ASSESSING THE PULSE

A Pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The middle three fingertips are used for palpating all pulse sites except the apex of the heart. A stethoscope is used for assessing apical pulses and fetal heart tones. Increasingly, a Doppler Ultrasound Stethoscope (DUS) is being used for pulses that are difficult to assess. The DUS headset has earpieces similar to standard stethoscope earpieces, but it has a long cord attached to a volume-controlled audio unit and an ultrasound transducer. The DUS detects movement of red blood cells through a blood vessel. In contrast to the conventional stethoscope, it excludes environment sounds. I t cannot detect blood flow in deep vessels or in those underlying bone or in, such as the vessels in the abdomen, thorax, or skull. The DUS is battery operated, and batteries must be replaced about every 6 months.

The cardiac monitoring machine is another device for assessing the apical pulse. It indicates the rate on a screen or readout graph.

A pulse is normally palpated by applying moderate pressure with the three middle fingers of the hand. The pads on the most distal aspect of the finger are the most distal aspects of the finger are the most sensitive areas for detecting a pulse. With excessive pressure, one can obliterate a pulse, whereas with too little pressure, one may not be able to detect it. Before the nurse assesses the resting pulse, the client should assume a comfortable position. The nurse should also be aware of the following:

• Any medication that could affect the heart rate

• Whether the client has been physically active. If so, wait 10 to 15 minutes until the client has rested and the pulse has slowed to its usual rate.

• Any baseline data about the normal heart rate for the client. For example, a physically fit athlete may have a heart below 60 beats per minute.

• Whether the client should assume a particular position (eg, sitting). In some clients the rate changes in blood flow volume and autonomic nervous system activity.

When assessing the pulse, the nurse collects the following data: the rate, rhythm, volume, arterial wall elasticity, and presence or absence of bilateral equality. An excessively fast heart rate (eg, over 100 beats per minute in an adult) is referred to as tachycardia. A heart rate in an adult of 60 beats per minute or less is called bradycardia. If a client has either tachycardia or bradycardia, the apical pulse should be assessed.

The pulse rhythm is the pattern of the beats and the intervals between the beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm iseferred to as a dysrhythmia or arrhythmia. It may consist or random, irregular beats. When a dysrhythmia is detected, the apical pulse should be assessed. An electrocardiogram (ECG or EKG) is necessary to define the dysrhythmia further.

Pulse volume, also called the pulse strength or amplitude, refers to the force of blood with each beat. Usually, the pulse volume is the same with each beat. It can range from absent to bounding. A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. A forceful or full blood volume that is obliterated only with difficulty is called a full or bounding pulse. A pulse that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or thready. A pulse volume is usually measured on a scale of 0 to 3.

The elasticity of the arterial wall reflects it expansion or its deformities. A healthy, normal artery feels straight, smooth, soft, and pliable. Elderly people often have inelastic arteries that feel twisted (tortuous) and irregular upon palpation. The elasticity of the arteries may not affect the pulse rate, rhythm, or volume, but it does reflect the status of the client’s vascular system.

When assessing a peripheral pulse to determine the adequacy of blood flow to a particular are of the body, the nurse should also assess the corresponding pulse on the other side of the body, the second assessment gives the nurse data with which to compare the pulses. For example, when assessing the blood flow to the right foot, the nurse assesses the right dorsalis pedis pulse and then the left dorsalis pedis pulse. If the client’s right and left pulses are the same, the client’s dosali pedis pulses are bilaterally equal.

PERIPHERAL PULSE ASSESSMENT

A peripheral pulse, usually the radial pulse, is assessed by palpation in all individuals except:

• Newborn and children up to 2 or 3 years. Apical pulses are assessed in these clients.

• Very obese or elderly client’s, whose radial pulse may be difficult to palpate. Doppler equipment may be use for some clients, whose radial pulse may be difficult to palpate. Doppler equipment may be use for some clients, or the apical pulse is assessed.

• Individuals with a heart disease, who require apical pulse assessment.

• Individuals in whom the circulation to a specific body part must be assessed; for example, following leg surgery, the pedal (dorsalis pedis) pulse is assessed.

APICAL PULSE ASSESSMENT

Assessment of the apical pulse is indicated for clients whose peripheral pulse is irregular as well as for clients with known cardiovascular, pulmonary, and renal disease. It is commonly assessed prior to administering medications that affect heart disease. The apical site is also used to assess the pulse for newborns, infants, and children up to 2 to 3 years old.

APICAL AND RADIAL PULSE ASSESSMENT

An apical-radial pulse may need to be assessed for clients with certain cardiovascular disorders. Normally, the apical and radial rates are identical. An apical pulse rate greater than a radial pulse rate can indicate that the thrust of the blood from heart is too feeble for the wave to be felt at the peripheral pulse site, or it can indicate that vascular disease is preventing impulses from being transmitted. Any discrepancy between the two pulse rates needs to be reported promptly. In no instance is the radial pulse greater than the apical pulse.

An apical-radial pulse can be taken by two nurses or one nurse, although the two-nurse technique may be more accurate.

Procedure in Assessing a Peripheral Pulse

Procedure in Assessing an Apical-radial Pulse

Methods of Hand Washing

It has been established that washing hands at least 10-15 seconds will kill most transient microorganism in the skin. Wash time however may depend on how severely soiled the hands are. Ordinary soap may be used in routine hand washing procedures. But in order to inhibit microorganism and reduce infection level, antiseptic agents should be used. Antibacterial soaps are also in wide use when it comes to areas to or situations wherein the nurse has to reduce total microbial counts in the hands. This commonly occurs when the nurse comes in contact with patients who have wounds, bruises or those who are immunosuppressed. These agents are also used when the nurse is to perform an invasive procedure.

In cases when facilities for hand washing may be considered inadequate, alcohol-based solutions are used. Normal hand washing should however be immediately performed as soon as possible.

Nurses are the ones who are tasked to educate patients/visitors on how to properly perform hand washing. Education is especially important if care is to continue at home.

Hand Washing Procedure

Assessing Body Temperature

There are a number of sites for measuring body temperature. The three most common are oral, rectal, and axillary. In recent years, the tympanic membrane site has also been used. Each of sites has advantages and disadvantages. In a resting adult, rectal temperature is slightly higher than the temperature of the arterial blood, about the same as the temperature of the liver, and slightly lower than that of the brain. When measures in the axilla or orally (by mouth), the temperature is about 0.65 ºC (1 ºF) less than the rectal temperature.

The body temperature is usually measured orally. This method reflects changing body temperature more quickly than the rectal method. Traditionally, the oral method was not use for client receiving oxygen, because the accuracy of the measurement was considered questionable. Recent evidences, however suggest the oral reading area accurate in client’s who receive oxygen by nasal cannula or face mask and client who have nasogastric tubes and nasal endotracheal tubes, provided that the client can breathe through the nose. If a client has been taking cold or hot food or fluids or smoking, the nurse should wait 30 minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the food, fluid, or warm smoke.

Procedure in Assessing the Body Temperature Using a Mercury Thermometer

Assessing Respirations

Resting respirations should be assessed when the client is at rest because exercise affects respirations, increasing their rate and depth as well. Respirations may also need to be assessed after exercise to identify the client’s tolerance to activity. Before assessing a client’s respirations, a nurse should be aware of

• The client’s normal breathing pattern

• The influence of the client’s health problems on respirations

• Any medications or therapies that might affect respirations

• The relationship of the client’s respirations to cardiovascular function

The rate, depth, rhythm, and special characteristics of respirations should be assessed.

The respiratory rate is normally described in breaths per minute. A healthy adult normally takes between 15 to 20 breaths per minute. Breathing that is normal in rate and depth is called eupnea. Abnormally slow respirations are called tachypnea or polypnea. For the respiratory rated of different groups several factors influence respiratory rate;

The depth of a person’s respirations can be established by watching the movement of the chest. Respiratory depth is generally described as normal, deep, or shallow. Deep respirations are those in which a large volume of air is inhaled and exhaled, inflating most of the lungs. Shallow respirations involve the exchange of a small volume of air and often the minimal use of lung tissue. During a normal inspiration and expiration, an adult takes in about 500 ml of air. This volume is called the tidal volume and pulmonary capacities.

Body position also affects the amount of air that can be inhales. People in a supine position experience two physiologic processes the suppress respiration: an increase in the volume off blood inside the thoracic cavity and compression of the chest. Consequently, clients in a back lying position have poorer lung aeration, which predispose them to the stasis on fluids and subsequent infection. Certain medications also affect the respiratory depth. For example, barbiturates such as secobarbital sodium, when taken in large doses, depress the respiratory centers in the brain, thereby depressing the respiratory rate and depth.

Respiratory rhythm or pattern refers to the regularity of the expirations and the inspirations. Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular or irregular. An infant’s respiratory rhythm may be less regular than an adult’s.

Respiratory quality or character refers to those aspects of breathing that are different from normal, effortless breathing. Two of these are the amount of effortless breathing. Two of these are amount of effort a client must exert to breathe and the sound of breathing. Usually, breathing does not require noticeable effort, some client, however, breathe only with decided effort.

The sound of breathing is also significant. Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear. Many sounds occur as a result of the presence of fluid in the lungs and most clearly heard with a stethoscope. For auscultation and percussion methods used to assess lung sounds. For details about altered breathing patterns and terms used to describe various patterns and sounds.

BREATHING PATTERN AND SOUNDS

Breathing Patterns Rate
• Eupnea – normal respirations that is quit, rhythmic, and effortless
• Tachypnea – rapid respiration marked by quick, shallow breaths
• Bradypnea – abnormally slow breathing

Volume
• Hyperventilation – an increase in the amount of air in the lungs characterized by prolonged and deep breaths; may be associated with anxiety.
• Hypoventilation – a reduction in the amount of air in the lung; characterized by shallow respirations.

Rhythm
• Cheyne-stroke breathing – rhythmic waxing and waning of respirations; from very deep to very shallow breathing and temporary apnea; often associated with cardiac failure, increased intracranial pressure, or brain damage.

Ease or effort
• Dyspnea – difficult and labored breathing, during which the individual has a persistent, unsatisfied need of air and distressed.
• Orthopnea – ability to breath only in upright sitting or standing positions.


Breath Sounds

Audible without amplification
• Stridor – a shrill, harsh sound hear during inspiration with laryngeal obstruction.
• Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper airway.
• Wheeze - continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway.
• Bubbling – gurgling sounds heard as air passes through moist secretions in the respiratory tract.

Audible by stethoscope
• Crackles (formerly called (rales) – dry or wet crackling sounds stimulated by rolling a lock of hair near the ear, generally heard on inspiration as air moves through accumulated moist secretion. Fine – to – medium crackles when air passes through moisture in small air passages and alveoli. Medium to coarse crackles occur when air passes through moisture in bronchioles, bronchi, and the trachea.

Chest Movements
• Intercostal retraction – indrawing between the ribs
• Substernal retraction – indrawing beneath the breastbone
• Suprasternal retraction – indrawing above the clavicles
• Tracheal tug – indrawing and downward pull during inspiration
• Flail chest – the ballooning out of the chest wall through injured rib spaces; results in paradoxical breathing, during which the chest wall balloons on expiration but is depressed or sucked inward on inspiration.

Secretions and Coughing
• Hemoptysis – the presence of blood in the sputum
• Productive cough – a cough accompanied by expectorated secretions
• Nonproductive cough – a dry, harsh cough without secretions


Procedure in Counting Respirations

ASSESSING BLOOD PRESSURE

Equipment. Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a stethoscope. The blood pressure cuff consists of a rubber bag that can be inflated with air. It is called the bladder. It is usually covered with cloth and has two tubes attached to it. One tube connects to rubber bulb that inflates the bladder. When turned counterclockwise, a small valve on the side of this bulb releases the air in the bladder. When the valve is tightened (tuned clockwise), air pumped into the bladder remains there. The other tube is attached to a sphygmomanometer.

The sphygmomanometer indicates the pressure of the air within the bladder. There are two types of sphygmomanometers: aneroid and mercury. The aneroid sphygmomanometer is a calibrated dial with a needle that points to the calibrations. The mercury sphygmomanometer is a calibrated cylinder filled with mercury. The pressure is indicated at the point to which the base of meniscus of the mercury rises, that is, the point where the meniscus touches the side of the glass tube.

Some agencies use electronic sphygmomanometers, which eliminate the need to listen to the sounds of the client’s systolic and diastolic blood pressure through a stethoscope. With some electronic sphygmomanometers, as the pressure in the cuff is lowered, light flashes to indicate the systolic and diastolic pressure.

Ultrasound Doppler stethoscopes are also needed to assess blood pressure. These are of particular value when blood pressure sounds are difficult to hear, such as an infants, obese clients, and clients, and clients in shock. The nurse applies transmission gel to a transducer probe, places the probe over the pulse point, and measures the blood pressure. A systolic blood pressure assessed with Doppler stethoscope is recorded with a large D, for example, 85 D. Systolic pressure may be only blood pressure obtainable with some ultrasound models.

Blood pressure cuffs some in various sizes, because the bladder must be the correct width length for the client’s arm. If the bladder is too narrow, the blood pressure reading will be erroneously low. The width should be 40% of the circumference, or 20% wider than the diameter of the midpoint of the limb on which it is used. The bladder dimensions by arm circumference, not the age of the client, should always be used to determine bladder size. The nurse can also determine whether the width of a blood pressure cuff is appropriate: Lay the cuff lengthwise at the midpoint of the upper arm, and hold the outermost side of the bladder edge laterally on the arm. With the other hand, wrap the width of the cuff around the arm, and ensure that the width is 40% of the arm circumference.

The length of the bladder also affects the accuracy of measurement. The bladder should be sufficiently long almost to encircle the limb and to cover at least two-thirds of its circumference.

The length of the bladder also affects the accuracy of measurement. The bladder should be sufficiently long almost to encircle the limb and to cover at least two-thirds of its circumference.

Blood pressure cuffs are made of nondistensible material so that an even pressure is exerted around the limb. Most cuffs are held in place by hooks, snaps, or Velcro. Others have a cloth bandage that is long enough to encircle the limb several times: this type is closed by tucking the end of the bandage into one of the bandage folds.

Sites: The blood pressure is usually assessed in the client’s arm using the brachial artery and a standard stethoscope. If the arm is very large or grossly misshapen and the conventional cuff cannot be properly applied, leg or forearm measurements can be taken. To obtain a leg blood pressure, a standard sized cuff is applied over the lower leg with the distal border of the cuff at the malleoli. Auscultate blood pressure sounds over the posterior tibial or dorsalis pedis arteries. To obtain a thigh blood pressure, apply an appropriate-sized cuff to the thigh, and auscultateted the pulsations of the blood over the popliteal artery. To obtain a forearm blood pressure, apply an appropriate sized cuff to the forearm 13 cm (5in) below the elbow. Blood pressure sounds then can be heard over the radial artery.

Recommended Bladder Sizes of Blood Pressure Cuffs



Assessing the blood pressure on a client’s thigh is usually indicated in these situations:

• The blood pressure cannot be measured on either arm (eg, because of burns or other trauma).
• The blood pressure in one thigh is to be compared with blood pressure in the other thigh.

Blood pressure is not measured on client’s arm, or thigh in the following situations:
• The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.
• There is a cast or bulky bandage on any part of the limb.
• The client has had breast or axilla (or hip) surgery on that side.
• The client has an intravenous infusion or blood transfusion running.
• The client has an arteriovenous fistula (eg, for renal dialysis.)

Procedure in Assessing Blood Pressure



Sources of Error in Blood Pressure Assessment

Assessing Blood Pressure

Equipment. Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a stethoscope. The blood pressure cuff consists of a rubber bag that can be inflated with air. It is called the bladder. It is usually covered with cloth and has two tubes attached to it. One tube connects to rubber bulb that inflates the bladder. When turned counterclockwise, a small valve on the side of this bulb releases the air in the bladder. When the valve is tightened (tuned clockwise), air pumped into the bladder remains there. The other tube is attached to a sphygmomanometer.

The sphygmomanometer indicates the pressure of the air within the bladder. There are two types of sphygmomanometers: aneroid and mercury. The aneroid sphygmomanometer is a calibrated dial with a needle that points to the calibrations. The mercury sphygmomanometer is a calibrated cylinder filled with mercury. The pressure is indicated at the point to which the base of meniscus of the mercury rises, that is, the point where the meniscus touches the side of the glass tube.

Some agencies use electronic sphygmomanometers, which eliminate the need to listen to the sounds of the client’s systolic and diastolic blood pressure through a stethoscope. With some electronic sphygmomanometers, as the pressure in the cuff is lowered, light flashes to indicate the systolic and diastolic pressure.

Ultrasound Doppler stethoscopes are also needed to assess blood pressure. These are of particular value when blood pressure sounds are difficult to hear, such as an infants, obese clients, and clients, and clients in shock. The nurse applies transmission gel to a transducer probe, places the probe over the pulse point, and measures the blood pressure. A systolic blood pressure assessed with Doppler stethoscope is recorded with a large D, for example, 85 D. Systolic pressure may be only blood pressure obtainable with some ultrasound models.

Blood pressure cuffs some in various sizes, because the bladder must be the correct width length for the client’s arm. If the bladder is too narrow, the blood pressure reading will be erroneously low. The width should be 40% of the circumference, or 20% wider than the diameter of the midpoint of the limb on which it is used. The bladder dimensions by arm circumference, not the age of the client, should always be used to determine bladder size. The nurse can also determine whether the width of a blood pressure cuff is appropriate: Lay the cuff lengthwise at the midpoint of the upper arm, and hold the outermost side of the bladder edge laterally on the arm. With the other hand, wrap the width of the cuff around the arm, and ensure that the width is 40% of the arm circumference.

The length of the bladder also affects the accuracy of measurement. The bladder should be sufficiently long almost to encircle the limb and to cover at least two-thirds of its circumference.

The length of the bladder also affects the accuracy of measurement. The bladder should be sufficiently long almost to encircle the limb and to cover at least two-thirds of its circumference.

Blood pressure cuffs are made of nondistensible material so that an even pressure is exerted around the limb. Most cuffs are held in place by hooks, snaps, or Velcro. Others have a cloth bandage that is long enough to encircle the limb several times: this type is closed by tucking the end of the bandage into one of the bandage folds.

Sites: The blood pressure is usually assessed in the client’s arm using the brachial artery and a standard stethoscope. If the arm is very large or grossly misshapen and the conventional cuff cannot be properly applied, leg or forearm measurements can be taken. To obtain a leg blood pressure, a standard sized cuff is applied over the lower leg with the distal border of the cuff at the malleoli. Auscultate blood pressure sounds over the posterior tibial or dorsalis pedis arteries. To obtain a thigh blood pressure, apply an appropriate-sized cuff to the thigh, and auscultateted the pulsations of the blood over the popliteal artery. To obtain a forearm blood pressure, apply an appropriate sized cuff to the forearm 13 cm (5in) below the elbow. Blood pressure sounds then can be heard over the radial artery.

Recommended Bladder Sizes of Blood Pressure Cuffs



Assessing the blood pressure on a client’s thigh is usually indicated in these situations:

• The blood pressure cannot be measured on either arm (eg, because of burns or other trauma).
• The blood pressure in one thigh is to be compared with blood pressure in the other thigh.

Blood pressure is not measured on client’s arm, or thigh in the following situations:
• The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.
• There is a cast or bulky bandage on any part of the limb.
• The client has had breast or axilla (or hip) surgery on that side.
• The client has an intravenous infusion or blood transfusion running.
• The client has an arteriovenous fistula (eg, for renal dialysis.)

Procedure in Assessing Blood Pressure

Selected Sources of Error in Blood Pressure Assessment

Body Mechanics

Definition:

Refers to the movement and coordination of the body in response to stimuli and the body’s coordinated efforts to maintain its balance while responding to the stimuli. It is used to describe efficient body movement to move other person or object.

Three basin elements:
1. Spiral alignment (posture)
2. Balance (stability)
3. Coordinated body movement

Purposes:
1. To maintain good body posture
2. To help promote good physiologic functions of the body.
3. To use the body correctly and to maintain its effectiveness.
4. To help prevent injury to or limitation of the musculo-skeletal system.

Body mechanics for Health Care Workers
1. When planning to move client, arrange for adequate help. Use mechanical aids if help is unavailable. Two workers lifting together divide the workload by 50%.
2. Encourage client to assist as much as possible. This promotes clients independence and strength while minimizing workload.
3. Keep back, neck, pelvis, and feet aligned. Avoid twisting. Reduces risk of injury to lumbar vertebrae and muscle groups. Twisting increases risk of injury.
4. Flex knees; keep feet wide apart. A broad base of support increases stability.
5. Position self close to client (or object being lifted). The force is minimized Ten pounds held at waist height close to body is equal to 100 pounds held at arm’s length.
6. Use arms and legs (not back). The leg muscles are stronger, larger muscle capable of greater work without injury.
7. Slide client toward yourself using a pull sheet. Sliding requires less effort then lifting. Pull sheet minimizes shearing forces, which can damage client’s skill.
8. Set (tighten) abdominal and gluteal muscles is preparation for move. Preparing muscles for the load minimizes strain and stabilizes the trunk.
9. Person on a lift team with the heaviest load coordinates efforts of the lift team involved by counting to three. Simultaneous lifting minimizes the load for any one lift.

POSITIONING AND TRANSFERRING A CLIENT

Procedure in Turning Client to Side-Lying Position



Procedure in Turning Client to Prone Position



Procedure in Moving the Patient Up in the Bed