Taking a Pulse

Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects

blood into the aorta. Assessment of pulse characteristics provides clinical data regarding the hearts pumping

action and the adequacy of peripheral artery blood flow.

 

Taking a Radial (Wrist) Pulse

1. Wash hands.

2. Inform client of the site(s) at which you will measure pulse.

3. Flex clients elbow and place lower part of arm across chest.

4. Support clients wrist by grasping outer aspect with thumb.

5. Place your index and middle finger on inner aspect of clients wrist over the radial artery

and apply light but firm pressure until pulse is palpated.

6. Identify pulse rhythm.

7. Determine pulse volume.

8. Count pulse rate by using second hand on watch. For a regular rhythm, count number of beats for 30 seconds and multiply by 2. For an irregular rhythm, count number of

beats for a full minute, noting number of irregular beats.

9. Wash hands.

10. Raise clients gown to expose sternum and left side of chest.

11. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.

12. Put stethoscope around your neck.

13. Locate apex of heart:

With client lying on left side, locate suprasternal notch.

Palpate second intercostal space to left of sternum.

Place index finger in intercostal space, counting downward until fifth intercostal space is located.

Move index finger along fourth intercostals space left of the sternal border and to the fifth intercostal space, left of the midclavicular line to palpate the point of maximal impulse (PMI).

Keep index finger of nondominant hand on the PMI.

14. Inform client that you are going to listen to his heart. Instruct client to remain silent.

15. With dominant hand, put earpiece of the stethoscope in your ears and grasp diaphragm of the stethoscope in palm of your hand for 510 seconds.

16. Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound.

17. Note regularity of rhythm.

18. Start to count while looking at second hand of watch. Count lub-dub sound as one beat:

For a regular rhythm, count rate for 30 seconds and multiply by 2.

For an irregular rhythm, count rate for a full minute, noting number of irregular beats.

19. Share your findings with client.

20. Record by site the rate, rhythm, and, if applicable, number of irregular beats.

21. Wash hands.

 

PULSE POINT ASSESSMENT CRITERIA

PULSE POINTS

Temporal: over temporal bone, superior and lateral to eye

Carotid: bilateral, under lower jaw in neck along media edge of sternocleidomastoid muscle

Apical: left midclavicular line at fourth to fifth intercostals space

Brachial: inner aspect between groove of biceps and triceps muscles at antecubital fossa

Radial: inner aspect of forearm on thumb side of wrist

Ulnar: outer aspect of forearm on finger side of wrist

Femoral: in groin, below inguinal ligament (midpoint between symphysis pubis and anterosuperior iliac spine)

Popliteal: behind knee, at center in popliteal fossa

Posterior tibial: inner aspect of ankle between Achilles tendon and tibia (below medial malleolus)

Dorsalis pedis: over instep, midpoint between extension tendons of great and second toe