skin. Rationale: Ultrasound beams do not
 travel well through air. The gel makes an airtight seal, which then promotes optimal
ultrasound wave transmission.
 Press the “on” button.
 Hold the probe against the skin over the pulse site. Use a light pressure, and keep
the probe in contact with the skin. ❷ Rationale: Too much pressure can stop the
blood flow and obliterate the signal.
 Adjust the volume if necessary. Distinguish artery sounds from vein sounds. The
artery sound (signal) is distinctively pulsating and has a pumping quality. The venous
sound is intermittent and varies with respirations. Both artery and vein sounds are
heard simultaneously through the DUS because major arteries and veins are situated
close together throughout the body. If arterial sounds cannot be easily heard,
reposition the probe. If you cannot hear any pulse, move the probe to several
different locations in the same area before determining that no pulse is present.
 After assessing the pulse, remove all gel from the probe to prevent damage to the
surface. Clean the transducer with water-based solution. Rationale: Alcohol or other
disinfectants may damage the face of the transducer.
 Remove all gel from the client.

EVALUATION
 Compare the pulse rate to baseline data or normal range for age of client.
 Relate pulse rate and volume to other vital signs; relate pulse rhythm and volume to
baseline data and health status.
 If assessing peripheral pulses, evaluate equality, rate, and volume in corresponding
extremities.
 Conduct appropriate follow-up such as notifying the primary care provider or giving
medication.

Apical Pulse Assessment

Assessment of the apical pulse is indicated for clients whose peripheral pulse is
irregular or unavailable and for clients with known cardiovascular, pulmonary, and renal
diseases. It is commonly assessed prior to administering medications that affect heart rate.
The apical site is also used to assess the pulse for newborns, infants, and children up to 2 to
3 years old. Skill 29–3 presents guidelines for assessing the apical pulse.

Assessing an Apical Pulse

PURPOSES
 To obtain the heart rate of an adult with an irregular peripheral pulse
 To establish baseline data for subsequent evaluation
 To determine whether the cardiac rate is within normal range and the rhythm is
regular
 To monitor clients with cardiac, pulmonary, or renal disease and those receiving
medications to improve heart action
ASSESSMENT
Assess
Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations),
fatigue/weakness, pallor, cyanosis (bluish discoloration of skin and mucous membranes),
palpitations, syncope (fainting), or impaired peripheral tissue perfusion as evidenced by skin
discoloration and cool temperature
Factors that may alter pulse rate (e.g., emotional status, activity level, and
medications that affect heart rate such as digoxin, beta-blockers, or calcium channel
blockers

PLANNING
DELEGATION
Due to the degree of skill and knowledge required, UAP are generally not responsible for
assessing apical pulses.

Equipment
 Clock or watch with a sweep second hand or digital seconds indikator
 Stethoscope
 Antiseptic wipes
 If using a DUS: the transducer probe, the stethoscope headset, transmission gel, and
tissues/wipes

IMPLEMENTATION
Preparation
If using a DUS, check that the equipment is functioning normally
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity
using agency protocol. Explain to the client what you are going to do, why it is
necessary, and how he or she can participate. Discuss how the results will be used in
planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Provide for client privacy.
4. Position the client appropriately in a comfortable supine position or in a sitting
position. Expose the area of the chest over the apex of the heart.
5. Locate the apical impulse. This is the point over the apex of the heart where the
apical pulse can be most clearly heard.
 Palpate the angle of Louis (the angle between the manubrium, the top of the
sternum, and the body of the sternum). It is palpated just below the
suprasternal notch and is felt as a prominence (see Figure 29–14).
 Slide your index finger just to the left of the sternum, and palpate the second
intercostal space.Assessing an apical pulse may be within the scope of
practice for many health care providers. For example, in addition to nurses,
respiratory therapists may check the client’s apical pulse before, during, and
after treatment, and physicians often check the apical pulse when assessing
the chest during examinations. Although these providers may verbally
 communicate their findings and plan to other health care team members, the
nurse must also know where to locate their documentation in the client’s
medical record.
 Place your middle or next finger in the third intercostal space, and continue
palpating downward until you locate the fifth intercostal space.
 Move your index finger laterally along the fifth intercostal space toward the
MCL. Normally, the apical impulse is palpable at or just medial to the MCL
(see Figure 29–14).
6. Auscultate and count heartbeats.
 Use antiseptic wipes to clean the earpieces and diaphragm of the
stethoscope. Rationale: The diaphragm needs to be cleaned and disinfected if
soiled with body substances. Both earpieces and diaphragms have been
shown to harbor pathogenic bacteria (Muniz, Sethi, Zaghi, Ziniel, & Sandora,
2012).
 Warm the diaphragm of the stethoscope by holding it in the palm of the hand
for a moment. Rationale: The metal of the diaphragm is usually cold and can
startle the client when placed immediately on the chest.
 Insert the earpieces of the stethoscope into your ears in the direction of the
ear canals, or slightly forward. Rationale: This position facilitates hearing.
 Tap your finger lightly on the diaphragm. Rationale: This is to be sure it is the
active side of the head. If necessary, rotate the head to select the diaphragm
side.
 Place the diaphragm of the stethoscope over the apical impulse and listen for
the normal S1 and S2 heart sounds, which are heard as “lub-dub.”
Rationale: The heartbeat is normally loudest over the apex of the heart. Each
lub-dub is counted as one heartbeat. Rationale: The two heart sounds are
produced by closure of the heart valves. The S1 heart sound (lub) occurs
when the atrioventricular valves close after the ventricles have been
sufficiently filled. The S2 heart sound (dub) occurs when the semilunar valves
close after the ventricles empty.
 If you have difficulty hearing the apical pulse, ask the supine client to roll
onto his or her left side or the sitting client to lean slightly forward. Rationale:
This positioning moves the apex of the heart closer to the chest wall.
 If the rhythm is regular, count the heartbeats for 30 seconds and multiply by
2. If the rhythm is irregular or for giving certain medications such as digoxin,
count the beats for 60 seconds
Rationale: A 60-second count provides a more accurate assessment of an
irregular pulse than a 30-second count.
7. Assess the rhythm and the strength of the heartbeat.
 Assess the rhythm of the heartbeat by noting the pattern of intervals
between the beats. A normal pulse has equal time periods between beats.
 Assess the strength (volume) of the heartbeat. Normally, the heartbeats are
equal in strength and can be described as strong or weak.
 8. Document the pulse rate and rhythm, and nursing actions in the client record. Also
record pertinent related data such as variation in pulse rate compared to normal for
the client and abnormal skin color and skin temperature.

EVALUATION
 Relate the pulse rate to other vital signs. Relate the pulse rhythm to baseline data
and health status.
 Report to the primary care provider any abnormal findings such as irregular rhythm,
reduced ability to hear the heartbeat, pallor, cyanosis, dyspnea, tachycardia, or
bradycardia.
 Conduct appropriate follow-up such as administering medication ordered based on
apical heart rate.

LIFESPAN CONSIDERATIONS Pulse

INFANTS
 Use the apical pulse for the heart rate of newborns, infants, and children 2 to 3 years
old to establish baseline data for subsequent evaluation, to determine whether the
cardiac rate is within normal range, and to determine if the rhythm is regular.
 Place a baby in a supine position, and offer a pacifier if the baby is crying or restless.
Crying and physical activity will increase the pulse rate. For this reason, take the
resting apical pulse rate of infants and small children before assessing body
temperatures.
 Locate the apical pulse in the left fourth intercostal space, lateral to the
midclavicular line during infancy.
 Brachial, popliteal, and femoral pulses may be palpated. Due to a normally low blood
pressure and rapid heart rate, infants’ other distal pulses may be hard to feel.
 Newborn infants may have heart murmurs that are not pathologic, but reflect
functional incomplete closure of fetal heart structures (ductus arteriosus or foramen
ovale).

CHILDREN
 To take a peripheral pulse, position the child comfortably in the adult’s arms or have
the adult remain close by. This may decrease anxiety and yield more accurate
results.
 To assess the apical pulse, assist a young child to a comfortable supine or sitting
position.
 Demonstrate the procedure to the child using a stuffed animal or doll, and allow the
child to handle the stethoscope before beginning the procedure. This will decrease
anxiety and promote cooperation.
 he apex of the heart is normally located in the left fourth intercostal space in young
children; fifth intercostal space in children 7 years of age and over, between the MCL
and the anterior axillary line (see Figure 29–14).
  Count the pulse prior to other uncomfortable procedures so that the rate is not
artificially elevated by the discomfort.

OLDER ADULTS
 If the client has severe hand or arm tremors, the radial pulse may be difficult to
count.
 Cardiac changes in older adults, such as decrease in cardiac output, sclerotic changes
to heart valves, and dysrhythmias, may suggest that obtaining an apical pulse will be
more accurate than a peripheral pulse.
 Older adults often have decreased peripheral circulation. To detect these, pedal
pulses should also be checked for regularity, volume, and symmetry.
 The pulse returns to baseline after exercise more slowly than with other age groups.

APICAL-RADIAL PULSE ASSESSMENT

An apical-radial pulse may need to be assessed for clients with certain
cardiovascular disorders. Normally, the apical and radial rates are identical. An apical pulse
rate greater than a radial pulse rate can indicate that the thrust of the blood from the heart
is too weak for the wave to be felt at the peripheral pulse site, or it can indicate that
vascular disease is preventing impulses from being transmitted. Any discrepancy between
the two pulse rates is called a pulse deficit and needs to be reported promptly. In no
instance is the radial pulse greater than the apical pulse.
An apical-radial pulse can be taken by two nurses or one nurse, although the two-
nurse technique may be more accurate. Skill 29–4 outlines the steps for assessing an apical-
radial pulse.

Assessing an Apical-Radial Pulse

PURPOSE
To determine adequacy of peripheral circulation or presence of pulse deficit

ASSESSMENT
Assess
Clinical signs of hypovolemic shock (hypotension, pallor, cyanosis, and cold, clammy skin)

PLANNING
DELEGATION
UAP are generally not responsible for assessing apical-radial pulses using the one-nurse
technique. UAP may perform the radial pulse count for the two-nurse technique.

Equipment
 Clock or watch with a sweep second hand or digital seconds indikator
 Stethoscope
  Antiseptic wipes

IMPLEMENTATION
Preparation
If using the two-nurse technique, ensure that the other nurse is available at this time.

Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity
using agency protocol. Explain to the client what you are going to do, why it is
necessary, and how he or she can participate. Discuss how the results will be used in
planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Provide for client privacy.
4. Position the client appropriately. Assist the client to a comfortable supine or sitting
position. Expose the area of the chest over the apex of the heart. If previous
measurements were taken, determine what position the client assumed, and use the
same position.
Rationale: This ensures an accurate comparative measurement.
5. Locate the apical and radial pulse sites. In the two-nurse technique, one nurse
locates the apical impulse by palpation or with the stethoscope while the other
nurse palpates the radial pulse site (see Skills 29–2 and 29–3).
6. Count the apical and radial pulse rates.
Two-Nurse Technique
 Place the clock or watch where both nurses can see it. The nurse who is
taking the radial pulse may hold the watch
 Decide on a time to begin counting. A time when the second hand is on 12, 3,
6, or 9 or an even number on digital clocks is usually selected. The nurse
taking the radial pulse says “Start.”
Rationale: This ensures that simultaneous counts are taken.
 Each nurse counts the pulse rate for 60 seconds. Both nurses end the count
when the nurse taking the radial pulse says, “Stop.” Rationale: A full 60-
second count is necessary for accurate assessment of any discrepancies
between the two pulse sites.
 The nurse who assesses the apical rate also assesses the apical pulse rhythm
and volume (i.e., whether the heartbeat is strong or weak). If the pulse is
irregular, note whether the irregular beats come at random or at predictable
times.
 The nurse assessing the radial pulse rate also assesses the radial pulse
rhythm and volume
One-Nurse Technique
 Within a few minutes:
 Assess the apical pulse for 60 seconds, and
7. Document the apical and radial (AR) pulse rates, rhythm, volume, and any pulse
deficit in the client record. Also record related data such as variation in pulse rate
 compared to normal for the client and other pertinent observations, such as pallor,
cyanosis, or dyspnea

EVALUATION
 Relate pulse rate and rhythm to other vital signs, to baseline data, and to general
health status.
 Report to the primary care provider any changes from previous measurements or
any discrepancy between the two pulse rates.

Cardiac Glycoside or Digitalis Glycoside Digoxin (Lanoxin)

CLIENT WITH CARDIAC MEDICATIONS

THAT AFFECT HEART RATE
Cardiac glycosides increase cardiac contractility, which increases cardiac
output. As a result, perfusion to the kidneys is increased, which increases the
production of urine. Cardiac glycosides also decrease heart rate by prolonging
cardiac conduction, especially at the AV node.
Digoxin is commonly used for the clinical management of heart failure, atrial
fibrillation, atrial flutter, and paroxysmal atrial tachycardia.

NURSING RESPONSIBILITIES
 Take the apical pulse for 1 minute before administering the dose. If the apical pulse
is < 60 beats/min or another specific parameter set by the health care provider, do
not administer the dose and retake the pulse in 1 hour. If pulse remains < 60, call the
prescriber. Note: If the initial resting pulse is significantly < 60 or the client has
symptoms of bradycardia such as dizziness, notify the primary care provider without
waiting to retake.
 Monitor electrolyte levels: Low potassium and low magnesium and high levels of
calcium place the client at risk for digitalis toxicity. Check the client’s most recent
electrolyte laboratory work for safe levels before administering the dose.
 Avoid giving with meals because this will delay absorption.
 Monitor for therapeutic drug levels: 0.5–2 ng/mL. Digoxin has a narrow therapeutic
index, which means that there is not much difference between a therapeutic effect
and a toxic effect
 Assess for signs of digoxin toxicity: anorexia, nausea, vomiting, diarrhea, blurred or
“yellow” vision, unusual tiredness and weakness.

CLIENT AND FAMILY TEACHING

 Explain the reason for taking digoxin and the importance of medical checkups that
may include laboratory work to evaluate the effects and dosage of the drug.
 Teach the client and/or family how to check the radial or carotid pulse for a full
minute. Inform them to take the pulse at the same time each day and to write it on
 the calendar. Provide pulse parameters and tell them when it is appropriate to call
the health care provider.
 Caution the client not to stop taking the digoxin without approval of the health care
provider.
 Caution the client to avoid over-the-counter drugs, except on the advice of the health care
provider, because many can interact with digoxin.
 Explain the signs and symptoms of digoxin toxicity and the importance of calling the health
care provider

RESPIRATIONS
Respiration is the act of breathing. Inhalation or inspiration refers to the intake of
air into the lungs. Exhalation or expiration refers to breathing out or the movement of
gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement
of air in and out of the lungs.
There are basically two types of breathing: costal (thoracic) breathing and
diaphragmatic (abdominal) breathing. Costal breathing involves the external intercostal
muscles and other accessory muscles, such as the sternocleidomastoid muscles. It can be
observed by the movement of the chest upward and outward. By contrast, diaphragmatic
breathing involves the contraction and relaxation of the diaphragm, and it is observed by
the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and
downward movement.

Mechanics and Regulation of Breathing

During inhalation, the following processes normally occur (Figure 29–16 •): The diaphragm
contracts (flattens), the ribs move upward and outward, and the sternum moves outward, thus
enlarging the thorax and permitting the lungs to expand. During exhalation (Figure 29–17 •), the
diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus
decreasing the size of the thorax as the lungs are compressed. Normal breathing is automatic and
effortless. A normal adult inspiration lasts 1 to 1.5 seconds, and an expiration lasts 2 to 3 seconds.
Respiration is controlled by (a) respiratory centers in the medulla oblongata and the pons of
the brain and (b) chemoreceptors located centrally in the medulla and peripherally in the carotid
and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen
(O2), carbon dioxide (CO2), and hydrogen (H+ ) in the arterial blood. See Chapter 50 for details.