NAME: MARANGIT,Nabila Dp. ares Maren 24,2092 ASSESSING PULSE RATE DEFINITION: S€Ssing owl i intin ( i i PURPOSE: indica: ‘heal ie i EQUIPMENT: a Lo | is CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE: z i ial acti erate, i) TOURING! 1f the patient is olsacd and _tomfortable “AFTER: wash and Avy your hards- THINGS TO DOCUMENT AFTER THE PROCEDURE: PERFORMANCE INDICATORS: C—The step was correctly performed X- The step was not performed N- The execution of the step needs improvement R. The step was correctly performed after remediation PROCEDURE RATIONALE [ex [NR Initial Preparation 4, | Identify the client and explain the procedure to the [To lessen Anxiety and client to obtain informed consent. Promote Cooperation 2, | Gather the necessary equipment and then bring to |FAGWabes organized ” | the bedside. Assessment A measurement _ 3, | Adhere to local infection control polices and To prevent contamination ensure proper hand hygiene (hand washing) Place client in a comfortable position eitherina | ¢y an qccurate : 4 | siting oF supine position. Tetord 5. | Provide privacy To maintain dignity. |AL_ ASSESSING THE RADIAL PULSE 4 To check the radial pulse, position the client'sarm [The, relaxed position Of the «, | along the side of the body or across the upper | wrist ind pans fac abdomen with the client's wrist relaxed and palms | upward permit ful expostve, either facing upward or downward. nf the artery to paleartion: 6 | NSG 102.2 | HEALTH ASSESSMENT LABORATORY MANUAL‘Apply light pressure with the pads of the fingers ich pressive. occludes the} ] (Your forefinger and index finger) in the groove [pulse impairs \olood flow, and 7. | along the radial or thumb side ofthe client's inner _|mmay reswip in the nurce wrist. Be careful not to apply too much pressure, | counting his] her Ow pulse rate. as this can impair blood flow. 8 Identify the pulse, feeling for the characteristic Because an irreawlr weak wave-like sensation. st conbe-asignof healtn issn 9. Looking at a clock or watch with a second hand, [0 AUHIENE the OvenrnHe count the number of beats over 60 seconds. Pulse per minute. 10. | Assess bilaterally [To provide Accmerte. wearsurementy 11, | During or after counting the rate, assess for pulse ~ | rate, rhythm, quality and amplitude. Ho determine 1 the. Cee regular Avolume is apprpvAte. |B. ASSESSING THE APICAL PULSE Clean the earpieces and diaphragm of the 12, | stethoscope with alcohol wipes or cotton balls with alcohol. Discard wipes or cotton balls proper) To prevent Spreading of miadorgpnism and maintain heath sanitation. 13, | With the client supine or sitting, expose the left side of the chest but only as much as necessary. To easily access the Aetiesiope and provide privacy: Palpate the 5 intercostal space at the midclavicular line by: a. Sliding your finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet). b, Slide your finger over to the left sternal border to the 24 intercostal space 14. | c. Now place your index or ring finger in the 2*¢ intercostal space, and count down to the St intercostal space by placing a finger in each of the spaces, 4. Slide over to the midclavicular line, keeping your fingers in the S® intercostal space. The palpated apical pulse is also called the point of ‘maximal impulse (PMI) Paris 5 parr OF wearin impule Wyrere the heart beat i9 west Head: Warm the stethoscope in your hand for 10 45, | Seconds then place the diaphragm over the PMI * | and listen to the normal $1 and S2 heart sounds (lub dub) Tor the poriont to be comterinbe: 16, | Count the beats for a full minute using a watch witha second hand. To ensure accavany OF he _assestament 17, | Place back patient's clothing and place * | comfortably in bed. Ho provide tomfort and privary to the porient- 19, | During or after counting the rate, assess for pulse rate, rhythm, quality and amplitude. To determine: if the ratnm [Pequidw- A wohwe is appropiate: C ASSESSING THE BRACHIAL PULSE, Using firm pressure with the pads of your forefinger and index fingers, press in the inner aspect ofthe antecubital fossa until you palpate the brachial artery. 19. Whe avie 40 palpate he ‘o\ped. pacsir uae avery, witlnof ocelading the artery Ifyou have difficulty palpating the brachial pulse, | To easily pal palm of the hand downward). mane 21, | Identify the pulse, feeling for the characteristic | To\dewtify ¥f Yheve, ave, “ | wave-like sensation. Dono MALItICS - 22, | Count the beats for a full minute using a watch ” | witha second hand, To determaG tre acuwary Lot Ye ceressment. 7 | NSG 102.2 | HEALTH ASSESSMENT LABORATORY MANUAL23, Assess bilaterally [ror accurate measurement 24, During or after counting the rate, assess for pulse Fate, rhythm, quality and amplitude. He detemnine We reGulnityT ES LSE icreqylarity of We price To check the carotid pulse, place your fingers on For cotteck placement of 25, | the client's trachea and slide them to the side into. [her Fingers Ona vegin the the groove between the trachea and the re oa sternocleidomastiod muscle. ormesiwent. Palpate the carotid artery lightly. Pressure on the [To wok ¥imulate the. wa gus 26, | carotid (especially in older adults) can stimulate | wewe and (ampromise tae the vagus nerve causing the pulse and BP to drop | ayajal bieod flow tone. suddenly. loin: 27, | Hentiy the pulse, feeling for the characteristic | TO \d@wtity if there 16 avty wave-like sensation. Aloweina ites Do not palpate the carotid pulse except during a inis d0€S yor disappear 2g, | cardiopulmonary resuscitation (CPR) inan adult | yndev low breed Pressure & and in certain situations to assess for circulation | fo decide Whetwer- ey not CPR tothe head. ‘ghonld_loe jeitiated- Fo, During or ater counting the rate assess for pulse [Te deteowve tic eli OF ahd rate, rhythm, quality and amplitude. and fhe volume © APP? PrIATE E-ASSESSING THE DORSALIS PEDIS PULSE Palpate the dorsalispedis pulse by running the For aware vesutt OF 30. | pads of your fingers up to the groove between the | tye palpation reat and first toes to the top of the foot. nals 431, | Palpate very lightly because dorsalispedis pulse is | Palpation can ve fettley easily obliterated sour finger pads. 432, | Hdentify the pulse, feeling forthe characteristic [To deteymine if the puise wave-like sensation. is meimal_ oY not. 33. | Assess bilaterally Foy petrey regults. 734, | During or after counting the rate assess for pulse [TO Actenwine if the Vitam 15 rate, rhythm, quality and amplitude. equa koe wove’ appeyrmt FrASSESSING THE FEMORAL PULSE Palpate the femoral pulse by pressing deeply in To beain Ye assent 35. | the groin midway between the anterosupeior iliac . spine and the symphysis pubis A geawave palpation The femoral artery lies very deep and requires [Yow wilt wot fe ate tO do 436, | sianificant pressure to palpate. You mayneedto [ne assovsment without Use both hands to feel the femoral pulse onan |fecling the Gulse appeprota adult. 37, | entity the pulse, feeling forthe characteristic | To AeXovwite- wave-like sensation. AonamMa ities . Looking ata clock or watch with a secondhand, [TO Know the average 38. | count the number of beats over 60 seconds. pulse per minute. Go, | During orate counting the rate assess for pulse [To devenmine. te. raul ot "| rate, rhythm, quality and amplitude. rhytn G.ASSE! iG THE POSTERIOR TIBIAL PULSE Palpate the posterior tibial pulse by pressing on | “Io begin the asscsement 40. | the inner (medial) side of the ankle below the 54 : medial malleolus & for apprepriats palpation. “a, | Press down moderately and then Increase the | Foy acawate-vecult . pressure until you feel the pulse Identify the pulse, feeling for the characteristic To identity any iseeqwianiti 42. ty ty oats wave-like sensation. DY av 8 | NSG 102.2 |HEALTH ASSESSMENT LABORATORY MANUAL43, | Looking at a clock or watch with a second hand, count the number of beats over 60 seconds. TO know the avenge Puige Por minute. 44. | Assess bilaterally For better Veuits. 45, | During or after counting the rate, assess for pulse 46, | Palpate the popliteal pulse by pressing behind the knees in the middle of the popliteal fossa ate, rhythm, quality and amplitude. EAL PULS To beqin Ywe, assessment. 47, | Press down moderately and then increase the pressure until you feel the pulse For acunrnie palpation. 4g, | Identify the pulse, feeling for the characteristic wave-like sensation. Rov documentation 49, | Looking ata clock or watch with a second hand, count the number of beats over 60 seconds. oidentity tre average PAlce eV minute. 50. | Assess bilaterally Yov_petver results. 51, | During or after counting the rate, assess for pulse rate, rhythm, quality and amplitude. Foy doumentalion and Referral gavpose - [ASSESSING THE TEMPORAL PULSE 52, | Palpate the temporal pulse by pressing lightly lateral (outside area) and superior (above) the eye Tobeain the arcesoment. 53, | Mdentify the pulse, feeling for the characteristic wave-like sensation. [io dctowmine, aug amorwalitis, 54, | During or after counting the rate, assess for pulse rate, rhythm, quality and amplitude. Hey Aboamentation and for Tefewal puvposcs | [-ASSESSING PULSE DEFICIT To assess for a pulse deficit, you will need another 55, | healthcare worker. One person assesses the radial * | pulse rate while the other person assesses the apical pulse ratesimultaneously. For accurate requis Of the Atesoment. Position the patient either in a supine ora sitting 56. | position and expose the patient's sternum and the left side of the chest. tov casiy accor, OF ctetwepe 40 OER apical pulse. Using the appropriate anatomical landmarks, 57 | locate the radial and the apical pulses. To beam the AEC Went. Both person will start counting on command and 58. | they count the pulse rates simultaneously for 1 full minute. To identity 1 tre pulse rates De the cient Ove equal . 59, | Both person will stop counting on command. For better ca\unlation. To calculate the pulse deficit, subtract the radial [Totind WF Ahere are Any 60. | pulse rate from the apical pulse rate. Pulse defiai. Ifyou find a pulse deficit, assess the patient for oa, [ebentgnetsamtonsstacerstecrdce [12 MOK AWE needs of + | Gutput suchas dyspnea fatigueschestpain,and | the paKont medication. palpitations K Bvaluation and Documentation Document the reading and rhythm or amplitude 62. | irregularities on the observation chart immediatel Tov baccine data. ‘Compare this figure with previous pulse readings, 63, | taking into consideration the patient's clinical condition To identify any hea bth, (s6nes. 9 | NSG 102.2 | HEALTH ASSESSMENT LABORATORY MANUAL