Radial Pulse (Home Health Care) - CE/NCPD

ALERT

Anxiety can raise the pulse rate. If the patient’s pulse rate is higher than expected, reassess it at the end of the physical assessment when the patient is more relaxed.

If an irregular pulse is palpated, further assessment may be required.

OVERVIEW

The pulse is the palpable impulse of ventricular depolarization and blood flow. The force of the blood exiting the heart and aortic distention create a pulse wave that travels rapidly toward the extremities. When the pulse wave reaches a peripheral artery, a pulse can be felt by lightly palpating the artery against underlying bone or muscle. The number of pulsing sensations that occur in 1 minute is the pulse rate per minute.

Assessing the patient’s peripheral pulse offers valuable data for determining cardiovascular function. An abnormally slow, rapid, or irregular pulse may indicate the cardiovascular system’s decreased ability to deliver an adequate blood supply to the body.

The pulse can be assessed using any central or peripheral artery (Table 1), but the radial artery is the most commonly used (Figure 1). During cardiovascular collapse, the radial pulse may not be palpable because of decreased blood pressure and decreased perfusion to the distal arteries. In cases of suspected shock, a more central site (e.g., carotid artery) should be used for pulse evaluation. A central pulse will be the last pulse present during cardiovascular collapse.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Teach the patient who takes prescribed cardiotonic or antiarrhythmic medications to assess the radial pulse to detect adverse effects. Include the family and caregivers in the education, as appropriate.
• Teach the patient the signs and symptoms of bradycardia and tachycardia (e.g., dizziness, lightheadedness, shortness of breath) and provide instructions on when to seek additional care.
• Teach a patient starting a prescribed exercise regimen how to monitor the radial pulse to determine the response to exercise.
• 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. Prepare an area in a clean, convenient location and assemble the necessary supplies.
6. Encourage the patient to relax as much as possible.
7. If the patient has been active and the patient's condition permits, wait several minutes before assessing the pulse.
8. Assess the patient for risk factors for an abnormal radial pulse:
   1. Invasive cardiovascular diagnostic tests (e.g., cardiac catherization using the radial artery for access)
   2. Surgery of an extremity
   3. Peripheral vascular disease
9. Assess the patient for signs and symptoms of altered cardiac function:
   1. Dyspnea
   2. Fatigue
   3. Chest pain
   4. Orthopnea
   5. Syncope
   6. Palpitations
   7. Dependent edema
   8. Cyanosis or pallor
10. Determine the patient’s previous baseline pulse rate from the patient’s record.
11. Help the patient assume a supine or sitting position.
12. If the patient is supine, place the forearm straight alongside the body or across the lower chest or upper abdomen with the wrist extended straight (Figure 2). If the patient is sitting, bend the elbow 90 degrees and support the lower arm on a chair or other surface.^{undefined#ref1">1}
13. Place the tips of the first two or three fingers over the groove along the radial (or thumb) side of the patient’s inner wrist (Figure 2). Slightly extend or flex the patient’s wrist with the palm down until the pulse is strongest.

    Rationale: The relaxed position of the lower arm and the extension of the wrist permit full exposure of the artery to palpation.

14. Lightly compress the artery against the radius, obliterating the pulse initially. Then ease the pressure so the pulse becomes easily palpable.

    Rationale: Pulse assessment is more accurate when using moderate pressure. Too much pressure occludes the pulse, impairs blood flow, and may result in the health care team member counting the health care team member’s pulse rate.

15. Determine the strength of the pulse (e.g., 0, 1+, 2+, 3+, 4+).^1,2 Observe whether the impulse of the vessel against the fingertips is absent, thready, weak, strong, or bounding (Box 1). If this is a repeat assessment, observe any changes in the intensity of the pulse.¹

    Rationale: Strength reflects the volume of blood ejected against the arterial wall with each heart contraction. An accurate description of strength improves communication among health care team members.

    Use this subjective scale as accurately as possible, especially if the presence or absence of pulses is a concern.

16. After determining that the pulse is regular, observe the position of the second hand on a wristwatch and then begin to count the rate.
17. If the pulse is regular, count the rate for 30 seconds and multiply the total by two.¹
18. If the pulse is irregular, count the rate for a full 60 seconds.¹ Assess the pattern of irregularity.

    Rationale: Inefficient contraction of the heart fails to transmit a pulse wave, resulting in an irregular pulse. A full minute assessment helps ensure an accurate estimate of beats per minute.

19. Compare the radial pulses bilaterally. If a marked difference between the sides exists, assess the extremities for perfusion. Notify the practitioner if signs of decreased perfusion, including a change in skin color, edema, a change in skin temperature, and decreased pulse palpability, are present.
20. Help the patient to a comfortable position.
21. Discuss the findings with the patient as needed.
22. If assessing a patient’s pulse for the first time, establish the radial pulse as the baseline if it is within the acceptable range.
23. Compare the pulse rate and character with the patient’s previous baseline and the acceptable range for the patient’s age.
24. Assess pain, treat if necessary, and reassess.
25. Discard or store supplies, remove PPE, and perform hand hygiene.
26. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Radial pulse is palpable and within normal range.
• Rhythm is regular.
• Radial pulse is strong, firm, and regular.

UNEXPECTED OUTCOMES

• Pulse is weak, difficult to palpate, or absent.
• Pulse rate for an adult is greater than 100 beats per minute (tachycardia).¹
• Pulse rate for an adult is less than 60 beats per minute (bradycardia).¹
• Pulse is irregular.

DOCUMENTATION

• Pulse rate
• Pulse rates before and after administration of specific therapies
• Pulse strength
• Abnormal findings
• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

• Palpating the pulse of an older adult or patient with obesity can be difficult.
• Older adults’ arteries may feel stiff and knotty because of decreased elasticity.
• In older adults, the heart rate takes longer to rise to meet sudden increased demands caused by stress, illness, or excitement. Once an older adult’s pulse rate is elevated, it takes longer to return to a normal resting rate than that of a younger patient.¹

REFERENCES

1. Ball, J.W. and others. (Eds.). (2023). Chapter 6: Vital signs and pain assessment. In Seidel’s guide to physical examination: An interprofessional approach (10th ed., pp. 79-92). St. Louis: Elsevier.
2. Gerhard-Herman, M. (2023). Chapter 55: Peripheral artery disease. In G.N. Levine (Ed.), Cardiology secrets (6th ed., pp. 449-458). Philadelphia: Elsevier.

ADDITIONAL READING

American Heart Association (AHA). (2022). Bradycardia: Slow heart rate. Retrieved May 9, 2023, from https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia/bradycardia--slow-heart-rate

Kusumoto, F.M. and others. (2018). 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Retrieved May 9, 2023, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000628