Key Takeaways
- Normal adult pulse is 60-100 beats per minute
- Use first two or three fingers (not thumb) to measure pulse
- Radial pulse (wrist) is most common; apical pulse (chest) is most accurate
- Count for full 60 seconds if pulse is irregular
- Report tachycardia (>100), bradycardia (<60), irregular rhythm, or pulse deficit
Pulse Measurement
The pulse is the wave of blood created when the heart contracts and pushes blood through the arteries. CNAs measure pulse rate, rhythm, and strength to assess cardiovascular function.
Pulse Characteristics
When measuring pulse, assess three things:
| Characteristic | What to Note |
|---|---|
| Rate | Number of beats per minute (normal: 60-100) |
| Rhythm | Regular or irregular pattern |
| Strength/Quality | Strong (bounding), normal, weak (thready) |
Pulse Sites
| Site | Location | When Used |
|---|---|---|
| Radial | Thumb side of wrist | Most common, routine measurement |
| Apical | Left side of chest, below nipple | Most accurate; used for irregular pulse |
| Brachial | Inner elbow | Blood pressure measurement, infants |
| Carotid | Side of neck | Emergencies, unconscious patients |
| Femoral | Groin area | Emergencies, circulation check |
| Popliteal | Behind knee | Leg circulation |
| Pedal (dorsalis pedis) | Top of foot | Foot circulation |
| Posterior tibial | Behind ankle bone | Foot circulation |
Radial Pulse Measurement
The radial pulse is the most commonly used site for routine assessment.
Procedure:
- Wash hands
- Position patient comfortably with palm down
- Place your first two or three fingers (NOT thumb) on radial artery
- Press gently until you feel pulse
- Count beats for 60 seconds (or 30 seconds × 2 for regular pulse)
- Note rhythm and strength
- Record rate, rhythm, and quality
Why NOT Use Your Thumb: Your thumb has its own pulse, which you might count instead of the patient's pulse.
Apical Pulse Measurement
The apical pulse is the heartbeat heard directly over the heart. It is the most accurate pulse measurement.
When to Use Apical Pulse:
- Irregular radial pulse detected
- Patients on heart medications
- Before giving certain medications (digoxin)
- Infants and children
- When accuracy is essential
Location:
- Left side of chest
- 5th intercostal space (between 5th and 6th ribs)
- At the midclavicular line (nipple line)
- Called Point of Maximum Impulse (PMI)
Procedure:
- Provide privacy
- Clean stethoscope earpieces and diaphragm
- Warm stethoscope diaphragm
- Locate PMI on left chest
- Place diaphragm on PMI
- Count heartbeats for full 60 seconds
- Record as "apical pulse"
Apical-Radial Pulse
Sometimes nurses need to compare apical and radial pulses simultaneously. This is called apical-radial pulse and requires two people.
Pulse Deficit: If apical pulse is higher than radial pulse, the difference is called a pulse deficit. This indicates the heart is beating, but not all beats are strong enough to reach the wrist.
| Measurement | Example |
|---|---|
| Apical pulse | 92 |
| Radial pulse | 84 |
| Pulse deficit | 8 |
Pulse Abnormalities
| Term | Definition | Normal Range |
|---|---|---|
| Tachycardia | Fast pulse | Above 100 bpm |
| Bradycardia | Slow pulse | Below 60 bpm |
| Arrhythmia (dysrhythmia) | Irregular rhythm | Irregular pattern |
| Bounding pulse | Strong, easily felt | Abnormally strong |
| Thready pulse | Weak, hard to feel | Abnormally weak |
Factors Affecting Pulse
| Increases Pulse | Decreases Pulse |
|---|---|
| Exercise | Rest/sleep |
| Fever | Hypothermia |
| Anxiety/stress | Some medications |
| Pain | Deep relaxation |
| Dehydration | Athletic conditioning |
| Some medications | |
| Blood loss |
Documentation Example
Correct: "Radial pulse 78, regular, strong" Correct: "Apical pulse 84, irregular rhythm, reported to nurse" Correct: "Pedal pulses present bilaterally, weak on left"
Why should you NOT use your thumb when taking a radial pulse?
When should an apical pulse be measured instead of a radial pulse?
What is a "pulse deficit"?