/policies/,/policies/clinical/,/policies/clinical/uwmf-clinical/,/policies/clinical/uwmf-clinical/uwmf-wide/,/policies/clinical/uwmf-clinical/uwmf-wide/clinical-policies-and-procedures/,/policies/clinical/uwmf-clinical/uwmf-wide/clinical-policies-and-procedures/patient-assessment/,

/policies/clinical/uwmf-clinical/uwmf-wide/clinical-policies-and-procedures/patient-assessment/102100.policy

20150376

page

100

UWHC,UWMF,

Policies,Clinical,UWMF Clinical,UWMF-wide,Clinical Policies and Procedures,Patient Assessment

Measuring A Pulse (102.100)

Measuring A Pulse (102.100) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Patient Assessment

102.100

1
UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: MEASURING A PULSE

Effective Date: March, 2002 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed October, 2003 March, 2005 February, 2008 October 2011


PURPOSE: To provide guidelines for taking a pulse of a patient at UWMF Clinics.

DEFINITION: The character of a client's pulse provides valuable data regarding the
integrity of his cardiovascular system. The radial pulse is usually the most accessible.
When it is inaccessible because of a dressing, cast, or other encumbrance, the apical pulse
can be assessed instead. The apical pulse is assessed with a stethoscope. The apical pulse
is also the best site for assessing the pulse of an infant or young child. Before assessing a
patient's pulse, the staff should be aware that four factors--exercise, anxiety, pain, and
postural change--might cause false elevations or decreases in heart rate.

POLICY: The clinical staff will utilize the following guidelines to measure a pulse in a
UWMF patient.

The clinical staff will take a pulse with each corresponding blood pressure.

SUPPLIES: Wristwatch with second hand or digital display, Pen, stethoscope
Provider’s order, patient’s record

PROCEDURE:
1. Check provider’s order and clarify any
inconsistencies.

2. Wash hands.

3. Determine the most appropriate location
for obtaining a pulse.

4. Introduce yourself to the patient and
identify the patient by verifying name and
date of birth

5. Explain procedure to the patient


.

2

Assessing Radial Pulse

6. Take two fingers, preferably the 2nd and 3rd finger, and place them in the groove in
the wrist that lies beneath the thumb. Move your fingers back and forth gently until you
can feel a slight pulsation

7. Determine strength of pulse.
NOTE: whether thrust of vessel is bounding, strong, weak, or thready.

8. After pulse can be felt regularly, look watch's second hand and begin to count rate,
starting with 0, and then 1, etc.

9. If pulse is regular, count for 15 seconds and multiply total by 4.

10. If pulse is irregular, count for full minute and double check with the apical pulse.

12. Assist patient to a comfortable position and wash hands.
13. Documentation:
Within vitals section in Healthlink
Use Comment Entry field when appropriate; ie recording of irregular pulse or
‘thready’ pulse .

14. Report abnormalities to provider.

Assessing Apical Pulse

1. Begin with Step 1 through 5 above

2. Unlike the other sites, the apical pulse is not taken over an artery. Instead, it is taken
over the heart itself. The apical pulse (actually, the heartbeat) can be felt over the apex of
the heart (the pointed lower end of the heart.) This site is located to the (patient's) left of
the breastbone and two to three inches above the bottom of the breastbone. The apical
pulse is easily heard when a stethoscope is used.

3. Use a watch's second hand and count for 60 seconds.

4. Documentation:
Within vitals section in Health Link
Use Comment Entry field for documenting that an apical pulse was obtained and
any descriptions of rate or rhythm.


3
5. Report abnormalities to provider.


NOTE: This is a diagram indicating the differences in locations of apical
pulse for adults, children and infants.


REVIEWED BY:
LaVay Morrison, RN, BSN, Clinical Staff Educator

REVISED BY:
LaVay Morrison, RN, BSN, Clinical Staff Educator

WRITTEN BY:
Ronnie Peterson, R.N., M.S., Manager of Clinical Support

REFERENCES:

Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St.
Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. &
Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.
Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5th ed.). Ambler, PA:
Lippincott Williams & Wilkins.

AUTHORIZATION:



Medical Director Date