8.4 Pulse and Respiration Measurement (INACE Skill)

Pulse and Respiration as a Tested INACE Skill

Measuring and recording radial pulse and respirations is part of the mandated INACE TPR (temperature, pulse, respiration) performance skill. The two are taken back-to-back for one reason that examiners specifically watch for: counting respirations is only accurate when the resident does not realize their breathing is being observed. By keeping your fingers on the wrist after the pulse, you count breaths discreetly.

Understanding the Pulse

The pulse is the wave of pressure you feel each time the heart beats and pushes blood through an artery near the skin's surface.

Radial Pulse Procedure (Step by Step)

1. Wash hands, identify the resident, explain the procedure.
2. Position the arm comfortably, palm up.
3. Locate the radial artery on the thumb side of the inner wrist.
4. Place your first two or three fingertips over the artery — never your thumb, which has its own pulse you could miscount.
5. Press gently until you feel the beat.
6. Count for one full minute (60 seconds) — full-minute counts are required when teaching/testing and whenever the rhythm is irregular.
7. Note the rate, rhythm, and quality.
8. Record immediately.

Counting Respirations

Respirations are counted immediately after the pulse without announcing it. One rise and fall of the chest equals one respiration.

Respiration Procedure

1. Keep your fingers on the wrist as though still taking the pulse — this hides that you are now watching breathing.
2. Watch the chest rise and fall; if movement is hard to see, rest the resident's arm across the chest to feel it.
3. Count for one full minute (60 seconds).
4. Note the rate, rhythm, depth, and effort.
5. Record immediately.

Abnormal Breathing Patterns

Worked Example

You count a pulse of 96 bpm that skips unevenly, then 28 labored breaths in one minute. Because the pulse is irregular and respirations are above 24 and labored (tachypnea with dyspnea), you report both to the nurse right away and stay with the resident, raising the head of the bed for easier breathing if allowed.

Pulse Oximetry

Though not one of the 21 mandated skills, many Illinois facilities train CNAs to use a pulse oximeter, a clip-on sensor measuring blood oxygen saturation (SpO2).

Common Traps

• Trap: Using the thumb for the radial pulse — you may count your own pulse.
• Trap: Counting for only 15 or 30 seconds and multiplying on the skills test — count the full 60 seconds.
• Trap: Telling the resident "now I'll count your breathing" — this changes the rate.
• Trap: Charting respirations as breaths counting only the rise or only the fall — a full rise-and-fall is one breath.

When to Use an Apical Pulse

If the radial pulse is irregular, very weak, or hard to feel, the nurse may direct that an apical pulse be counted instead. This is taken with a stethoscope over the apex of the heart (about the fifth intercostal space, just left of the breastbone) for a full 60 seconds. An apical pulse is also commonly checked before certain heart medications. The difference between the apical and radial rate is called the pulse deficit; a large deficit means some heartbeats are too weak to reach the wrist and must be reported, because it can signal a serious cardiac problem.

Connecting Pulse, Respirations, and Oxygen

Pulse, respirations, and oxygen saturation move together because they all serve one goal — delivering oxygen to the body's tissues. When oxygen drops, the heart often beats faster (rising pulse) and the resident breathes faster (rising respirations) to compensate. So a resident who is suddenly short of breath with a fast pulse and a falling SpO2 is showing one connected emergency, not three separate findings. Report the whole picture, keep the resident in an upright position to ease breathing, do not leave them alone, and call for the nurse.

Documenting all three values with the time gives the nurse the trend needed to act quickly and may prevent a transfer to the hospital.