ASSESSING PERIPHERAL PULSE

DEFINITION:
Pulse is defined ad checking rate, rhythm, and volume of throbbing of an artery against a bony
prominence

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

PRINCIPLES:
 Wash hands before and after taking body temperature.
 Provide client privacy
 Before taking the vital signs, be sure that the patient has rested.
 In taking the PR, it will always depend on the condition of the patient.
 Check equipment is in good condition to prevent inaccurate readings

EQUIPMENT:
 Clock or watch with a sweep second hand or digital indicator

STEPS:
1. Introduce self, identify the client (ask the
complete name, check the wristband, and bed
tag) and explain the procedure.
RATIONALE:
Checking physician’s order can help the nurse to
know what specific part of the body to be treated.
Introducing oneself helps build trust and rapport
with the patient. And explaining the procedure
helps the patient understand, prepare for the
procedure, and reduces anxiety.

2. Wash hands. To prevent the spread of microorganism.

3. Provide for client's privacy. For the patient to be comfortable and ease anxiety.

4. Select the pulse point. Normally, the radial To provide accurate pulse rate.
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 To provide accurate pulse rate.

position.
 When the radial pulse is assessed, position
the client's palm facing downward, so the
client's arm can rest along the side of the
body, or the forearm can rest at a 90-degree
angle across the chest.
 For the clients 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 2 or 3 middle Using the thumb is contraindicated because the
 fingertips lightly and squarely over the pulse nurse’s thumb has a pulse that could be mistaken
point. Count for one full minute. for the client’s pulse.

7. Assess the pulse rhythm and volume. To obtain accurate result

 Assess the pulse rhythm by noting the pattern of
the intervals between the beats. Normally, it has
equal time periods between beats.
 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. Make the client comfortable and wash your To have fast recovery of the patient and to decrease
hands. the risk of spreading infection.

9. Document the pulse rate, rhythm, and volume in For documentation and baseline data for health
the client record. plan.

REFERENCE:
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017a). Fundamentals of Nursing. Elsevier
Gezondheidszorg.
Berman, A. T., Snyder, S., & Msn Rn, F. G. E. (2020). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice (11th ed.). Pearson.