Seneca College Assessing Pulse Skills Checklist

Review Nursing Consideration for Every Skill

1. health care provider (HCP) order 1. Hand Hygiene
2. specific health care facility policy 2. Appropriate PPE
3. if you have the knowledge, skill and 3. Introduce self with designation
judgment to perform the skill 4. Confirmation of patient with 2 indicators
5. Patient privacy
6. Explain procedure & obtain consent
7. Allergies and Sensitivities
8. Check for pain, discomfort or need to use washroom
9. Adjust bed and bedside table to appropriate working height
10. Provide health teaching
Assess
 Risk factors for alterations in pulse
 S&S of altered stroke volume and cardiac output
o dyspnea, fatigue, orthopnea, syncope, palpitation, jugular venous distension, edema of
dependent body parts, cyanosis or pallor of skin
 Factors that normally influence pulse rate and rhythm
o age, exercise, position changes, fluid balance, medications, temperature, sympathetic nervous
system stimulation
 Previous baseline pulse in records
Palpate Radial 1. Position patient in a comfortable position, preferably sitting or lying.
Pulse 2. Ensure patient’s lower arm is relaxed and supported
3. Place tips of first 2-3 fingers over groove along radial side (thumb) of inner wrist
4. Lightly compress your fingertips against patient’s radius, obliterate pulse initially,
then relax pressure so pulse becomes easily palpable
5. Determine Force or strength of pulse (thrust of vessel against fingertips)
0 = absent / non-palpable
1+ = weak / diminished thread
2+ = Normal / strong
3+ = Full / Bounding
6. Determine Rhythm of pulse
 regular or irregular
7. Determine Equality of pulse, if indicated
 Comparing both arm’s radial pulses, noting discrepancies
8. Determine Rate of pulse (number of pulsations in 60 seconds).
 Using at clock with a second hand, count pulsations
 Start from “0” when a pulsation is felt when the second had is directly at a
number on the watch. Count each pulsation for the full 30 or 60 seconds.
 If regular, count the rate for 30 seconds, then multiply by 2 for the rate
 If irregular, count rate for 60 seconds (the full minute)
After assessing pulse
9. **If assessing respiratory rate, please continue with the Respiratory Skills Check
List**
10. Perform Hand Hygiene
11. Compare findings to patient’s baseline and to age appropriate parameters.
12. Record rate, rhythm, strength and equality and assessment site
13. Report abnormal finding
Seneca College Assessing Pulse Skills Checklist
Auscultate Apical Apical Pulse is indicated for newborn to 3 years, patient with cardiac distress, and
Pulse used to determine discrepancies with radial pulse. Preferred method < 10y/o
1. Clean stethoscope diaphragm with alcohol swab
2. Assist patient to appropriate supine or sitting position, exposing left side of chest.
If required, ask female client’s to reposition own breast tissue
3. Palpate the Apical Impulse – locate space between the fifth and sixth ribs (called
fifth Intercostal space = 5 ICS), at the left midclavicular line,
4. Auscultate Apical Pulse- Place diaphragm of stethoscope over apical impulse (5th
ICS) and auscultate for normal S1 (lub) and S2 (dub) heart sounds.
5. When S1 and S2 are heard with regularity, look at watch and begin to count rate
when second hand reaches a number on watch dial
6. Determine rate of pulse (number of pulsations in 60 seconds). Look at watch,
beginning to count pulse rate when second hand reaches a number of the watch dial
After assessing pulse
14. Perform Hand Hygiene
15. Compare findings to patient’s baseline and to age appropriate parameters.
16. Record rate, rhythm, and strength
17. Report abnormal finding