Pulse

Question 1

Definition

Answer 1

The expansion of the arterial walls occuring with each ventricular contraction.

Question 2

Purposes

Answer 2

1. To count the number of times that the heart beats per minute.
2. To obtain information regarding condition of the heart action and patient’s general condition.

Question 3

Special Considerations

Answer 3

• Remember that one pulse or one complete rise and fall of the arterial wall is considered one beat or count.
• Take the pulse at a convenient site for the patient and the nurse.
• When taking the pulse, note the rate, rhythm, the volume and quality of the arterial wall.
• Do not take pulse when the patient is restless or when a child is crying.
• If peripheral pulse is difficult to obtain, take the apical pulse or cardiac rate.

Question 4

Equipment

Answer 4

Watch with a second hand and stethoscope if needed (apical pulse).

Question 5

Step 1

Answer 5

Have the patient rest his arm alongside of his body with the wrist extended and the palm of the hand facing downward.

Question 6

Step 1 rationale

Answer 6

The position places the radial artery on the inner aspect of the patient’s wrist.
The nurse’s fingers rest conveniently on the artery with the thumb in a position on the outer aspect of the patient’s wrist.

Question 7

Step 2

Answer 7

Place the 1st, 2nd, 3rd fingers along the radial artery and press it gently against the radius; rest the thumb on the back of the patient’s wrist.

Question 8

Step 2 rationale

Answer 8

The fingerprints, sensitive to touch, will feel the pulsation of the patient’s radial artery.
If the thumb is used for palpating the patient’s pulse the nurse may feel her own pulse.

Question 9

Step 3

Answer 9

Apply only enough pressure so that you can feel the patient’s pulsating artery directly.

Question 10

Step 3 rationale

Answer 10

Moderate pressure allows the nurse to feel the superficial radial artery expand and contract with each heart beat; too much pressure will obliterate the pulse.
If too little pressure is applied, the pulse will be imperceptible.

Question 11

Step 4 + rationale

Answer 11

Using a watch with a second hand, count the number of pulsation felt on the patientcs artery for one full minute.

• Sufficient time is necessary to detect irregularities or other defects.

Question 12

Step 5 + rationale

Answer 12

If the pulse rate is abnormal, repeat the counting in order to determine accurately the rate, the quality, and the rhythm of the pulse.

• Repeating the count is necessary to allow regular timing between beats.