Taking a client’s pulse is a fundamental nursing skill that provides valuable information about the client’s cardiovascular status. When assessing a client’s pulse, the nurse evaluates the pulse rate, rhythm, volume, and other qualities in order to identify any abnormalities and determine the adequacy of cardiac output and peripheral perfusion.
Obtaining the Pulse
To assess the pulse, the nurse should:
- Explain the procedure to the client
- Position the client comfortably with the arm at heart level
- Locate the pulse point, such as the radial artery on the thumb side of the wrist or the brachial artery on the inner aspect of the arm
- Apply light pressure with the index and middle fingers until the pulse is felt
- Count the pulse for 30 or 60 seconds
- Document the rate, rhythm, volume and any other abnormalities
The nurse should assess pulse in both arms to check for symmetry and equality. Differences may indicate vascular obstruction.
Assessing Pulse Rate
The pulse rate indicates the number of times the heart contracts or beats per minute. The normal pulse ranges are:
| Age | Normal Pulse Rate (beats/minute) |
|---|---|
| Newborn | 100-180 |
| Infant | 100-160 |
| Toddler | 90-150 |
| Preschooler | 80-140 |
| School age | 70-120 |
| Adolescent | 60-100 |
| Adult | 60-100 |
| Older adult | 50-90 |
The nurse should identify any pulse rates above or below the expected normal range for the client’s age. An abnormal pulse rate may indicate:
- Tachycardia – elevated pulse >100 bpm
- Bradycardia – low pulse
- Heart rhythm disturbances
- Fever
- Dehydration
- Shock
- Electrolyte imbalances
- Anemia
- Medication effects
- Pain
- Anxiety
Assessing Pulse Rhythm
The nurse should assess the rhythm or pattern of the pulsations. A normal pulse has a regular rhythm. Irregular rhythms may indicate:
- Atrial or ventricular arrhythmias
- Heart blocks
- Premature contractions
- Atrial fibrillation
Examples of abnormal pulse rhythms:
- Irregularly irregular: atrial fibrillation, multifocal atrial tachycardia
- Regularly irregular: premature ventricular contractions, premature atrial contractions
- Irregularly regular: sinus arrhythmia, wandering atrial pacemaker
The nurse should also assess if there are any missed or extra beats in the pulse pattern.
Assessing Pulse Volume
The volume or strength of the pulse indicates the force of blood flow with each beat. It is influenced by the stroke volume and blood pressure. A normal pulse has a bounding, full volume. Abnormal volumes include:
- Weak or thready: low cardiac output, hypovolemia, heart failure, shock
- Absent: cardiac arrest, profound shock, hypothermia, peripheral vascular disease, occlusion of the artery
- Bounding or full: hypertension, anxiety, fever, anemia, AV shunts, Paget’s disease
Assessing Pulse Quality
The nurse may also note certain qualities about the pulse by palpating the artery:
- Hypokinetic pulse: slow rise and decline of pulse volume, decreased cardiac output
- Hyperkinetic pulse: rapid rise and collapse of pulse volume, reflects increased sympathetic stimulation
- Anacrotic pulse: two peaks to each pulse wave, indicative of aortic valve stenosis
- Pulsus alternans: regular alternation in pulse volume, associated with decreased cardiac output and ventricular dysfunction
- Pulsus paradoxus: exaggerated drop in systolic BP during inspiration, can indicate cardiac tamponade or asthma exacerbation
Documenting Pulse Assessment
Proper documentation of the pulse assessment includes:
- Pulse rate
- Rhythm
- Volume
- Quality
- Any applicable descriptors such as thready, irregular, bounding
- Comparison between extremities
- Interpretation of findings
- Any follow up actions or monitoring required
Significance of Pulse Assessment
A comprehensive pulse assessment provides key information about cardiovascular status and function, fluid volume, and adequacy of perfusion. Key implications include:
- Changes in pulse rate may reflect hemorrhage, dehydration, infection, pain, electrolyte imbalance, myocardial ischemia, or effects of medications.
- Altered rate and rhythm can indicate heart disease, systemic illness, or drug toxicity.
- Small volume pulses may be a sign of shock or ineffective cardiac output.
- A thready or irregular pulse requires prompt assessment of cardiac status.
- Significant pulse deficits indicate peripheral vascular disease or blocked arteries.
- Trends in pulse quality reveal therapeutic effectiveness and disease progression.
Careful analysis of all pulse characteristics allows nurses to detect deterioration early and intervene appropriately.
Nursing Interventions
Based on the pulse assessment, the nurse may implement actions such as:
- Increasing fluid intake for dehydration
- Keeping the patient warm for bradycardia
- Administering antipyretics for fever
- Giving oxygen for hypoxemia
- Initiating electronic cardiac monitoring
- Obtaining electrolyte levels
- Conducting orthostatic vital signs
- Starting IV access and fluid resuscitation
- Providing medication such as atropine
- Obtaining a 12-lead ECG and consulting cardiology
- Preparing for potential CPR or defibrillation
- Notifying rapid response team for unstable vital signs
The nurse plays a pivotal role in managing any instability identified through pulse assessment and advocating for the client.
Patient Education
Patient teaching about the pulse assessment includes:
- Explain why pulse assessment is important
- Teach normal parameters and meaning of abnormalities
- Instruct on signs or symptoms to report
- Encourage recording pulse rate at home
- Review any related diagnoses and medication effects
- Provide information on lifestyle changes to improve cardiovascular health
Educating patients and families helps them understand the significance of an abnormal pulse and when to seek care.
Conclusion
A comprehensive nursing pulse assessment evaluates the rate, rhythm, volume and other qualities to identify abnormalities and determine cardiovascular status. Altered pulse findings prompt further evaluation of cardiac function, fluid status, perfusion and systemic factors that may require prompt intervention. Thorough documentation provides an accurate record and supports clinical decision-making. Patient education enhances understanding of pulse monitoring, meaningful changes to report, and promotion of cardiovascular health. As a fundamental nursing skill, careful pulse assessment is essential for detecting problems early and guiding appropriate actions.
