7.3 Pulse Measurement

What the Pulse Tells You

The pulse is the wave of blood pushed through the arteries each time the heart's left ventricle contracts. Every pulse check assesses three things, not just a number.

Pulse Sites

Taking a Radial Pulse

Wash hands, rest the patient's arm with the palm down, and place your first two or three fingers over the radial artery. Press gently until you feel the beat. If the rhythm is regular you may count 30 seconds and multiply by 2; if it is irregular, count the full 60 seconds. On the NNAAP skills exam your count must land within about +/- 4 beats of the evaluator's, so do not round.

Why never the thumb: your thumb carries its own arterial pulse, so you could count your heartbeat instead of the patient's.

Apical Pulse, Pulse Deficit, and Abnormalities

Apical Pulse

The apical pulse is heard directly over the heart with a stethoscope and is the most accurate count. Locate the point of maximum impulse (PMI) at the 5th intercostal space, midclavicular line on the left chest. Warm and clean the diaphragm, then count for the full 60 seconds.

Use the apical site when:

• The radial pulse felt irregular
• The patient takes cardiac drugs, especially digoxin (the nurse often wants an apical rate before a dose)
• The patient is an infant or young child
• Maximum accuracy is required

Pulse Deficit

Two staff count at the same time, one apical and one radial. If the apical rate is higher, the difference is the pulse deficit, meaning some heartbeats are too weak to push blood all the way to the wrist.

A pulse deficit always gets reported to the nurse.

Naming Abnormal Pulses

What Moves the Pulse

Documentation examples: "Radial pulse 78, regular, strong." "Apical pulse 84, irregular, nurse notified." "Pedal pulses present bilaterally, weak on left." Always pair the number with rhythm and strength rather than a bare figure.

Counting Method, Peripheral Pulses, and Test Scenarios

How Long to Count

The counting window is itself a tested decision. For a regular pulse you may count for 30 seconds and multiply by 2, which still meets the NNAAP tolerance of about plus or minus 4 beats. For any irregular pulse, an infant, or a pre-digoxin check, count the full 60 seconds, because doubling a short count of an uneven rhythm magnifies the error. A frequent written-test trap offers "count 15 seconds and multiply by 4"; that shortcut is too inaccurate for nursing assistants and is the wrong answer.

Why Peripheral Pulses Are Checked

The pedal (dorsalis pedis) and posterior tibial pulses are felt in the feet to confirm that blood is reaching the lower limbs. A weak or absent foot pulse, especially in a diabetic resident or someone with peripheral vascular disease, is reported because it can signal poor circulation that leads to slow wound healing and skin breakdown. You document them as present or absent and as equal or unequal between the two feet.

Worked Scenario

A CNA counts a radial pulse and feels an occasional skipped beat. The correct sequence is: do not estimate, switch to a full 60-second count, and because the rhythm is irregular move to or request an apical assessment for accuracy, then report "irregular pulse, rate 88 apical" to the nurse. The CNA does not decide whether the irregularity is dangerous; that is the nurse's call.

Quality Words You Must Know

Use precise terms so the nurse understands what you felt. A bounding pulse is unusually forceful and may accompany fever, anxiety, or fluid overload. A thready pulse is faint and easily lost under your fingers and may accompany shock, dehydration, or blood loss. Reporting "thready, rapid pulse" alongside pale, cool, clammy skin is a classic early warning of shock that the nurse needs immediately. Never normalize an abnormal feel; describe exactly what you assessed in rate, rhythm, and strength.