Health Assessment, part 5: Assessing Pulse

Hi. I'm Meris, and in this video, I'm going to be reviewing with you key components of how to assess your patient's pulse and then different expected findings and unexpected findings to be aware of for your clinical practice and your nursing school exams. I'm going to be following along using our health assessment flashcards. These are available on our website, LevelUpRN.com if you want to grab a set for yourself, but if you already have your own, I would invite you to go ahead and follow along with me. All right. Let's get started. So first up, I'm going to be talking to you about the assessment components involved in taking your patient's pulse. So there's a couple of things that we are going to assess when we are taking a pulse. We're going to assess the rate, how fast or slow it is. The regularity, are the beats happening at regular intervals or are they kind of sporadic and not happening regularly? What's the strength, meaning how strongly do I feel that pulse against my fingers? And then what is the equality? And equality means from side to side, so if I'm assessing the left and the right radial pulses, I want to see is the left the same as the right, or is it stronger or weaker? We're going to be assessing the quality there. Now, if my patient has a regular heart rhythm, meaning that those beats are happening at regular intervals, then I can count my patient's pulse for 30 seconds and multiply by two. That is just fine. However, if my patient has an irregular pulse, maybe this is something that I've noticed on assessment or I am aware that they have an irregular pulse such as having atrial fibrillation, then I need to actually listen to my patient's apical heart rate for a full minute, 60 full seconds. Another reason that I might want to do this is if my patient is taking any cardiac medications. So if my patient is on digoxin, for instance, I'm going to want to listen to their apical heart rate with a stethoscope for 60 full seconds.

Now, what if I go to assess my patient's pulse and I find that it's not there? Oh gosh. I'm feeling on their feet, right? I'm feeling for that pedal pulse, and I don't feel it. Do I just chart it as zero and I just move on? No. If I cannot feel that pulse, then I need to get a Doppler to listen for that pulse. And a Doppler is a device that uses ultrasound and amplifies the sounds within our body. So if I can't feel that pulse, then I need to make sure I can hear that pulse, and if I can't hear that pulse, I'm going to alert the provider. Now let's talk about how to obtain pulses, specifically radial and apical. So radial pulse, remember where your radius is. Your radius is on the thumb side. Your ulna is on the pinky side. So when I am assessing my patient's radial pulse, I want to feel along the thumb side. And this is exactly where you're going to feel right here. It's going to be on the wrist just proximal to the thumb, and I'm going to use the pads of my first two or three. It is also correct to use three fingers. Two fingers is fine. What I will not do is use my thumb because there is an artery in your thumb that you can feel your own heartbeat if you push down using your thumb, so I'm going to use my first two or three fingers to assess that pulse. An apical pulse, however, what does apical mean? It means that we are listening to the apex, that very pointy part down at the end of the heart where the two ventricles meet at the bottom. That's the apex of the heart. So where do I listen to that? I'm going to listen, again, listen. I'm not listening to radial pulses, I'm feeling, but I'm listening, auscultating, to the apical pulse. We're going to do that.

And this, again, you've heard me say it once; you'll hear me say it again. Learn it, love it, get a necklace that says it. You've got to know this now and for the rest of your nursing career. When we assess an apical pulse, we are listening at the fifth intercostal space at the left midclavicular line. So fifth intercostal space. You're going to count, two, three, four, five, and then you're going to go over to the midclavicular line, which is what it sounds like. It's a line that runs down the middle of my clavicle. So it's not the sternal border. It's not the midaxillary line. It's the midclavicular line at the level of the fifth intercostal space, and that's where you're going to listen for the apical heart rate. And again, remember, for 60 full seconds if it's irregular or if our patient is taking cardiac medications. Now, let's move on to some expected findings of a patient's pulse. First, you just have to know the pulse ranges. They're on here, and you can see we've got one of them bold in red. Before I tell you these pulse ranges, I want you to know that different institutions, different textbooks, different facilities, different schools use different ranges slightly. These ranges that I give you have all been referenced using the most up-to-date, peer-reviewed information that is out there. However, if your school or your facility or your institution wants you to know a different number, then I want you to just take a pen and scratch it out and write it down, what the thing is that you need to know for your school, okay? So here's the expected range. For adults is 60 to 100 beats per minute. For children, it is 70 to 120 beats per minute, and for infants, it is 100 to 160 beats per minute. Again, defer to your school or facility.

Now, the regularity of a pulse, it should be regular, meaning that there are equal-length pauses in between beats. That's what we expect to find. We also expect that the strength of your pulse is going to be what we call 2+, and 2+ just means how forceful it feels. Knowing that we can score that from 0 to 4+, how strongly is that pulse beating against my fingers? A nice normal pulse is 2+. And equality, the pulses should feel equal in strength and frequency, meaning when I feel a beat here, I should feel a beat here as well. They should be the same strength and happening at the same rate in any bilateral pulses, whether that's radial, posterior tib, dorsalis pedis. Any pulses that are on one side and the other should be equal in strength and in rate. Now let's talk about unexpected findings because this is the fun stuff, right? Again, deferring to your school's limits, bradycardia is a heart rate less than 60 beats per minute while tachycardia is a heart rate greater than 100 beats per minute in an adult patient. There's a key point icon on here that is super important for you to know, which is that athletes may have a below-average resting heart rate, and that's their baseline. It's an expected finding for them because they're in really good cardiac shape. So if my patient is not symptomatic with bradycardia, I'm not concerned, okay? That's okay.

Now, an irregular pulse would also be an unexpected finding. And again, another key point on here is about a sinus arrhythmia. This is an unexpected finding, but it's what we call sort of like a normal variation. It doesn't mean something is wrong. A sinus arrhythmia means that the heart rate increases with inspiration and decreases when I exhale. This is very common in children and in young adults. It's typically harmless. It's a common finding, but it is considered to be an unexpected finding. Now strength. Strength of 0 means it's absent, 1+ means it's diminished. Remember 2+ is normal, 3+ is considered strong, and 4+ is bounding. That means it is really hitting against the pads of my finger. Pulsus alternans, so this is going to be where we have alternating strong and weak beats, so I'm feeling that pulse and it's strong, weak, strong, weak. That is called pulsus alternans. And then pulse deficit, a pulse deficit is a difference between the apical pulse and the peripheral pulse, meaning that I'm listening to the apical pulse and I count 64 beats a minute, and my partner is feeling the radial pulse and he counts 57 beats per minute. Something is getting lost in translation from the heart to the extremity. So why that is, we would have to investigate further, but that is still considered an abnormal, unexpected finding. And keep in mind, you yourself cannot simultaneously count the apical heart rate and the radial heart rate, so in order to truly assess for a pulse deficit, I need to have two examiners. One is feeling that radial pulse and one is listening to the apical, okay? So don't get that question wrong on your exam because you think that you can count two pulses at once. You can't.

All right. Let's go ahead and test your knowledge of some key facts I provided in this video with my quiz questions. What is the expected range for an adult's pulse? The expected range for an adult's pulse is 60 to 100 beats per minute. How should the nurse describe a pulse that is normal in strength? A pulse with normal strength should be described as 2+. The nurse notes that the patient's heart rate increases with inspiration and decreases with expiration. How should the nurse describe this finding? This finding should be described as a sinus arrhythmia. How should the nurse assess a patient's apical pulse? The apical pulse can be assessed by auscultating at the fifth intercostal space of the left midclavicular line. All right. That is it for this video. I hope you found this review helpful. If you have any comments, I would love to hear them. And of course, if you have a great way to remember something, please tell me about it because I know that I want to hear it and so do other people watching this video. You're doing a really great job, and I'm super proud of you. Thanks for studying with me.