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Keywords: Adult/ assessment/ Practice Pulse rate Practice educator ●This article has been double-blind Patient safety peer reviewed Pulse assessment is a vital component of good nursing care. Nurses must feel confident in their ability to accurately measure the pulse to assess patients’ health statuses Assessing the pulse rate in adult patients

Learning points... 5 practice Finding the main pulse sites in adults points Normal pulse Accurately assessing the different 1rate in adults is Factors that can affect pulse rate between 60-100 beats per minute Pulse rate in Authors Mike Lowry is lecturer in nursing; around the body. These elastic arteries 2babies is higher Sarah Ashelford is lecturer in biological then recoil as the relaxes. The rhythm of sciences; both at the University of 3pulse should Bradford. What is the pulse? be regular and Abstract Lowry M, Ashelford S (2015) The momentary stretching and relaxing of consistent Assessing the pulse rate in adult patients. the arteries occurs with each heartbeat – Any deviation Nursing Times; 111: 36/37, 18-20. this is what is felt as the pulse, and should 4from normal Assessing the pulse is a common have regular and consistent rhythm. The pulse rate for the procedure and an important aspect of pulse starts in the aorta (for the systemic patient should be many nursing interventions; it should system) and spreads as a “pulse wave”, reported and always be done with care and reassessed which travels through all the arteries. The investigated as needed. Assessment should always farther away from the heart the artery is Pulse rates be taken seriously, with any deviations located, the fainter the pulse, because the 5should be from the norm reported to a senior energy of the pulse becomes dissipated as accurately clinician, and pulse rate, rhythm and it moves through the arteries. By the time documented strength must always be documented. blood reaches the capillaries, there is no Pulses indicate numerous patient longer a pulse, and pulses cannot be felt in characteristics including the degree of the veins that return blood to the heart. relaxation, regularity of cardiac The pulse is a pressure wave in the arte- contractions and sufficiency of cardiac rial wall. If an artery wall is pressed at a output. This article considers the relevant pulse point, the pulse of pressure in the , physiology and practice of pulse arterial wall can be felt as blood is squeezed assessment and recording. along with each contraction of the heart. The pulse, therefore, occurs with each ells require a constant supply of heartbeat; the frequency, or rate, at which oxygen and nutrients, and must it is felt indicates the rate at which the continuously remove waste heart is beating (the ). Cproducts such as carbon The strength (or amplitude) of the pulse dioxide. It is the function of the circulatory depends on the volume of blood squeezed system to transport nutrients, oxygen, out of the heart with each beat; this is carbon dioxide, waste metabolites and called the stroke volume. The strength of hormones throughout the body. the pulse is also influenced by the extent of The circulatory system consists of the elasticity of the artery wall. The arteries heart, blood vessels and blood. The heart become stiffer with age – this is called arte- acts as a pump to generate , riosclerosis – and the extent to which they which drives blood through the vessels. can stretch with each pulse reduces. Arteries – thick-walled vessels – carry blood away from the heart at high pres- Heart anatomy and function sure. The larger arteries have elastic fibres The heart rate and stroke volume deter- within their walls that enable them to mine the cardiac output – the volume of stretch momentarily as they fill with blood blood pumped out of the heart each when the heart contracts and pumps blood minute. As may be expected, cardiac

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Box 1. Required competencies and the norm can be easily explained. As men- documentation tioned, pain, stress or exertion will increase the pulse rate, but it should return to Nurses must be able to: normal when the underlying trigger is ● Identify key anatomical sites – this makes it easier to access sites and maximises the abated. A slower-than-normal pulse can potential for a safe assessment result from some , for example ● Obtain informed consent digoxin and beta-blockers, and may also be ● Ensure the patient is relaxed and the relative position of the chosen site is equal to, present in people who are accustomed to or lower than, the level of the heart strenuous activity. In the case of very fit When assessing a patient’s pulse, the following must always be documented: people, a slower pulse results from their ● Time heart capacity being enlarged, and there- ● Pulse rate fore needing to beat fewer times to circulate ● Pulse quality the blood adequately. Required competen- cies and documentation are listed in Box 1. output must be maintained at all times for nervous system causes the heart rate to Main pulses the circulation to continue. Heart rate, and increase and increases the force at which There are many pulses in the body but the therefore pulse rate, depends on a number the heart contracts, while the parasympa- main ones are: of physiological factors. thetic system causes the heart rate to » Carotid; Muscle tissue requires an electrical decrease. This dual nerve supply enables » Brachial; signal to contract. For the skeletal muscles, the heart rate to be carefully regulated. At » Radial; which are used to move limbs and to alter rest, the parasympathetic nerve stimula- » Femoral; posture, this electrical signal comes from tion predominates and acts to slow the » Posterior tibial; peripheral nerves; however, the myocar- heart rate from its natural pacemaker rate. » Dorsal pedal. dium – which is the muscle that makes Many factors will activate the sympathetic When assessing any pulse, the site up most of the heart – can generate its nervous system to cause an increase in being assessed should ideally be level with, own signal. heart rate (and therefore pulse rate), or below, the level of the heart. If the site is This signal comes from the sinoatrial including: above the heart, blood is travelling node (more commonly called the pace- » Exercise; upwards and so the pulse might be less maker), which is a patch of specialised » Pain; easy to palpate. Some people have stronger tissue in the right atrium. It constitutes a » Infection; palpable pulses on one side than the other wave of electrical activity and spreads » Anxiety and other forms of stress so if you experience difficulty feeling a across the atria and then, after a short (exams, interviews); pulse, try the opposite side. delay at the atrioventricular node, travels » Excitement. Pulse assessments must always be accu- down the bundle of His (specialised heart Several hormones also affect the heart rately documented, and any deviations muscle cells that transmit electrical rate; one of these is adrenalin, which is from the norm reported. Providing they impulses) and across the ventricles. This commonly recognised. This is produced are conscious and competent, a patient’s causes the atria to contract together to from the adrenal glands after sympathetic consent must be gained before a pulse pump blood into the ventricles. The ventri- nerve stimulation. Adrenalin acts in the assessment is undertaken. cles then contract, producing the pressure same way as the sympathetic nervous to squeeze blood from the heart. The elec- system and will speed up the heart rate, Carotid pulse trical signal is carried through the heart increasing the force of contraction. This The landmark for this pulse is the anterior muscle by the heart’s conduction system. may produce a rapid, bounding pulse. triangle. This is formed by the mandible, The energy is known as synergy because trachea and muscle. The carotid pulse is each action results in another, like a line of Assessing the pulses: what to located in front of the sternocleidomastoid falling dominoes. The electrical activity of look for (Fig 1) and is sometimes deeper than antici- the heart can be picked up on an electro- A normal adult pulse will beat regularly pated. When locating this pulse, the cardiogram and displayed as an electrocar- between 60 and 100 times each minute at diograph. rest; in babies and children they are much FIG 1. carotid pulse The pacemaker has a natural rate, faster. Pulses are usually easily palpable; which is around 90 beats per minute. This patients with a weak or unstable pulse natural pacemaker-generated heart rate is should be assessed further; weak pulses faster than the normal resting heart rate. indicate reduced cardiac output and can At rest, something slows the heart rate progress to deterioration, for example down; to understand this, the other factors fainting, or perhaps a more serious that affect heart rate must be considered. problem. The heart is supplied with nerve fibres The rhythm of the pulses should be reg- from the autonomic nervous system, ular and consistent; unstable or irregular which has two divisions: pulses indicate irregular contractions of » The sympathetic nervous system; the heart and should be referred to a senior » The parasympathetic nervous system. clinician. A strong, bounding pulse indi- In general, the actions of these two divi- cates high blood pressure. sions oppose each other. The sympathetic It is important that any deviations from Lamb Peter

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Nursing Practice Practice educator

FIG 2. brachial pulse FIG 3. radial pulse FIG 4. femoral pulse

patient’s head should be in a comfortable aspect is the radial styloid – the thickened below the level of the inguinal ligament. position that requires no hyperextension. bone at the distal end of the radius. Use the pads of your fingertips to press on It is important to assess this pulse on Applying excess or insufficient pressure this area. If there is a lot of subcutaneous one side only and move the fingertips pro- will make it difficult to feel the pulse; the fat you will need to press more firmly, how- gressively towards the anticipated site of ideal pressure is equal to the weight of the ever take care not to compress the artery palpation. Caution must be exercised when hand and wrist, which will happen au- too much or the pulse will not be felt. assessing the carotid pulse due to the prox- tomatically when the correct position is imity of the carotid sinus – stimulation of adopted and the pulse felt for. Posterior tibial pulse the carotid sinus can result in a reduced To achieve the correct position, place Locate the inner ankle (medial malleolus) pulse rate, which will be undesirable for a two fingertips directly alongside the radial and feel 2-3cm behind and below it (Fig 5). patient with bradycardia, for example. styloid, just to the inside (Fig 3). Turn the The posterior tibial pulse is deeper than patient’s hand over to allow it to hang from the dorsal pedal pulse and requires more Brachial pulse your fingertips. Ensure the patient’s arm is concentration to locate and assess. This pulse is commonly used when manu- relaxed, so you are supporting the weight ally assessing blood pressure. The main of hand and wrist on your fingertips. Dorsal pedal pulse site is at the brachial plexus, in line with If the patient has cold hands a radial To find the dorsal pedal pulse, trace a line the biceps tendon. The patient’s arm pulse may be difficult to palpate because of between the medial and lateral malleoli should be extended, with the palm facing reduced peripheral circulation. Similarly, towards the first toe. The pulse is located upwards. Find the medial aspect of the if blood pressure is very low, the peripheral between the malleoli and can be found volar forearm, close to the and circulation will be compromised. about a third of the distance from there ulnar styloid (Fig 2). and towards the first toe (Fig 6). Femoral pulse Radial pulse The femoral artery lies midway between Conclusion To find the radial pulse, trace the thumb to the pubic symphysis and the anterior supe- Pulse assessment is a key element of its base and to where the radial bone rior iliac spine (Fig 4). Maximal pulsation healthcare and is used to indicate a begins at the wrist. On the volar/palmar of the femoral artery occurs immediately patient’s health status. It is, therefore, vital that nurses feel confident in their ability to FIG 5. posterior tibial FIG 6. dorsal pedal accurately locate and measure the pulses. pulse pulse There are many pulses throughout the body and as well as being able to locate them, nurses must be aware of the factors that can affect pulse rate so these can be taken into consideration. Once the selected pulse sites have been located and the pulse rate taken, it must be documented accurately. The patient must always be referred to another healthcare practitioner if any abnormality is detected. NT

For more on this topic go online... Effect of recording site on pulse oximetry readings Bit.ly/NTPulseOximetry Peter Lamb Peter

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