Explain the procedure to the patient especially if two nurses are taking the pulse. Position the client appropriately. Assist the client to assume the position described for taking the apical pulse. If previous measurements were taken, determine what position the client assumed, and use the same position. Locate the apical and radial pulse sites. In the two-nurse technique, one nurse locates the apical impulse by palpation or with the stethoscope while the other nurse palpates the radial pulse site. Count the apical and radial pulse rates.
One-Nurse Technique
Assess the apical pulse for 60 seconds. Assess the radial pulse for 60 seconds. Document and report pertinent assessment data. Promptly report to the nurse in charge any notable changes from previous measurement or any discrepancy between the two pulses. Document the apical and radial (AR) pulse rates, rhythm, volume, and any pulse deficit. Record any other pertinent observations such as pallor, cyanosis, or dyspnea. Check the physician’s order for any directions related to a discrepancy in the AR pulse rates.
Prepare and position the client appropriately. Make sure the client has not smoke or ingested caffeine within 30 minutes prior to measurement. Make sure that the bladder of the cuff encircles at least two-thirds of the arm and the width of the cuff is appropriate. Position the client in a sitting position unless otherwise specified. Expose the upper arm. Wrap the deflated cuff evenly around the upper arm. Apply the center of the bladder directly over the medial aspect of the arm. This is the client’s initial examination; perform a preliminary palpatory determination of systolic pressure. Palpate the brachial artery with the fingertips. The brachial artery is normally found medially in the antecubital space. Close the valve on the pump by turning the knob clockwise. Pump up the cuff until you no longer feel the brachial pulse. Note the pressure on the sphygmomanometer at which the pulse is no longer felt. Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurements. Position the stethoscope appropriately. Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward. Ensure the stethoscope hangs freely from the ears to the diaphragm. Place the diaphragm of the stethoscope over the brachial pulse. Use the bell-shaped diaphragm. Hold the diaphragm with the thumb and index finger. Auscultate the client’s blood pressure. Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the point where the brachial pulse disappeared. Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mm Hg per second. Deflate the cuff rapidly and completely. Wait 1 to 2 minutes before making further determinations. Repeat the above steps once or twice as necessary to confirm the accuracy of the reading. Remove the cuff from the client’s arm.
Evaluation Focus on the blood pressure in relation to baseline data, normal range for age, and health status, relationship to pulse and respiration. Record on appropriate forms/sheets according to hospital policy. Report any abnormal findings to the appropriate person.
