Vital Signs
Assessing Radial Pulse
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- » Taking a Temperature
- » Assessing Radial Pulse
- » Assessing Apical Pulse
- » Assessing Apical-Radial Pulse
- » Assessing Respiration: Rate, Rhythm, and Effort
- » Obtaining Blood Pressure by the One-Step Method
- » Obtaining Blood Pressure by the Two-Step Method
- » Measuring Oxygen Saturation with Pulse Oximetry
- » Assessing Pain
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Take the Review Test:
Safety
- Use Standard Precautions when assessing radial pulse.
- If the pulse is irregular, assess for a pulse deficit, which may indicate an alteration in cardiac output. (For details, see “Assessing Apical-Radial Pulse.”)
- Report a radial pulse of less than 60 or more than 100 beats per minute, an irregular rhythm, or weak strength to the health care provider without delay. Immediate intervention may be needed.
Equipment
(Roll cursor over items to see labels)
Gloves
Wristwatch with second hand or digital display
PrintableDelegation
Do not delegate the skill of assessing radial pulse to nursing assistive personnel (NAP) when the patient’s condition is unstable or when you must evaluate the patient’s response to medication or another treatment. Before delegating this skill under other circumstances, be sure to inform NAP of the following:
- The appropriate site for checking the pulse rate, frequency of measurement, and factors related to the patient’s history (e.g., risk for abnormally slow, rapid, or irregular pulse).
- The patient’s usual pulse rate and the need to report significant changes to you.
- Report any specific abnormalities immediately.
Preparation
- Determine the need to assess the radial pulse:
- Note any risk factors for pulse alterations, such as history of heart disease, cardiac dysrhythmia, onset of sudden chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of a large volume of intravenous (IV) fluid, internal or external hemorrhage, or administration of medications that alter cardiac function.
- Assess for signs and symptoms of altered cardiac function, such as the presence of dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin.
- Assess for signs and symptoms of peripheral vascular disease, such as pale, cool extremities; thin, shiny skin with decreased hair growth; and thickened nails.
- Assess for factors that affect radial pulse rate and rhythm, such as age, exercise, position changes, fluid balance, medication, temperature, and sympathetic stimulation, such as from caffeine or nicotine.
- Determine the previous baseline pulse rate (if available) from the patient’s record.
- If the patient has been active, wait 5 to 10 minutes before assessing pulse. If patient has been smoking or ingesting caffeine wait 15 minutes before assessing pulse.
Follow-up
- When assessing the pulse for the first time, establish the radial pulse as the baseline and compare it with the acceptable range for the patient’s age.
- During subsequent assessments, compare the pulse rate and character with the patient’s baseline and with the acceptable range for the patient's age.
- Report any pulse abnormalities to the nurse in charge or to the health care provider.
Documentation
- Record the pulse rate and site assessed.
- Document measurement of the pulse rate after administration of specific therapies. Report abnormal findings to the nurse in charge or to the health care provider.
Review Questions
1. During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose?
Assessment of peripheral blood perfusion
Establishment of a baseline as part of the patient’s vital signs - Assessment of the patient’s cardiovascular disease risk
- Determination of oxygen saturation
INCORRECT. Assessment of peripheral blood perfusion is not the primary reason for assessing the radial pulse during the admission process.
CORRECT. It is essential to establish a point of reference against which future radial pulse rate measurements can be compared.
INCORRECT. Assessing radial pulse will not necessarily provide information about the patient’s risk for cardiovascular disease. Other factors (such as age, smoking, dietary patterns, and exercise habits) contribute to the risk for cardiovascular disease.
INCORRECT. Pulse oximetry is the measurement of arterial blood oxygen saturation, not a radial pulse.
2. What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse?
- Place the patient in the lateral (side-lying) position before measuring the pulse.
- Apply gloves with each patient before measuring the pulse.
- Document whether the patient’s pulse is bounding or has diminished.
- Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.
INCORRECT. The patient may assume a sitting or supine position before measuring the radial pulse.
INCORRECT. Gloves are not usually required to measure the radial pulse. The radial pulse site harbors normal skin flora, not pathogenic microorganisms, in the general population.
INCORRECT. This option pertains to documentation of the procedure, not to the procedure itself.
CORRECT. The thumb side of the wrist easily accesses the radial artery for the radial pulse. The ulnar artery is on the little finger side of wrist. The nurse’s thumb has pulsation that will interfere with accuracy; therefore the fingertips are the most sensitive parts of the hand to palpate arterial pulsation.
3. What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
- Reassess the pulse for 1 full minute.
- Assess the patient for a pulse deficit.
- Wait 5 minutes, and then reassess the pulse.
- Review documentation regarding an irregular rhythm.
INCORRECT. Although reassessing the pulse is appropriate, this is not the priority action because the presence of an irregular rhythm has already been established.
CORRECT. Assessing the patient for a pulse deficit is useful in identifying an alteration in cardiac output.
INCORRECT. Waiting 5 minutes to reassess the radial pulse is not appropriate and could be dangerous for the patient in some unstable cardiac conditions.
INCORRECT. This is not the priority action because establishing a history of an irregular heartbeat is not essential.
4. Inadequate oxygenation to the body will cause the radial pulse to become:
CORRECT. The heart rate will increase to circulate more available oxygen to tissues. Tachycardia is more than 100 beats/minute.
INCORRECT. The heart rate will increase, not decrease. Bradycardia is less than 60 beats/minute.
INCORRECT. Heart rhythm (regular or irregular) is determined by the electrical conduction through the heart, not oxygenation.
INCORRECT. A bounding pulse indicates increased blood volume ejected against the arterial wall.
5. Which action would best assess the effect of exercise on a patient’s radial pulse measurement?
- Measuring the patient’s radial pulse before and after exercise
- Assessing the patient’s radial pulse 30 minutes after exercise
- Comparing the patient’s radial and apical pulses after exercise
- Comparing the patient’s pre-exercise radial and post-exercise apical pulses
CORRECT. Measuring the patient’s radial pulse before and after exercise best assesses the effect of the exercise on the radial pulse because it compares the same pulse site before and after exercise.
INCORRECT. Thirty minutes after exercise is too long to wait to obtain useful information about the effect of exercise on the patient’s radial pulse.
INCORRECT. Assessing the patient’s apical pulse will not determine the effect of exercise on the radial pulse.
INCORRECT. Assessing the patient’s apical pulse, whether pre-exercise or post-exercise assessment, will not determine the effect of exercise on the radial pulse.
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