Assessing a Peripheral Pulse by Palpation

Goal: The patient’s pulse is assessed accurately without injury and the patient experiences only minimal discomfort.

1. Check medical order or nursing care plan for frequency of pulse assessment. More frequent pulse measurement may be appropriate based on nursing judgment.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with patient and assess the patient’s ability to assist with the procedure.

5. Put on gloves, as appropriate.

6. Select the appropriate peripheral site based on assessment data.

7. Move the patient’s clothing to expose only the site chosen.

8. Place your first, second, and third fingers over the artery. Lightly compress the artery so pulsations can be felt and counted.

9. Using a watch with a second hand, count the number of pulsations felt for 30 seconds. 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.

10. Note the rhythm and amplitude of the pulse.

11. When measurement is completed, remove gloves, if worn. Cover the patient and help him or her to a position of comfort.

12. Remove additional PPE, if used. Perform hand hygiene.


Post a Comment