ASSESSING A PERIPHERAL PULSE

PURPOSES:
• To establish baseline data for subsequent evaluation.
• To identify whether the pulse rate is within normal range.
• To determine whether the pulse rhythm is regular and the pulse volume is
appropriate.
• To compare the equality of corresponding peripheral pulses on each side of the
body.
• To monitor and assess changes in the client’s health status.
• To monitor clients at risk for pulse alterations (eg, those with a history of heart
disease or experiencing cardiac arrhythmias, hemorrhage, acute pain, infusion of
large volumes of fluids, fever.)

EXPECTED BEHAVIOR RATIONALE

ASSESSMENT:
1. Assess appropriate site
to obtain pulse.
2. Check pulse with health
status changes.
3. Assess for rate, rhythm,
pattern, and volume.
4. take an apical pulse on
patients with irregular
rhythms or those on
heart medications.
5. Take an apical-radial
pulse when deficits
occur between apical
and radial
measurements.

PLANNING:
1. To determine if the
pulse rate is within
normal range and if the
rhythm is regular.
2. Evaluate the quality of
corresponding arterial
pulses.
3. To determine presence
of peripheral pulses
when palpation is
ineffective.
4. To monitor and evaluate
changes in the patients
 health status.

INTERVENTION:
1. Position the client
appropriately.
• Assist an adult or young
child to a comfortable
supine position with the
head of the bed elevated,
or to a sitting position on
a chair, the edge of the
bed, or the examination
table.
• Place a baby in a supine Crying and physical activity will increase
position, and offer a the pulse rate.
pacifier if the baby is
crying or restless. For
this reason, take the
apical pulse rate of
infants and small
children before
assessing body
temperature.
• Demonstrate the This will decrease anxiety and promote
procedure to child using cooperation.
a stuffed animal or doll,
and allow the child to
handle the stethoscope
before beginning the
procedure.
• Expose the area of the
chest over the apex of
the heart.
2. Locate the apical pulse.
• This is the point over the
apex of the heart where
the apical pulse can be
most clearly heard. It is
also referred to as the
point of maximal
impulse (PMI). In 50%
of the adult population,
the apical impulse can
be palpated (Malasanos
et al 1990).
• Palpate the angle of
 Louis (the angle
between the manubrium
the top of the sternum).
It is palpated just below
the supresternal notch
and is felt as a
prominence.
• Place your index finger The apex of the heart is normally located in
just to the left of the the fifth intercostals space in individuals
client sternum, and who are 7 years of age and over; it is in the
palpate the second fourth intercostals space in young children
intercostals space. and one or two spaces above the adult apex
• Place your middle or during infancy.
next finger in the third
intercostals space, and
continue palpating
downward until you
locate the apical pulse,
usually about the fifth
intercostals space.
• Palpate the apical pulse.
If the client is an adult,
move your index finger
laterally along the fifth
intercostal space to the
MCL. Normally, the
apical pulse is palpable
at or just medial to the
MCL. For a young child,
move your finger along
the fourth intercostals
space to a position
between the MCL and
the anterior axillary line.

3. Auscultate and count

heartbeats.
• Use antiseptic wipes to The diaphragm needs to be cleaned and
clean the earpiece and disinfected if soiled with body substances.
diaphragm of the
stethoscope if their
cleanliness is in doubt.
• Warm the diaphragm of The metal of the diaphragm is usually cold
the stethoscope by and can startle the client when placed
holding it in the palm of immediately on the chest.
the hand for a moment.
• Insert the earpieces of
the stethoscope into the
ears. The earpieces
maybe straight or bent.
If they are bent, place
them in the direction of
the ear canals, or slightly
forward, to facilitate
hearing.
• Place the diaphragm of The heartbeat is normally loudest over the
the stethoscope over the apex of the heart. The two heart sounds are
apical impulse and listen produce by closure of the valves of the
for normal S1 and S2 heart.
heart sounds, which are
heard as “”lub dub. Each
“lub dub” is counted as
one heartbeat. The S1
heartbeat sounds (lub)
occur when the
atriventricular have been
sufficiently filled. The
S1 heart sound(lub)
occurs when the
semilunar valves close
after the ventricles
empty.
• Count the heartbeat for
30 seconds and multiply A 60-second provides a more accurate
by 2 if the rhythm is assessment of an irregular pulse than a 30-
irregular or if the apical second count.
impulse is being taken
on an infant or child.

4. Assess the rhythm and

the strength of the
heartbeat.
• Assess the rhythm of the • A normal pulse has equal time
heartbeat by noting the periods between beats.
pattern of intervals
between the beats. As
normal pulse has an
equal time period
between the beats.
• Assess the strength • Normally, the heartbeats are equal
(volume) of the in strength and can be described as
heartbeat. strong or weak.
 5. Document and report
pertinent assessment
data.
• Record the pulse site
and rate, rhythm, and
volume.
• Reports to the nurse in
charge any pertinent
data such as pallor,
cyanosis, dyspnea,
tachycardia,
bradycardia, irregular
rhythms, and reduced
strength of the heartbeat.

EVALUATION FOCUS:

The apical rate in relation to

baseline data or normal range
for the age of the client;
relationship to other vital signs;
apical pulse rhythm and volume
in relationship to baseline data
and health status.