Vital signs - pulse monitoring.

Vital signs - pulse monitoring.

1. Pulse PREPARED BY: USHA RANI KANDULA, ASSISTANT PROFESSOR, DEPARTMENT OF ADULT HEALTH NURSING, ARSI UNIVERSITY,ASELLA,ETHIOPIA, SOUTH EAST AFRICA.

2. Introduction The heart’s four chambers rhythmically contract and relax.

3. With each contraction of the ventricles, oxygenated blood is forced out of the left ventricle through the aorta to be delivered to the body’s arteries.

4. The amount of blood discharged from the left ventricle with each contraction is known as the stroke volume.

5. This pumping action of the heart results in a fluid wave of blood that travels through the arteries as they rhythmically expand and contract.

6. Definition This arterial fluid wave can be palpated as a gentle pulsing, tapping, or throbbing sensation at various points over the body; this is called the pulse.

7. The pulse corresponds to the contractions or beats of the heart and is counted by the number of beats per minute ( bpm ).

8. The volume of blood pumped from the heart in 1 minute is known as the cardiac output. The average adult heart pumps approximately 5 liters per minute.

9. The central or primary pulse site, the apical pulse, is located over the apex of the heart where the contraction is the strongest .

10. The apex of the heart, the cone-shaped end of the left ventricle, actually touches the anterior chest wall at or near the fifth intercostal space.

11. This spot is known as the point of maximum impulse (PMI) and is located 3 to 4 inches to the left of the sternum, generally in the fifth intercostal space, at the midclavicular line.

12. In a child, it may be found in the fourth or fifth intercostal space. You should be able to feel the PMI with your fingertips.

13. The PMI is the site over which you will place your stethoscope to auscultate , or listen to, the apical pulse.

14. Although less convenient to assess, the apical pulse is the most accurate pulse because both heart sounds can generally be heard and it provides information about the valves and contraction of the atria and ventricles that cannot be detected when assessing peripheral pulses.

15. The apical pulse can be auscultated even when peripheral pulses cannot be detected. It is assessed for a full minute to listen for irregularities.

16. When auscultating the heart sounds, you normally hear two sounds called the S1 and S2, or “ lubb-dupp . ” Together, these two sounds represent one complete heartbeat.

17. If both the S1 and S2 or lubb-dupp sounds are heard clearly and distinctly, the volume or strength of the apical pulse is described as distinct or strong.

18. If both heart sounds cannot be heard distinctly, it is described as distant or muffled.

19. The apical pulse should be the same rate as the peripheral pulses, but if the heart does not pump effectively, blood flow may not be strong enough to consistently deliver a fluid wave to the more distant pulse sites from the heart.

20. Often this occurs when the pulse is irregular, resulting in an apical pulse rate that is faster than the radial pulse. When the radial pulse is slower than the apical pulse, this is known as a pulse deficit.

21. For example, the heart rate may be 83 bpm but the radial pulse is only 77 bpm . This would be a pulse deficit of 6 bpm and should be recorded and reported.

22. The number of the pulse deficit, 6 in the previous example, represents the number of heartbeats in which the force of the heart’s contraction fails to produce a pulse wave strong enough to be felt at, or perfuse to, the radial pulse site.

23. Beats that do not perfuse are ineffective in circulating the blood.

24. Peripheral Pulse Sites There are various other pulse sites where the pulse may be palpated by applying gentle fingertip pressure over the artery against the underlying bone. These sites are known as the peripheral pulses.

25. The peripheral pulse sites include the following: • Temporal : can be used when radial pulse is not accessible • Carotid : used in cardiac arrest and cardiopulmonary resuscitation (CPR) • Brachial : used to measure BP; can be used to assess pulse rate in small children

26. • Radial : routinely used for pulse rate assessment • Femoral : used to determine circulation to the leg, cardiac arrest • Popliteal : used to determine circulation to the lower leg

27. • Posterior tibialis : used to determine circulation to the foot • Dorsalis pedis : used to determine circulation to the foot

28. The temporal pulse can be felt over the temporal bones on the sides of the head. The carotid pulse is located on the sides of the neck between the trachea and the sternocleidomastoid muscle.

29. The brachial pulse is found in the medial elbow crease of each arm, known as the antecubital space . The radial pulse runs parallel to the radius bone on the thumb side of the wrist.

30. The femoral pulse can be palpated along the groin crease at the top of the thigh. The most difficult pulse to locate is the popliteal , found behind the knee.

31. When palpating the popliteal pulse, first have the patient slightly flex the knee. To feel the dorsalis pedis pulse, place your fingertips at the space between the great toe and the second toe.

32. Move the fingers proximally until they rest over the metatarsals of the foot. The posterior tibialis pulse is located by laying your fingertips on the medial aspect of the ankle, directly behind the medial malleolus bone.

33. Any of the peripheral pulses can be used to assess the heart rate, but the easily accessible radial pulse is the most commonly used site; if it is weak or cannot be felt, then the apical pulse is auscultated .

34. Use the apical pulse for assessing pulse rate in children under the age of 3 years, when the radial pulse is weak or has irregular rhythm, and prior to administering heart rate–altering medications such as digoxin .

35. The peripheral pulses are generally assessed for strength or volume, comparing the right and left sides for equal strength. During CPR, the carotid artery is easily palpated to determine the presence of a pulse.

36. Pulse Assessment As a nurse, you will assess three characteristics of the pulse: 1. Rate 2. Rhythm 3. Volume (strength) The normal range of pulse rate for adults is 60 to 100 bpm .

37. A pulse less than 60 bpm is known as bradycardia ; A pulse greater than 100 bpm is termed tachycardia. Numerous factors can affect the pulse rate . The rhythm is determined by comparing the intervals between the beats.

38. If all the beats are evenly spaced, the rhythm is described as regular. If there are differences in the interval lengths, the pulse is termed irregular.

39. If peripheral pulses are palpated with each cardiac contraction, the blood fluid wave is reaching the pulse points, or is perfusing .

40. Volume or strength of a radial pulse is some what subjective in its description. A scale of 0 to 3 is generally used to assess pulse volume . If the palpated pulse is easily detected, it is generally described as strong or 21 .

41. This would be considered a normal finding. A pulse that is faint and difficult to feel is categorized as weak or 11.

42. If the pulse is so weak that slight fingertip pressure on the pulse site results in the pulse disappearing, the pulse is classified as thready or feeble.

43. A thready pulse disappears, or obliterates, because an inadequate volume of blood is being ejected from the heart with each contraction.

44. In other words, the pumping action of the heart is too weak to deliver an adequate blood fluid wave to the peripheral pulse sites.

45. The result of this problem is decreased delivery of oxygen and nutrients to the tissues, thus preventing optimal functioning of tissues, organs, and systems.

46. A pulse that is very strong and does not disappear, even with moderate pressure, would be classified as a full, bounding, or 31 pulse.

47. If a pulse is not detectable by palpation, it is termed absent or rated as a 0 . If this occurs, your next step is to palpate for the next proximal pulse in that extremity.

48. If you cannot feel the next proximal pulse either, proceed up the limb to the next proximal pulse until you detect the peripheral pulse that is farthest away from the heart.

49. For example, if you cannot palpate the dorsalis pedis pulse, palpate for the posterior tibialis pulse, and if unable to feel it, palpate for the popliteal pulse, and finally the femoral pulse.

50. While assessing for these pulses, there are further assessments you should perform on the extremity distal to the pulse site, including skin color, skin temperature, sensation, and capillary refill time.

51. Is the color a healthy pink, or is it pale or cyanotic, indicating impaired circulation? Is the temperature of the skin warm, as it should be?

52. Or is it cool or cold, again indicating impaired circulation? Does the patient have adequate sensation in the distal aspect of the extremity?

53. Can he or she differentiate between dull and sharp sensations as you apply the stimuli to the distal portion of the extremity?

54. You may use something soft, such as a gentle brush of your fingertip or a tissue across the patient’s skin. You can use something like a pencil eraser or the side of the barrel of your ink pen.

55. Use something that is relatively sharper, such as a pin or the pointed tip of a pencil or ink pen, to provide a sharp stimulus.

56. What is the capillary refill time? This is assessed by gently squeezing a nailbed of the extremity to empty the capillaries of blood.

57. The nailbed will turn pale until you remove the pressure, after which it should return to a pink color as the capillaries refill with blood.

58. Normally this will occur within 3 seconds in an adult and within 5 seconds in an elderly patient.

59. If it takes longer to refill, this is an indication that there is circulatory impairment.

60. In a patient whose nails are thickened and yellowed or one who is wearing nail polish, you may press the tip of the finger or toe to assess capillary refill.

61. After assessing the extremity for proximal pulses and other signs of adequate circulation, obtain a Doppler ultrasound machine, a device that uses sound waves to determine if blood flow is present.

62. Listen for the most distal peripheral pulse that you were unable to palpate, to confirm that there is adequate arterial blood flow to the site. The use of Doppler ultrasound to assess nonpalpable pulses.

63. Factors Affecting Pulse Rate Age Newborns: 120–160 bpm 1–2 years: 90–120 bpm 3–18 years: 80–100 bpm Adults: 60–100 bpm

64. Emotions, hormones, stress Stimulate sympathetic nervous system, increasing pulse rate

65. Medications Can either speed or slow pulse rate Drugs such as digitalis or propranolol slow the rate, while epinephrine and theophylline speed up the rate

66. Caffeine and nicotine Speed the rate

67. Exercise Speeds the rate during activity Long-term training and conditioning, as in athletes, will slow the rate Well-conditioned Athletes may have a pulse rate less than 60 bpm

68. Meditation, rest, sleep Lower the pulse rate

69. Circadian rhythm Pulse rates are slowest from pre dawn hours to dawn and faster as the day progresses toward evening.

70. Blood volume: Decreased, as in hemorrhage and dehydration Hemorrhage and dehydration will increase the pulse rate in an effort to more quickly transport the oxygen carried by red blood cells to the body tissues.

71. Increased, as in fluid overload Fluid overload will cause pulses to be full and bounding; sometimes faster.

72. Body temperature As body temperature increases, each degree Fahrenheit results in speeding the heart approximately 10 bpm As the body cools, each degree results in slowing the pulse by 10 bpm

73. Hypoxia Increases the pulse rate Cardiovascular disease Different diseases can raise, lower, or make the pulse irregular

74. Increased intracranial pressure Typically lowers the pulse rate and may cause it to be irregular.

75. Scale for Measuring Peripheral Pulse Volume Description of Pulse Pulse feels very strong and full and is easily counted. Does not obliterate even with moderate pressure. 3+ or bounding

76. Pulse is easily detected, feels strong, and is easily counted. Can be obliterated with moderate pressure. Considered the normal finding. 2+ or strong

77. Pulse feels weak and can be obliterated with slight pressure. If the pulse is so faint and weak that it is difficult to feel it long enough to count the rate, an additional descriptor may be used. 1+ or weak Thready

78. Pulse is not detectable. 0 or absent

79. Thanking you