This document defines and describes the pulse. It discusses: - The pulse corresponds to heart contractions and is counted in beats per minute. It results from the arterial wave of blood pumped from the left ventricle. - There are multiple peripheral pulse sites that can be palpated including the carotid, radial, femoral, and dorsalis pedis. The apical pulse over the heart is most accurate. - When assessing the pulse, you evaluate the rate, rhythm, and volume. The radial pulse is most commonly used due to ease of access. Other sites are used if the radial is difficult to detect.

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