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May.27.2021

Pulse Measurement Education (Home Health Care) - CE

ALERT

If the carotid site is chosen for pulse measurement, caution the patient against vigorously massaging the neck while locating the pulse and against attempting to locate both arteries at the same time. Stimulating the carotid sinus stimulates the vagus nerve and leads to reflex slowing of the heart rate. In addition, simultaneously occluding both carotid arteries decreases blood to the brain and causes fainting.

OVERVIEW

A variety of illnesses (e.g., cardiac, kidney, or vascular diseases) place patients at risk for wide pulse variations. Patients who know how to measure pulse and recognize when the pulse rate is outside acceptable ranges or is not a regular rhythm benefit from earlier medical attention and intervention. Among patients who should know how to measure pulse are those with heart disease and those involved in cardiac rehabilitation programs. In addition, patients who exercise should learn how their bodies respond to exercise and should be able to determine appropriate exercise plans based on the pulse before, during, and after exercise.

Pulse measurement helps the nurse establish baseline data about the patient and analyze trends related to medications, exercise, or a rehabilitation program. To facilitate gathering this essential information about a patient who is at home, the nurse should teach him or her to recognize signs and symptoms that indicate a need for pulse measurement. The nurse should also teach the patient to measure his or her pulse regularly, record the measurements, and interpret readings that are outside of individualized normal values (goal heart rate).

Signs and symptoms that indicate the need to perform pulse measurement include:

  • Palpitations
  • Shortness of breath
  • Fainting
  • Chest discomfort
  • Dizziness
  • Weakness or fatigue

SUPPLIES

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EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Ensure that the patient understands the practitioner’s recommendations for the treatment regimen, including potential side effects and interactions of any medication therapies.
  • Teach the patient what a pulse reading measures, specific medical issues that affect pulse readings, and why an awareness of variations in rate and rhythm is important to his or her well-being.
  • Teach the patient the signs and symptoms of bradycardia and tachycardia (e.g., fatigue, lightheadedness, dizziness) and instruct him or her on when to seek additional care.
  • Educate the patient on a normal pulse range, his or her goal heart rate, and symptoms and common causes of high or low readings.
  • Describe symptoms that indicate the need to perform pulse measurement.
  • Educate the patient about when to withhold medications in the event of pulse alteration.
    • Confirm specific pulse goals with the patient’s practitioner, document information in a home health record, and provide clear, written instructions for the patient.
    • Instruct a patient who is experiencing tachycardia (pulse greater than 100 beats per minute) to follow prearranged guidelines for his or her goal rate or to contact the practitioner.4
    • Instruct the patient to withhold beta-adrenergic blockers (e.g., propranolol), calcium channel blockers (e.g., verapamil hydrochloride), or cardiac glycosides (e.g., digoxin) if his or her pulse is outside the goal range and to take action according to the prearranged guidelines provided by the practitioner.
  • Teach the patient to monitor pulse routinely even if it remains in the normal range.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Prepare an area in a clean, convenient location and assemble the necessary supplies. Ensure that the selected area of the home is as quiet and free from distractions as possible.
  7. Assess the patient’s, family’s, or caregivers’ visual acuity, as well as the ability to see a clock, watch, or electronic device that counts seconds.
  8. Assess the patient’s, family’s, and caregivers’ ability to feel the pulse.
  9. Encourage the patient, family, or caregivers to perform measurements on a routine schedule for a long-term monitoring plan.
  10. If the patient has been active, instruct him or her to wait several minutes before assessing pulse.
  11. If the patient has been smoking or using smokeless tobacco, instruct him or her to wait 20 minutes before assessing pulse.5
    Rationale: The effects of nicotine on the heart rate decline as soon as 20 minutes after smoking.5
  12. Instruct the patient to take the measurement in a comfortable position, with the arm supported and feet flat on the floor, and in a warm, quiet environment.
  13. In the teaching phase, explain the procedure to the patient and have him or her rest for a few minutes before taking the measurement.
  14. Discuss with the patient the best sites for assessing pulse (i.e., radial preferred over carotid).
  15. Rationale: In most cases, the radial pulse is recommended and is the easiest to palpate. The carotid pulse may be used as an alternative site, but care must be taken to not palpate for long periods of time to avoid impinging on blood flow to the brain or causing a vagal reflex, leading to decreased pulse rate.
  16. Teach the patient how to use a watch, clock, or electronic device that counts seconds to count the pulse.
  17. Demonstrate and discuss these steps for palpating a radial pulse:
    1. Locate the artery on the wrist.
    2. Use the fingertips (never the thumb) for palpation. Beginning at the side of the thumb, run the fingers down to the wrist to locate the radial pulse point.
    3. Rationale: The thumb has a pulse that may interfere with counting the pulse.
    4. Gently compress the artery.
    5. Rationale: Pressing too hard over the pulse site may occlude the artery.
    6. Palpate the pulse before counting.
    7. Count the pulse for 1 full minute.1
    8. Rationale: Consistent timing at 1 minute reduces confusion and forgetfulness about time or starting point used for pulse measurement.1 A full 1-minute count increases the patient’s accuracy in counting the number of beats and detecting irregularities.1
    9. Note any irregularities to the rhythm.
  18. Instruct the patient to notice and report any irregularities. Explain that the patient should expect that the pulse should maintain a steady rhythm the entire time.
  19. Instruct the patient to identify irregularities by taking additional pulse measurements at different times of the day if he or she has a history of irregular pulse or feels dizzy.
  20. Discuss the patient's normal goal pulse ranges, the purposes for monitoring, and when to take measurements (e.g., before and after taking heart medications; before, during, and after exercise).
  21. Rationale: The patient must be able to determine when measurements should be taken and when values are not within desired ranges.
  22. Observe the patient perform each step of the skill on you, a family member, or caregiver.
  23. Observe the patient demonstrate the techniques on himself or herself (Figure 1)Figure 1.
  24. Ask the patient whether the readings are or are not within the desired range. If they are not within the desired range, ask the patient when and to whom he or she will report abnormal readings.
  25. Ensure the patient's understanding by having him or her describe the reason for pulse monitoring and any related medications (e.g., antiarrhythmics) or treatment (e.g., diet and exercise).
  26. Provide the patient with printed instructions with a written or pictorial guide that demonstrates the procedure or a video showing the procedure, if possible.
  27. Rationale: Printed and audiovisual references promote confidence for independent performance.
  28. Teach the patient to record whether or not medications were taken that affect pulse.
  29. Instruct the patient to use the written or electronic record to report pulse readings to the practitioner. If the patient is being telemonitored, instruct him or her in the proper use of the equipment, scheduling of readings, and the method for transmitting readings. Some electronic monitors may not detect an irregular pulse.
    Rationale: Keeping an organized record of pulse readings and medications empowers the patient and provides accurate information to the practitioner.3
  30. Discard or store supplies, remove PPE, and perform hand hygiene.
  31. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient, family, or caregivers can measure pulse with accurate results.
  • Patient understands purposes of measurement and implications of therapy.

UNEXPECTED OUTCOMES

  • Patient, family, or caregivers are unable to measure pulse due to cognitive or sensory problems (e.g., inability to see numbers on clock, neuropathy interfering with palpating pulse).
  • Patient does not adequately understand purposes of measurement or implications of therapy.

DOCUMENTATION

  • Patient's pulse, including rate and rhythm
  • Education
  • Patient's ability to measure and record heart rate
  • Patient's progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment
  • Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

  • Musculoskeletal changes, such as arthritis or other joint conditions, may impair an older adult patient’s ability to position the limb comfortably or perform the fine motor skills that are required to measure pulse.
  • Older adult patients should be taught how to exercise safely. Cardiac output is lower in older adult patients; therefore, the heart cannot adapt as well to sudden demands for increased oxygen. This calculation should be used to determine a safe maximum heart rate during exercise in the older adult population: (220 – age) × 0.7.2 For example, if the patient is 77 years old, this formula establishes a safe maximum heart rate of 100 beats per minute.2

REFERENCES

  1. American Heart Association (AHA). (2015). All about heart rate (pulse). Retrieved March 24, 2021, from https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/all-about-heart-rate-pulse (classic reference)* (Level VII)
  2. American Heart Association (AHA). (2021). Target heart rates chart. Retrieved March 24, 2021, from https://www.heart.org/en/healthy-living/fitness/fitness-basics/target-heart-rates#.VsOxHevHzmJ (Level VII)
  3. Gulanick, M., Myers, J.L. (2022). Chapter 6: Cardiac and vascular care plans. In Nursing care plans: Diagnoses, interventions, & outcomes (10th ed., pp. 286-384). St. Louis: Elsevier.
  4. Hogan, M. (2018). Chapter 13: Endocrine and metabolic disorders. In Medical-surgical nursing: Pearson reviews & rationales (4th ed., pp. 435-470). Boston: Pearson.
  5. U.S. Food and Drug Administration (FDA). (2020). How smoking affects heart health. Retrieved on March 24, 2021 from, https://www.fda.gov/tobacco-products/health-information/how-smoking-affects-heart-health (Level VII)

ADDITIONAL READINGS

Glasser, A. and others. (2017). Overview of electronic nicotine delivery systems: A systematic review. American Journal of Preventive Medicine, 52(2), e33-e66. doi:10.1016/j.amepre.2016.10.036

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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