Skill Variation:Assessing Peripheral Pulse Using a Portable Doppler Ultrasound

The peripheral pulse is a throbbing sensation that can be palpated (felt) over a peripheral artery, such as the radial artery or the carotid artery. Peripheral pulses result from a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle. Each time the left ventricle contracts to eject blood into an already full aorta, the arterial walls in the cardiovascular system expand to compensate for the increase in pressure of the blood. The peripheral pulses may be felt wherever an artery passes over a solid structure, such as bone or cartilage. Characteristics of the peripheral pulse include rate, rhythm, strength (amplitude), and elasticity. These characteristics are indicators of the effectiveness of the heart as a pump, the volume of blood ejected with each heartbeat (stroke volume), and the adequacy of peripheral blood flow.

Pulse rates are measured in beats per minute. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats per minute. Pulse strength (amplitude) refers to and describes the quality of the pulse in terms of its fullness, indicates the volume of blood flowing through the vessel, and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flow through the vessel and may be described as full and bounding when it is forceful or weak, and thready when it is decreased in quality. Pulse rhythm is the pattern of the pulsations and the intervals between them. Pulse rhythm is normally regular; the pulsations and the pauses between occur at evenly spaced intervals. An irregular pulse rhythm occurs when the pulsations and pauses between beats occur at unequal, varied intervals. Pulse elasticity is assessed by the feel of the blood vessel upon palpation. The normal artery feels smooth, straight, and resilient (springy) (Jensen, 2019; Weber & Kelley, 2018). Blood vessels may feel more rigid, less resilient, and crooked from loss of elasticity, such as occurs with aging, for example.

Assess the pulse by palpating peripheral arteries (refer to the steps outlined below), by auscultating the apical pulse with a stethoscope (see Skill 2-5), or by using a portable Doppler ultrasound (see the accompanying Skill Variation on page 68). To assess the pulse accurately, you need to know which site to choose and what method is most appropriate for the patient.

The most commonly used sites to palpate peripheral pulses and one example of a scale used to describe pulse amplitude are illustrated in Box 2-2. Place your fingers over the artery so that the ends of your fingers are flat against the patient's skin when palpating peripheral pulses. Do not press with the tip of the fingers only (refer to Figure 1, Step 8).

See the accompanying Skill Variation on page 68 for a description of the procedure for assessing a peripheral pulse using a portable Doppler ultrasound.

Assessment

Choose a site to assess the pulse. For an adult patients and children, the most common site for obtaining a peripheral pulse is the radial pulse. Apical pulse measurement is the preferred method of pulse assessment for infants and children less than 2 years of age (Jarvis & Eckhardt, 2020; Kyle & Carmen, 2021). (Refer to Skill 2-5.) Assess for factors that could affect pulse characteristics, such as the patient's age, physical activity, fluid balance, medications, body temperature, and presence of disease and/or health conditions. Note baseline or previous pulse measurements.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

• Altered tissue perfusion
• Impaired Cardiac Output
• Impaired comfort

Outcome Identification and Planning

The expected outcomes to achieve when measuring a pulse rate are that the patient's pulse is assessed accurately without injury, and that the patient experiences minimal discomfort. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

Implementation

Action	Rationale
1. Check prescribed interventions or plan of care for frequency of pulse assessment. More frequent pulse measurement may be appropriate based on nursing judgment.	Assessment and measurement of vital signs at appropriate intervals provide important data about the patient's health status.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient's ability to assist with the procedure.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation.
5. Put on gloves, if indicated.	Gloves are not usually worn to obtain a pulse measurement unless contact with blood or body fluids is anticipated. Gloves prevent contact with blood and body fluids.
6. Select the appropriate peripheral site based on assessment data.	Ensures safety and accuracy of measurement.
7. Move the patient's clothing to expose only the site chosen.	The site must be exposed for pulse assessment. Exposing only the site keeps the patient warm and maintains their dignity.
8. Place your first, second, and third fingers over the artery (Figure 1). Place your fingers over the artery so that the ends of your fingers are flat against the patient's skin when palpating peripheral pulses. Do not press with the tip of the fingers only. Lightly compress the artery so pulsations can be felt and counted.	The sensitive fingertips can feel the pulsation of the artery.
9. Using a watch with a second hand, count the number of pulsations felt for 30 seconds (Figure 2). Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute.	Ensures accuracy of measurement and assessment.
10. Note the rhythm and amplitude of the pulse, as well as the elasticity of the blood vessel.	Provides additional assessment data regarding the patient's cardiovascular status.
11. When measurement is completed, remove gloves, if worn. Perform hand hygiene. Cover the patient and help them to a position of comfort.	Proper removal of gloves reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Covering and positioning the patient ensures patient comfort.
12. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient's pulse has been assessed accurately without injury, and the patient experienced minimal discomfort.