8.4 Pulse and Respiration Measurement (INACE Skill)
Key Takeaways
- Use your first two or three fingertips (not your thumb) to take a radial pulse on the thumb side of the wrist
- Count both pulse and respirations for a full 60 seconds for accuracy
- Count respirations without the resident's knowledge to get an accurate reading
- Assess rate, rhythm, and quality/strength for pulse; rate, rhythm, depth, and effort for respirations
- Normal pulse: 60-100 bpm; Normal respirations: 12-20/min; Normal SpO2: 95-100%
- Report immediately: irregular pulse, pulse <60 or >100, respirations <10 or >24, SpO2 <90%
Pulse and Respiration Measurement (INACE Skill)
Measuring and recording radial pulse and respirations is one of the 21 mandated INACE performance skills. These two measurements are typically taken together because they are both affected by the same factors and because counting respirations is most accurate when the resident does not know they are being observed.
Pulse Measurement
The pulse is the pressure wave created each time the heart beats, felt at specific points where arteries are close to the body surface.
Pulse Sites
| Site | Location | When Used |
|---|---|---|
| Radial (most common) | Thumb side of inner wrist | Routine pulse measurement (INACE tested) |
| Carotid | Side of the neck | Emergency/CPR — check for pulse in unresponsive person |
| Brachial | Inner elbow | Blood pressure measurement; infant pulse |
| Temporal | Side of forehead | Quick pulse check |
| Femoral | Groin area | Emergency assessment (by nurse/physician) |
| Popliteal | Behind the knee | Circulation check in lower extremity |
| Dorsalis pedis | Top of the foot | Circulation check in feet (diabetes, PAD) |
| Posterior tibial | Behind the inner ankle | Circulation check in feet |
Radial Pulse Procedure (INACE Tested)
- Wash your hands and identify the resident
- Explain the procedure
- Position the resident's arm comfortably, palm up
- Locate the radial artery on the thumb side of the inner wrist
- Place your first two or three fingertips (NOT your thumb — your thumb has its own pulse) over the artery
- Press gently until you feel the pulse
- Count the beats for one full minute (60 seconds)
- Note the rate (beats per minute), rhythm (regular or irregular), and quality (strong/weak/bounding)
- Record immediately
Pulse Characteristics to Assess
| Characteristic | What to Observe |
|---|---|
| Rate | Number of beats per minute (normal: 60-100) |
| Rhythm | Regular (even spacing) or irregular (uneven spacing) |
| Quality/Strength | Strong/bounding, normal, weak/thready |
Respiration Measurement
Respirations are counted immediately after taking the pulse — do not tell the resident you are now counting their breathing, as awareness can change their breathing pattern.
Respiration Procedure
- Keep your fingers on the wrist as if still counting the pulse
- Watch the chest rise and fall — one rise AND fall = one respiration
- If you cannot see chest movement, place the resident's arm across their chest and feel the movement
- Count respirations for one full minute (60 seconds)
- Note the rate (breaths per minute), rhythm (regular or irregular), depth (shallow or deep), and effort (easy or labored)
- Record immediately
Respiratory Characteristics to Assess
| Characteristic | What to Observe |
|---|---|
| Rate | Breaths per minute (normal: 12-20) |
| Rhythm | Regular or irregular pattern |
| Depth | Shallow, normal, or deep |
| Effort | Easy, labored, or with accessory muscle use |
Abnormal Breathing Patterns
| Pattern | Description | Significance |
|---|---|---|
| Tachypnea | Rate above 20/min | Fever, anxiety, pain, respiratory distress |
| Bradypnea | Rate below 12/min | Medication effects, brain injury |
| Dyspnea | Difficult or labored breathing | Heart failure, COPD, pneumonia |
| Apnea | Absence of breathing | Life-threatening emergency |
| Cheyne-Stokes | Alternating deep and shallow breathing with apnea periods | Brain damage, approaching death |
| Orthopnea | Difficulty breathing when lying flat | Heart failure; resident needs elevated head |
| Kussmaul | Deep, rapid breathing | Metabolic acidosis (diabetic ketoacidosis) |
Pulse Oximetry
While not one of the 21 mandated skills, many Illinois facilities train CNAs to use pulse oximetry:
| Parameter | Details |
|---|---|
| What it measures | Blood oxygen saturation (SpO2) |
| Normal range | 95-100% |
| Report if | Below 90% |
| Placement | Fingertip sensor (clean, dry finger; remove nail polish) |
| Limitations | Cold hands, dark nail polish, poor circulation can affect accuracy |
Why should you NOT use your thumb to take a radial pulse?
Why should you count respirations without telling the resident?
A resident has a respiratory rate of 28 breaths per minute and appears to be working hard to breathe. This is called: