St.
Michael’s College
College of Nursing
Iligan City
Name: __________________________________________________ Group: ______________
Clinical Instructor: _________________________________________ Date: _______________
Assessing a Pulse
Concept:__________________________________________________________________________________
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Purpose:
:_________________________________________________________________________________________
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Equipments:______________________________________________________________________________
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Oral
Performed
Rationale
Procedure Written Rationale
Don Not
Yes No
e Done
1. Assessment:
Clinical signs of cardiovascular
alterations, other than pulse rate,
rhythm, or volume
Factors that may alter pulse rate
Site most appropriate for
assessment
Identify patient
2. Planning;
Gather all the necessary equipment
needed for the procedure.
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3. Implementation:
Explain the procedure to the
client.
Perform hand hygiene.
Palpating the Radial Pulse
Position the patient either supine
with arm alongside the body,
wrist extended, and palms lateral
or facing down or sitting with the
forearm at a 900 to body resting
on a support with the wrist
extended and palm downward or
facing laterally.
Place first, second, and third
fingers along the patient’s radial
artery and press gently against
the radius. Rest thumb on the
back of patient’s wrist.
Apply only enough pressure to
distinctly feel the artery.
Using a watch with a second
hand, count the number of
pulsations felt for 1 full minute.
Use other pulse sites if the radial
pulse cannot be palpable.
Auscultating the Apical Pulse Rate
Use an alcohol swab to clean
stethoscope earpieces and
diaphragm
Assist patient to sit in a chair or
sit up in bed and then expose
chest area
Hold the stethoscope diaphragm
against the palm of the hand for a
few seconds
Palpate the fifth intercostal space
and move to the left midclavicular
line. Place the diaphragm over
the apex of the heart.
Listen for heart sounds, identified
as “lub-dub” sound
Using a watch with a second
hand, count heartbeat for 1
minute.
4. Evaluation:
Document the pulse rate, rhythm,
site, volume, and client’s
responses or actions on paper,
flow sheet, or computerized
record.
Report abnormal findings to the
appropriate person.
Identify pulse sites of
assessment used if other than
radial pulse.
