Assessing Pulse Rate

ASSESSING PULSE RATE EQUIPMENTS:  Watch with a second hand  Stethoscope

Action 1. RADIAL PULSE a. Inform client of the site(s) at which yo will measre plse! b. "le# client$s el%ow and place lower part of arm across chest!

c. Spport client$s wrist %y &raspin& oter aspect with thm%! d. Place yor inde# and middle 'n&er on inner aspect of client$s wrist oer the radial artery and apply li&ht %t 'rm pressre ntil plse is palpated! e. Identify plse rhythm!

Rationale a. Encora&es participation and allays an#iety!

b. Maintains wrist in fll e#tension and e#poses artery for palpation! Placin& client$s hand oer chest will facilitate later respiratory assessment withot nde attention to yor action! c. Sta%ili,es wrist and allows for pressre to %e e#erted! d. "in&ertips are sensitie+ facilitatin& palpation of plsatin& plse! The *- may feel own plse if palpatin& with thm%! .pplyin& li&ht pressre preents occlsion of %lood /ow and plsation!

f. etermine plse olme!

e. Palpate plse ntil rhythm is determined! escri%e as re&lar or irre&lar!

g. *ont plse rate %y sin& second hand on a watch: "or an irre&lar rhythm+ cont  nm%er of %eats for a fll minte+ notin& nm%er of irre&lar %eats!

f. Qality of plse stren&th is an indication of stro0e olme! escri%e as normal+ wea0+ stron&+ or %ondin&!

2. APICAL PULSE a. 5aise client$s &own to e#pose sternm and left side of chest! b. *leanse earpiece and diaphra&m of stethoscope with an alcohol swa%! c. Pt stethoscope arond yor nec0!

g. .n irre&lar rhythm re1ires a fll minte of assessment to identify the nm%er of ine2cient cardiac contractions that fail to transmit a plsation+ referred to as a 3s0ipped4 or irre&lar %eat! a. .llows access to client$s chest for proper placement of stethoscope! b. ecreases transmission of microor&anisms from one practitioner to another (earpiece) and from one client to another (diaphra&m)! (diaphra&m)!

d. .pe# of heart: • With client lyin& on left side+ locate sprasternal notch! • Palpate second intercostal space to left of sternm!

• Identi'cation of landmar0s facilitates correct correct placement of the stethoscope at

• Place inde# 'n&er in intercostal space+ contin& downward ntil 'fth intercostal space is located! • Moe inde# 'n&er alon& forth intercostals space left of the sternal %order and to the 'fth intercostal space+ left of the midclaiclar line to palpate the point of ma#imal implse (PMI)

the 'fth intercostal space in order to hear point of ma#imal implse!

• Ensres correct placement of stethoscope!

• 6eep inde# 'n&er of nondominant hand on the PMI! e. Inform client that yo are &oin& to listen to his heart! Instrct client to remain silent! f. With dominant hand+ pt earpiece of the stethoscope in yor ears and &rasp diaphra&m of the stethoscope in palm of yor hand for 7 to 89 seconds!

e. Elicits client spport! Stethoscope ampli'es noise! f. ominant hand facilitates psychomotor de#terity for placement of earpiece with one hand! =eat warms metal or plastic diaphra&m and preents startlin& client!

g. Place diaphra&m of stethoscope oer the PMI and ascltate for sonds S8 and S to hear l%;d% sond! h. Note re&larity of rhythm!

i. Start to cont while loo0in& at second hand of watch! *ont l%;d% sond as one %eat: • "or a re&lar rhythm+ cont rate for <9 seconds!

h. Esta%lishment of a rhythm pattern determines len&th of time to cont the heart%eats to ensre accrate measrement! i. Ensres s2cient time to cont irre&lar %eats!

• "or an irre&lar rhythm+ cont rate for a fll minte+ notin& nm%er of irre&lar %eats!  . Share yor 'ndin&s with client! !. 5ecord %y site the rate+ rhythm+ and+ if applica%le+ nm%er of irre&lar %eats!

 . Spports client participation in care! !. 5ecord rate and characteristics at %edside to ensre accrate docmentation!

ASSESSING RESPIRATI"NS E#$i%&ent  Watch with a second hand Action 1. >efore replacin& client$s &own from ascltatin& heart sonds+ assess

Rationale 1. "acilitates o%seration of chest wall and a%dominal moements!

respirations! 2. Place yor hand oer client$s wrist and o%sere one complete respiratory cycle! '. Start to cont with 'rst inspiration while loo0in& at second hand sweep of watch! *ont a fll minte! (. ?%sere depth of respirations %y de&ree of chest wall moement and rhythm of cycle (re&lar or interrpted)! ). 5eplace client$s &own! *. 5ecord rate and character of respirations!

2. =and rises and falls with inspiration and e#piration! '. 5espiratory rate is one complete cycle (inspiration and e#piration)! (. 5eeals olme of air moement into and ot of the ln&s! escri%e as shallow+ normal+ or deep! ). Preents em%arrassment and chillin&! *. 5ecord rate and characteristics at %edside to ensre accrate docmentation

ASSESSING +L""D PRESSURE E,UIP-ENT  .lcohol swa%s  Sphy&momanometer with proper si,e c@   Stethoscope ACTI"N RATI"NALE 1. etermine which e#tremity is most 1. *@ in/ation can temporarily appropriate for readin&! o not ta0e a interrpt %lood /ow and compromise pressre readin& on an inAred or painfl circlation in an e#tremity already e#tremity or one in which an intraenos impaired or a ein receiin& intraenos line is rnnin&! /ids! 2. Select a c@ si,e that completely 2. Proides e1ali,ation of pressre on encircles pper arm withot oerlappin&! the artery to ensre accrate measrement! '. Moe clothin& away from pper '. Ensres accrate measrement! aspect of arm! (. Position arm at heart leel+ e#tend (. >lood pressre increases when arm is el%ow with palm trned pward! %elow leel of heart and decreases when arm is a%oe leel of heart! ). Ma0e sre c@ is flly de/ated and ). E1ipment mst fnction properly to pmp ale moes freely! o%tain an accrate readin&! *. Bocate %rachial artery in the *. esi&nates placement of stethoscope! antec%ital space! . .pply c@ sn&ly and smoothly oer . Ensres een pressre distri%tion pper arm+ !7 cm (8 in!) a%oe oer %rachial artery! Preents t%in& antec%ital space with center of c@ from %ein& constricted and allows oer %rachial artery! isali,ation of aneroid manometer dial! /. Insert earpiece of stethoscope in ears /. Enhances sond transmission from with a forward tilt+ ensrin& diaphra&m chestpiece to ears! han&s freely! 0. 5elocate %rachial plse with yor 0. Sond heard %est directly oer arteryC nondominant hand and place %ell or decreases mDed sonds that case diaphra&m chestpiece directly oer inaccrate readin&! >ell chestpiece is plse! *hestpiece shold %e in direct more sensitie to low;fre1ency sond contact with s0in and not toch c@! that occrs with pressre release! 1. With dominant hand+ trn ale 1. Preents air lea0 drin& in/ation! cloc0wise to close! *ompress pmp to in/ate c@! 11. Slowly trn ale contercloc0wise 11. Maintains constant release of so that mercry falls at a rate of F mm pressre to ensre hearin& 'rst systolic

=& per second! Bisten for 'e phases of 6orot0o@$s sonds while notin& manometer readin&:

• . faint+ clear tappin& sond appears and increases in intensity (phase I)! • Swishin& sond (phase II)! • Intense sond (phase III)! • .%rpt+ distinctie mDed sonds (phase IG)! • Sond disappears (phase G)! 1(. e/ate c@ rapidly and completely! 1). 5emoe c@ or wait  mintes %efore ta0in& a second readin&! 1*. Inform client of readin&! 1. 5ecord readin&! 1/. Bower %ed+ raise side rails+ place call li&ht in easy reach! 10. Pt all e1ipment in proper place! 2. Wash hands!

sond! Identify manometer readin&s for each of the 'e phases!

• Identify two consectie tappin& sonds to con'rm systolic readin&!

• Phase IG is the %est indicator of diastolic pressre in children! • Phase G is the %est inde# of diastolic %lood pressre in clients oer a&e 8F! 1(. Preents arterial occlsion and client discomfort of nm%ness or tin&lin&! 1). 5eleases trapped %lood in the essels! 1*. Promotes client participation in care! 1. Ensres accracy! 1/. Promotes client safety!

21. ocment measrements in client$s medical record on appropriate form+ sally ital si&ns /ow sheet! 22. *ompare data with client$s %aseline and normal ran&e for a&e &rop!

10. "osters maintenance of e1ipment! 2. Preents transmission of microor&anisms! 21. Gital si&n measrements are sally charted on the &raphic section of the ital si&ns form! 22. Proides for comparatie data analysis!

2'. If any measrements are a%normal+ measre a&ain and report a%normal 'ndin&s to instrctor or char&e nrse!

2'. 5eportin& a%normal measrements alerts sta@ to possi%le pro%lems re1irin& interention!