This section has two parts:
1. Pulse
2. Apical–radial
Learning outcomes
By the end of this section, you should be able to:
▪ provide an understanding and rationale for this practice
▪ prepare the patient for this nursing practice
▪ locate, assess, measure and record the radial pulse
▪ locate the major pulse points of the body
▪ locate, assess, measure and record the apical–radial pulses.
Background knowledge
To help you to palpate the pulse and interpret the results, it is necessary to have some knowledge of the structure, function and pathology of the cardiovascular system, particularly the heart, the conduction system and the arteries
For the practice of apical–radial pulse you should demonstrate competence in measuring and recording a radial pulse and in the correct use of a stethoscope.
1. PULSE
Indications and rationale for assessing the radial pulse
A pulse is the rhythmic expansion and recoil of the elastic arteries caused by the ejection of blood from the left ventricle. It can be palpated where an artery near the body surface can be pressed against a firm structure such as bone. Three aspects are usually noted when a pulse is being palpated – its rate, rhythm and strength.
The pulse may be assessed for the following reasons:
▪ on admission to ascertain the patient’s pulse and assess whether or not it falls within the normal range for the person’s age
▪ preoperatively to ascertain the patient’s baseline pulse rate, rhythm and quality so that comparisons can be made with postoperative assessments
▪ to help to estimate, in general terms, the degree of fluid loss when the level of body fluids is lowered, e.g. after excessive vomiting, excessive diarrhoea or haemorrhage. In the event of a large fluid loss from the body, the pulse is thready and rapid. Severe electrolyte imbalance causes impaired cell function and cardiac arrhythmias
▪ to compare with baseline admission assessments to help to evaluate the effect of treatment on patients who have cardiovascular or pulmonary disease. The majority of patients with these problems will have pulse irregularities that should stabilise with treatment
▪ to monitor the patient who is receiving a blood or blood product intravenous infusion. Elevated pulse and temperature are among the first signs of reaction to the infusion.
The following terms are used to describe the differing ranges of pulse rate:
— normal resting heart rate for adults and adolescents 60–100 beats per minute
— a pulse rate over 100 beats per minute is known as tachycardia
— a pulse rate below 60 beats per minute is known as bradycardia
Tachycardia (a rapid pulse rate) can be the result of pain, anger, fear or anxiety, all of which stimulate the sympathetic nervous system and cause the release of adrenaline (epinephrine). It can also occur in some heart diseases, anaemia and fever, and during exercise, all of which require a greater amount of oxygen and thus increase the cardiac output (Alexander et al 2006). Bradycardia (a slow pulse rate) occurs in any condition, for example raised intracranial pressure, which stimulates the parasympathetic nervous system. Specific heart conditions such as damage to the conducting mechanism after a myocardial infarction can also cause bradycardia. It also occurs in fit athletes, who develop a very efficient heart muscle action.
Rhythm
The rhythm should be regular; any irregularities should be noted. It should be observed whether the irregularities occur at regular or irregular intervals. A normal regular irregularity may occur, particularly in younger people, in conjunction with inspiration and expiration.
Strength
The pulse pressure is the difference between the systolic and the diastolic pressure. The force is a reflection of the pulse strength. The pulse is usually recorded as being normal, bounding, weak and thready, or absent (Goodall 2000).
Elasticity
The elastic recoil of the artery wall should be noted. The artery of a healthy young adult feels flexible and non-tortuous, quite different from that of an elderly patient suffering from a condition such as arteriosclerosis, whose artery will feel hard and cord-like.
The pulse rate is much higher in babies and young children than adults because they have a higher metabolic rate. A pacemaker occasionally ‘fires’ before the sinoatrial node; the resulting decrease in filling time of the heart chambers causes a pause in the rhythm, which can be detected when assessing the pulse.
Remember you are not solely assessing the pulse rate. You are also assessing the pulse for rhythm and strength. As pulse forms one part of the observation of your patient’s cardiovascular or respiratory status, it should be remembered that assessment of the colour of the lips, skin, nail beds and breathing pattern should also be noted.
Outline of the procedure
The pulse can be felt by placing two fingers over any artery lying close to the skin’s surface. The radial artery is the most commonly used site for assessing rate and rhythm. If the pulse is irregular, an apical–radial pulse should be performed (see Section 2).
Equipment1. Watch with a second hand
2. Observation chart
3. Black pen.
Guidelines and rationale for this nursing practice▪ explain the nursing practice to the patient to obtain consent and co-operation. Patients should be encouraged to be active partners in their care
▪ wash your hands to prevent cross-infection between patients (Jeanes 2005)
▪ ensure that the patient is in a position that is as comfortable and relaxed as possible. This will help the nurse to obtain a true baseline measurement
▪ observe the patient throughout this activity for any signs of discomfort or distress. This should allow the nurse to intervene immediately in the event of an adverse reaction
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