Assessing Peripheral Pulse by Palpitation
The nurse is preparing to measure an adult's radial pulse using a Doppler device. Place the following steps of the procedure in the correct order. Use all options.
1)Apply conducting gel to the site where the pulse will be auscultated. 2)Place the Doppler probe tip in the gel. 3)Adjust the volume of the device, as needed. 4)Maneuver the tip of the Doppler probe over the area until the pulse is heard. 5)Count the number of heartbeats for one full minute. 6)Wipe the gel off of the client's skin.
The nurse is assessing a client's radial pulse and notes that the rate is somewhat irregular. The nurse should count the pulse over which time frame?
60 seconds - If the nurse notes an abnormality when assessing a client's radial pulse, the nurse should count the pulse rate over 60 seconds (1 minute) to ensure that the results are accurate. If the pulse was normal, the nurse would count the rate over a period of 30 seconds and then multiply the number by two.
The nurse is to assess the pulse rate in an 18-month-old child. Which location provides the most accurate result?
Apical - Apical pulse measurement is the preferred method of assessment in infants and children less than 2 years of age. Assessment of the pulse by auscultation may be difficult in the older infant and toddler due to increased subcutaneous tissue in that age group, movement of the child or crying, and weak pulses in the infant. Listening to the pulse directly over the heart provides the most accurate assessment.
The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?
Assess the apical pulse. - If a radial pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would need to assess the apical pulse rate. By assessing the apical rate, the nurse can hear the rate instead of trying to feel the rate. Assessing the carotid pulse would also be done through touch, so the outcome would be the same and not accurate. If the nurse is concerned about the client, it does not hurt to have another nurse check the pulse, but the nurse should assess the apical pulse first. The findings should be documented, but only after all assessments have been completed.
The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?
Lightly compress the client's radial artery using the first, second, and third fingers. - The radial artery is the most common place to assess a peripheral pulse on an adult. The fingertips are sufficiently sensitive to palpate arterial pulsations using light compression and thus should be used, not the thumbs. The first, second, and third fingers of one hand are used to assess peripheral pulse, not the first fingers of each hand. Take care to avoid completely compressing the artery.
The nurse would use which part of the hand when assessing the radial pulse?
Pads of first, second, and third fingers - To assess the radial pulse, the nurse uses the pads of the index, second and third fingers of the hand. These three fingers help determine the volume, rate and rhythm of the pulse. The thumb of the hand should not be used, because it has its own pulse. The palm of the hand does not have enough sensitivity to determine volume and rhythm. Because of the sensitivity of the fingertips, they can interfere with an accurate measurement of the pulse.
The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use?
Palpate one artery at a time. - To palpate the carotid arteries, the nurse would lightly press on one side of the neck at a time. Never attempt to palpate both carotid arteries at the same time as bilateral palpation could result in reduced cerebral blood. It is not necessary to count the carotid rate.
