Groundwork
Explain and discuss the procedure with the patient. The patient should be resting either sitting or lying. Time should be allowed to rest after physical/emotional activity or smoking. The nurse should aim to measure pulse rates under the same conditions each time.
Equipment Required:
- a watch with as second hand
- observation chart
Usual infection control policies apply, e.g. handwashing. Special precautions may be required depending on patients condition, e.g. MRSA.
Procedure
- Choose a site to record the pulse. This is most routinely the radial pulse.
- Place second or third fingers along the appropriate artery and press gently (see image a).
- Count the pulse for a full 60 seconds to detect irregularities or other defects.
- Whilst measuring the rate per minute, also note the rhythm and volume/strength of the pulse felt.
- Also, whilse measuring pulse rates you can take the opportunity to assess the patient's skin colour. Pallor may indicate anaemia, while a bluish colour may indicate lack of oxygen (cyanosis).
(image a)
Post Procedure
Discuss the results and reason for any changes. Record findings and report any irregularities to the appropriate personnel.
Notes
Pulses may be felt at other sites of the body and can be used to assess limb perfusion or in an emergancy where the radial pulse can not be accessed (see image b).
(image b)
References
Bavin, C., Bedford-Turner, S., Cronin, P., Nicol, M. and Rawlings-Anderson, K. (2002) Essential Nursing Skills. Edinburgh: Mosby.
Baxter, A., Dolan, S. and Gale, N. (2001) Observations. In: Dougherty, L. and Mallet, J. (eds.) The Royal Marsden Hospital: Manual of Clinical Nursing Procedures. 5th Edn. London: Blackwell Science.
Maddex, S. (2005) Monitoring Vital Signs. In Baillie, L. (eds.) Developing Practical Nursing Skills. 2nd Edn. London: Hodder Arnold
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