Heart Rate Steps Rationale

HEART RATE
STEPS RATIONALE
1. Perform hand hygiene. Reduces transmission of
microorganisms.
2. Draw curtain around bed and/or Maintains privacy.
close door.
3. Obtain pulse measurement.
a. Radial pulse
(1) Help patient get into supine or sitting Provides easy access to pulse sites.
position.
(2) If supine, place patient's forearm Relaxed position of lower arm and slight
straight alongside body or across lower flexion of wrist promote exposure of
chest or upper abdomen with wrist artery to palpation without restriction.
extended straight. If sitting, bend
patient's elbow 90 degrees and support
lower arm on chair or on your arm.
(3) Place tips of first two or middle three Fingertips are most sensitive parts of
fingers of hand over groove along radial hand to palpate arterial pulsation. Your
or thumb side of patient's inner wrist. thumb has a pulsation that interferes
Slightly extend or flex wrist with palm with accuracy.
down until you note strongest pulse.
(4) Lightly compress pulse against Pulse is assessed more accurately with
radius, losing pulse initially, and then moderate pressure. Too much pressure
relax pressure so pulse becomes easily occludes pulse and impairs blood flow.
palpable.
(5) Determine strength of pulse. Note Strength reflects volume of blood
whether thrust of vessel against ejected against arterial wall with each
fingertips is bounding (4), full/strong (3), heap contraction. Accurate description
normal or expected (2), diminished or of strength improves communication
barely palpable (1), or absent (0). among nurses and other health care
providers.
6) After feeling a regular pulse, look at Determine rate only after knowing that
second hand of a watch and begin to you can palpate pulse. Timing begins
count rate: count the first beat after the with zero. Count of one is first beat
second hand hits the number on the palpated after timing begins
dial; count as one, then two, and so on.
(7) If pulse is regular, count rate for 30 A 30-second count is accurate for rapid,
seconds and multiply total by 2. slow, or regular pulse rates.
(8) If pulse is irregular, count rate for 1 Inefficient contraction of heart fails to
minute (60 seconds) Assess frequency transmit pulse wave, interfering with
and pattern of irregularity. Compare cardiac output, resulting in irregular
radial pulses bilaterally. pulse Longer time ensures accurate
count.
b. Apical pulse
(1) Clean earpieces and diaphragm of
Reduces transmission of
stethoscope with alcohol swab. Perform
microorganisms.
hand hygiene.
(2) Draw curtain around bed and/or Provides privacy and minimizes
close door. embarrassment.
(3) Help patient to supine or sitting Exposes portion of chest wall for
selection of auscultatory site.
position Move aside bed linen and
Stethoscope diaphragm must touch
gown to expose sternum and left side of skin to best hear sounds.
chest.
(4) Locate anatomical landmarks to Use of anatomical landmarks allows
identify point of maximal impulse (PM!), correct placement of stethoscope over
also called apical impulse (see apex of heart, enhancing ability to hear
illustrations A-D). Heart is located heart sounds clearly. If unable to
behind and to left of sternum with base palpate PMI, reposition patient on left
at top and apex at bottom. Find angle of side. In presence of serious heart
Louis just below suprasternal notch disease, PMI is located to left of MCL or
between sternal body and manubrium, at sixth ICS.
feels like bony prominence (illustration
A). Slip fingers down each side of angle
to find second intercostal space (ICS)
(illustration B). Carefully move fingers
down left side of sternum to fifth ICS
(illustration C) and laterally to left
midclavicular line (MCL) (illustration 0).
A light tap felt within an area 1 to 2 cm
(% to 1 inch) of PMI is reflected from
apex of heart.
(5) Place diaphragm of stethoscope in Warming of metal or plastic diaphragm
palm of hand for 5 to 10 seconds. prevents patient from being startled and
promotes comfort.
(6) Place diaphragm of stethoscope Allow stethoscope tubing to extend
over PMI at fifth ICS at left MCL and straight without kinks that would distort
auscultate for normal S, and S2 heart sound transmission. Normal sounds S,
sounds (heard as "lub-dub"). and S, are high pitched and best heard
With the diaphragm.
(7) When you hear S, and S2 with Determine apical rate accurately only
regularity, use second hand of watch after you are able to auscultate sounds
and begin to count rate; when sweep clearly. Timing begins with zero. Count
hand hits number 12 on dial, start of one is first sound auscultated after
counting with zero, then one, two, and timing begins.
so on.
(8) If apical rate is regular, count for 30 Regular rate is accurate when
seconds and multiply by 2. measured for 30 seconds.
(9) Note if heart rate is irregular and Irregular heart rate indicates
describe pattern or irregularity (S, and dysrhythmia Regular occurrence of
S2 occurring early or later after dysrhythmia within 1 minute indicates
previous sequence of sounds [e.g., inefficient contraction of heart and
every third or every fourth beat is alteration in cardiac output.
skipped]).
(10) Replace patient's gown and bed Restores comfort and promotes sense
linen; help of well-
patient return to comfort-able position. being
(11) Perform hand hygiene. Reduces transmission of
microorganisms.
(12) Clean earpieces and diaphragm of Prevents transmission of
stethoscope with alcohol swab routinely microorganisms
after each use.
4. Discuss findings with patient as Promotes participation in care and

needed. understanding of health status.

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HEART RATE

4. Discuss findings with patient as Promotes participation in care and

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