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Assessment of peripheral arterial pulses
Patient Assessment
Assessment of Peripheral Arterial
Pulses
For the home care provider, determination of adequate cardiac function is vital to the well-being of the patient at home. If the heart fails as a pump, the patient’s physical condition will deteriorate rapidly. This article will briefly review the normal blood vessel and blood flow principles and the principles guiding assessmentof peripheral arterial pulses.
BLOODVESSELSAND BLOOD FLOW All blood vessels have walls composed of three layers or coats called tunicae. The tunica externa is the outside layer of the vessel that consists of connective tissue to support the vessel. The tunica media, or middle layer, is a smooth muscle layer that constricts or dilates to control diameter. The inner layer, the tunica intima, has an elastic layer and a thick layer of endothelial cells that lie adjacent to the blood. This latter layer makes the vessel’s inner surface smooth and slippery, thus discouraging blood cell aggregation. The elastic layer allows the artery to stretch during systole when blood enters the vessels.’ Blood flow is determined by two factors: a pressure difference between the two ends of a vessel and the resistance that blood must overcome as it moves through the vessel. Systemic vascular resistance or total peripheral resistance is the overall resistance blood encounters as it flows through circulation. Wall tension is the force in the vessel wall that opposes the distending pressure inside. Compliance of the vessel is also a factor in blood flow and reflects the blood vessel’s distensibility. This distensibility of the arteries allows them to accommodate the pulsatile output of the heart.’ With every beat of the heart, an amount of blood (stroke volume) is pumped into the aorta. The force of this blood distends the arterial walls and generates a pressure wave, which is felt in the peripheral vessels as the pulse. Palpation of the peripheral pulse can reflect the rate and rhythm of the heart beat and communicate data regarding the artery’s condition.2 PRINCIPLES OF PULSE PALPATION The peripheral pulse should be palpated with the pads of the first three fingers. The number of beats in 30 seconds may be counted and multiplied by 2 if the heartrbytbm is regular. If an irregular rhythm exists, count the rate for 1 full minute. As the counting interval for
140
HOME CARE PROVIDER
obtaining the rate is begun, start the count with “zero” for the first pulse beat felt. The second beat felt is “one,” the third pulse beat is “two,” and so on. The pulse should be assessedfor rate, rhythm, force, and artery elasticity.2 Rate. In an adult at rest, the rate should between 60 to 100 beats per minute (bpm). If the rate is less than 60 bpm, bradycardia exists. A more rapid rate, more than 100 bpm, is tachycardia.l Some research reports indicate that the range of normal resting heart rate should be shifted down to 50 to 90 bpm rather than the traditional 60 to 100 bpm. This change takes into consideration the physically fit individual who has a resting heart rate well below 60. Also, lowering the threshold for tachycardia would agree with studies that show that heart rates greater than 90 do occur with conditions of sepsis or postmyocardial infarction.3 Rbytbm. The rhythm of the pulse normally should reflect an even beat. If an irregular rhythm is found, auscultation of heart sounds should be done for a more complete assessment.2 Force.The force of the pulse shows the strength of the heart’s contraction. This force then directly influences the stroke volume or the amount of blood the heart pumps out with each beat. A weak, thready pulse indicates a decreased stroke volume whereas a full, bounding pulse indicates an increased stroke volume. The force usually is recorded using this three-point scale: l
3+ = full and bounding
l
2+ = normal
l
I + = weak and thready
l
0
= absent
A d-point scale may be used in which 3+ equals increased and 4+
AUGUST
1999, VOL. 4 NO. 4
Brucbial. The brachial pulse is palpated and auscultated when blood
pressure is assessed.Palpate the pulse over the anterior surface of the elbow joint (antecubital fossa). The pulse is medial to the biceps tendon.4 Femoral.The femoral pulse is palpated in the groin area midway between the anterosuperior iliac crest and the symphysis pubis, below and medial to the inguinal ligament.4 This pulse is palpated by pressing deeply into the dorsal area of the knee, which should be slightly bent4
Popheal.
Dorsalispedis.The dorsalis pedis is palpated on the top of the foot. Apply light pressure about midway between the ankle and the toes on the dorsal aspect of the foot.4 Posterior tibial. This pulse is located slightly below and posterior to
the medial malleolus of the ankle. Light pressure should be applied to the area.4 equals full and bounding.2 The home care provider should follow agency protocol and use its scale. Because the use of these types of scales is somewhat subjective, clinical experience will improve the home care provider’s decisions and clinical judgment. Elasticity. If the artery is normal, it will feel springy, straight, and resilient. Here again, practice and experience will improve this assessmentskill. The pulse is best palpated over arteries that are close to the surface of the body and lie over a bony surface.”The pulse should be assessedbilaterally at the same time to assesssymmetry. PULSE SITES The pulse may be assessedat various areas on the peripheral parts of the body. Each pulse location will be reviewed here and in Table I. Carotid.This artery is in the groove in the anterior neck between the trachea and the sternocleidomastoid muscle. Palpate the area medial to and adjacent to the muscle. The carotid arteries should be palpated gently and on one side at a time to avoid compromising arterial blood flow to the brain. Avoid excessive pressure on the carotid sinus area higher in the neck because this action may cause vagal stimulation, which may lead to bradycardia, especially in older adults.’ Radial. The radial pulse often is assessedto determine the rate and rhythm of pulsation because of its easy access. The examiner should place the pads of the first and second fingers on the palmar surface of the patient’s relaxed and slightly flexed wrist medial to the radius bone. Exert enough pressure to occlude the artery during diastole yet allow the vessel to return to normal contour during systole.4
AUGUST
1999, VOL.
4
NO.
4
SUMMARY This article has reviewed basic information about normal blood flow in arteries and discussed peripheral arterial pulse sites. By conducting a thorough assessment of pulses in the homebound patient, the home care provider can evaluate cardiac function and peripheral circulation and note any problems early, which can result in more rapid medical treatment. REFERENCES 1. Porth C. Pathophysiology: concepts of altered health states. Philadelphia: Lippincott; 1998. 2. Jarvis C. Physical examination and health assessment. Philadelphia: W B Saunders; 1996. 3. Spodick DH. Redefinition of normal sinus heart rate. Chest 1993;104:939-41. 4. Barkauskas V, Stollenberg-Allen K, Baumann L, Darling-Fisher C. Health physical assessment. St. Louis: Mosby; 1998.
Sqndra Xrrtto
Farb, d&J, RPJ,‘is an assistant professor of nursing in the Florida State University School of Nursing in TaHahassee.
Address for correspondence: Sandra Hutto Faria, DSN, RN, Section Editor I529 Copperfield Circle Tallahassee. FL 323 I2 E-mail: [email protected] Reprint orders: Mosby, Inc., I I830 Westline 63 146-33 18; phone (3 14) 453-4350; reprint
Industrial no. 69/l/l
Dr., St. Louis, MO 330
HOME CARE PROVIDER
14 1
Assessment of Peripheral Arterial
Pulses
For the home care provider, determination of adequate cardiac function is vital to the well-being of the patient at home. If the heart fails as a pump, the patient’s physical condition will deteriorate rapidly. This article will briefly review the normal blood vessel and blood flow principles and the principles guiding assessmentof peripheral arterial pulses.
BLOODVESSELSAND BLOOD FLOW All blood vessels have walls composed of three layers or coats called tunicae. The tunica externa is the outside layer of the vessel that consists of connective tissue to support the vessel. The tunica media, or middle layer, is a smooth muscle layer that constricts or dilates to control diameter. The inner layer, the tunica intima, has an elastic layer and a thick layer of endothelial cells that lie adjacent to the blood. This latter layer makes the vessel’s inner surface smooth and slippery, thus discouraging blood cell aggregation. The elastic layer allows the artery to stretch during systole when blood enters the vessels.’ Blood flow is determined by two factors: a pressure difference between the two ends of a vessel and the resistance that blood must overcome as it moves through the vessel. Systemic vascular resistance or total peripheral resistance is the overall resistance blood encounters as it flows through circulation. Wall tension is the force in the vessel wall that opposes the distending pressure inside. Compliance of the vessel is also a factor in blood flow and reflects the blood vessel’s distensibility. This distensibility of the arteries allows them to accommodate the pulsatile output of the heart.’ With every beat of the heart, an amount of blood (stroke volume) is pumped into the aorta. The force of this blood distends the arterial walls and generates a pressure wave, which is felt in the peripheral vessels as the pulse. Palpation of the peripheral pulse can reflect the rate and rhythm of the heart beat and communicate data regarding the artery’s condition.2 PRINCIPLES OF PULSE PALPATION The peripheral pulse should be palpated with the pads of the first three fingers. The number of beats in 30 seconds may be counted and multiplied by 2 if the heartrbytbm is regular. If an irregular rhythm exists, count the rate for 1 full minute. As the counting interval for
140
HOME CARE PROVIDER
obtaining the rate is begun, start the count with “zero” for the first pulse beat felt. The second beat felt is “one,” the third pulse beat is “two,” and so on. The pulse should be assessedfor rate, rhythm, force, and artery elasticity.2 Rate. In an adult at rest, the rate should between 60 to 100 beats per minute (bpm). If the rate is less than 60 bpm, bradycardia exists. A more rapid rate, more than 100 bpm, is tachycardia.l Some research reports indicate that the range of normal resting heart rate should be shifted down to 50 to 90 bpm rather than the traditional 60 to 100 bpm. This change takes into consideration the physically fit individual who has a resting heart rate well below 60. Also, lowering the threshold for tachycardia would agree with studies that show that heart rates greater than 90 do occur with conditions of sepsis or postmyocardial infarction.3 Rbytbm. The rhythm of the pulse normally should reflect an even beat. If an irregular rhythm is found, auscultation of heart sounds should be done for a more complete assessment.2 Force.The force of the pulse shows the strength of the heart’s contraction. This force then directly influences the stroke volume or the amount of blood the heart pumps out with each beat. A weak, thready pulse indicates a decreased stroke volume whereas a full, bounding pulse indicates an increased stroke volume. The force usually is recorded using this three-point scale: l
3+ = full and bounding
l
2+ = normal
l
I + = weak and thready
l
0
= absent
A d-point scale may be used in which 3+ equals increased and 4+
AUGUST
1999, VOL. 4 NO. 4
Brucbial. The brachial pulse is palpated and auscultated when blood
pressure is assessed.Palpate the pulse over the anterior surface of the elbow joint (antecubital fossa). The pulse is medial to the biceps tendon.4 Femoral.The femoral pulse is palpated in the groin area midway between the anterosuperior iliac crest and the symphysis pubis, below and medial to the inguinal ligament.4 This pulse is palpated by pressing deeply into the dorsal area of the knee, which should be slightly bent4
Popheal.
Dorsalispedis.The dorsalis pedis is palpated on the top of the foot. Apply light pressure about midway between the ankle and the toes on the dorsal aspect of the foot.4 Posterior tibial. This pulse is located slightly below and posterior to
the medial malleolus of the ankle. Light pressure should be applied to the area.4 equals full and bounding.2 The home care provider should follow agency protocol and use its scale. Because the use of these types of scales is somewhat subjective, clinical experience will improve the home care provider’s decisions and clinical judgment. Elasticity. If the artery is normal, it will feel springy, straight, and resilient. Here again, practice and experience will improve this assessmentskill. The pulse is best palpated over arteries that are close to the surface of the body and lie over a bony surface.”The pulse should be assessedbilaterally at the same time to assesssymmetry. PULSE SITES The pulse may be assessedat various areas on the peripheral parts of the body. Each pulse location will be reviewed here and in Table I. Carotid.This artery is in the groove in the anterior neck between the trachea and the sternocleidomastoid muscle. Palpate the area medial to and adjacent to the muscle. The carotid arteries should be palpated gently and on one side at a time to avoid compromising arterial blood flow to the brain. Avoid excessive pressure on the carotid sinus area higher in the neck because this action may cause vagal stimulation, which may lead to bradycardia, especially in older adults.’ Radial. The radial pulse often is assessedto determine the rate and rhythm of pulsation because of its easy access. The examiner should place the pads of the first and second fingers on the palmar surface of the patient’s relaxed and slightly flexed wrist medial to the radius bone. Exert enough pressure to occlude the artery during diastole yet allow the vessel to return to normal contour during systole.4
AUGUST
1999, VOL.
4
NO.
4
SUMMARY This article has reviewed basic information about normal blood flow in arteries and discussed peripheral arterial pulse sites. By conducting a thorough assessment of pulses in the homebound patient, the home care provider can evaluate cardiac function and peripheral circulation and note any problems early, which can result in more rapid medical treatment. REFERENCES 1. Porth C. Pathophysiology: concepts of altered health states. Philadelphia: Lippincott; 1998. 2. Jarvis C. Physical examination and health assessment. Philadelphia: W B Saunders; 1996. 3. Spodick DH. Redefinition of normal sinus heart rate. Chest 1993;104:939-41. 4. Barkauskas V, Stollenberg-Allen K, Baumann L, Darling-Fisher C. Health physical assessment. St. Louis: Mosby; 1998.
Sqndra Xrrtto
Farb, d&J, RPJ,‘is an assistant professor of nursing in the Florida State University School of Nursing in TaHahassee.
Address for correspondence: Sandra Hutto Faria, DSN, RN, Section Editor I529 Copperfield Circle Tallahassee. FL 323 I2 E-mail: [email protected] Reprint orders: Mosby, Inc., I I830 Westline 63 146-33 18; phone (3 14) 453-4350; reprint
Industrial no. 69/l/l
Dr., St. Louis, MO 330
HOME CARE PROVIDER
14 1