01-03-pulse@ - Taking a Pulse Karrin Johnson, RN (DeLaune...

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Taking a Pulse Karrin Johnson, RN (DeLaune Revised) (Adapted from Fundamentals of Nursing: Standards and Practice) Overview of the Skill Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta. Assessment of pulse characteristics provides clinical data regarding the heart’s pumping action and the adequacy of peripheral artery blood flow. Assessment 1. Assess client for need to monitor pulse because certain diseases or conditions such as history of heart disease or cardiac dysrhythmias, chest pain, invasive cardiovascular diagnostic tests, infusion of large volume of IV fluids, or hemorrhage, can cause an increased risk for alterations in pulse. 2. Assess for signs and symptoms of cardiovascular alterations such as dyspnea, chest pain, orthopnea, syncope, palpitations, edema of extremities, cyanosis or fatigue because these signs may indicate a deficit in cardiac or vascular function. 3. Assess client for factors such as age, medications, exercise, change in position, or fever that may affect the character of the pulse . This enables the nurse to accurately assess for the significance of an alteration in pulse. 4. Assess for the appropriate site for measuring pulse so that the pulse will be accurate. 5. Assess the baseline heart rate and rhythm in the client’s chart in order to compare it with the current measurement.
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Diagnosis 1.4.2.1. Decreased Cardiac Output, due to alteration in the rate and rhythm of their pulse. 1.4.1.1. Altered Cardiopulmonary Tissue Perfusion Planning Expected Outcomes: 1. Pulse rate, quality, rhythm, and volume will be within normal range for the client’s age group. 2. The client will be comfortable with the procedure and demonstrate an understanding regarding its importance. Equipment Needed: • Watch with a second hand • Stethoscope • Alcohol swab • Gloves Estimated time to complete the skill: 5-10 minutes Client Education Needed: 1. Ask the client to relax and sit or lie quietly while you take his pulse rate. 2. Explain the normal pulse range to the client when killing him what his pulse rate is. This eases the client’s concerns regarding whether or not he is “normal.” 3. If the client is taking any medications that affect pulse rate, this is a good time to review the name and purpose of this medication. 4. If taking a pulse at a site other than radial explain to the client the reason for using an
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alternate site. 5. Have the client breathe normally through the nose, especially if taking an apical pulse. Breathing through the nose decreases breath sounds, making the heart sounds easier to hear. Implementation - Action and Rationale Taking a Radial (Wrist) Pulse Action: Wash hands. Rationale:
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This note was uploaded on 10/13/2010 for the course NURS 100 taught by Professor Beneker during the Spring '10 term at Columbus State Community College.

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01-03-pulse@ - Taking a Pulse Karrin Johnson, RN (DeLaune...

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