CPULSE &

RESPIRATIONUnit III: Ch. 19

Pulse & Respiration p. 321• Counted together, first pulse, then respirations

• Keep fingers on pulse while counting respirations

• Tell pt you are taking her/his pulse and continue counting respirations after obtaining pulse – why?

• Respirations are partly voluntary and if the pt knows they are counted, the breathing pattern is altered

• Count both for a full minute!

• Need 2nd hand on watch for this

Pulse p. 321• Pressure of blood against an artery wall when heart beats (pulse) and relaxes (no pulse)

• Easier felt in arteries close to surface that can be pressed against a bone

• Is the same in all arteries throughout body

• Indication of how well the cardiovascular system works

• Stethoscope p. 322• Used to listen to sounds inside body by intensifying sounds

• Parts: see Figure 19-3 p. 323 (need to know)

• ALWAYS clean earpieces, diaphragm, bell and tubing with alcohol or cavy wipes before and after use

• Used for obtaining apical pulse, blood pressure, listening to heart, lungs, abdomen

• See p. 324: Guidelines for using a stethoscope! • Inspect for damages

• Clean, clean, clean

• Always use directly against skin, not over clothing!

Radial pulse p. 322• Most commonly measured pulse

• Measured at radial artery on wrist, count for 1 full minute

• Pt arm should be in comfortable position, palm down, arm resting on flat surface

• Use tips of your fingers, never thumb

• Only used on conscious patients

• Unconscious pt: carotid artery or apical pulse

See Figure 19.1 for common pulse sites

Record as: beats per minute (bpm) ex. Pulse 85bpm R

Pulse rate/character p. 322Procedure 37: counting radial pulse p. 323

• Rate/speed: see Table 19.1 for normal pulse rates; need to know adult!!!!• Adult: 60-80• General: the smaller the body, the higher the pulse rate ex. Hummingbird 1000bpm• Bradycardia: unusually slow pulse rate; below 60 beats per minute (bpm)• Tachycardia: unusually fast pulse rate; over 100 bpm

• Character:• Rhythm: regular or irregular (normal: regular)• Volume/fullness: weak, strong, thread

• Always report any abnormalities to the nurse:• Bradycardia• Tachycardia• Irregular pulse• Threaddy/ weak pulse

Procedure 37: counting radial pulse p. 323

Influencing factors p. 322• Rate can be affected by:• Disease• Emotions• Age• Exercise• Elevated temp• Gender• Position• Physical training• Low temp• Drugs

Apical pulse p. 322• Measured by counting heart contractions using a stethoscope

• Measured at the apex (tip) of the heart at left side of front of chest, for 1 full minute

• Rate should be same as pulse

• When documenting: write AP after the bpm ex. 80 bpm AP

• Sound: lub/dub• Lub: contraction of ventricles pushing blood out• Dub: relaxation of ventricles when they fill back up with blood

• Used when:• There is a pulse deficit (see next slide)• Before RN gives heart rate altering medicine• In children when rapid pulse rate is difficult to count at radial artery• Everyone 12 months or younger• Irregular radial pulse or uncertain of accuracy of radial pulse

Apical-radial pulse rate p. 324• Comparing apical and radial pulse rate

• Should be the same

• If heart contracts to weekly, can’t send enough blood through the arteries for pulse to be felt

• One person takes apical pulse while other person takes radial pulse

see Procedure 38 p. 324

• Difference between apical and radial pulse = pulse deficit; found in some forms of heart disease

How to record pulse:

ex. 76 beats per minute, regular, strong

_____________/minute, ____________, _________________

Respirations p. 325• Function: supply O2, discard CO2

• If ineffective: less O2 for body, too much CO2 in body

• Cyanosis: bluish or dusky color of the skin

• 2 parts of respiration: Inspiration (inhalation), expiration (exhalation)

• Breathing patterns:• Normal: regular; 12-20 breaths per minute• Tachypnea: rapid, shallow• Shallow: breaths only fill lungs partially• Apnea: period of no respirations (ex. Sleep apnea)• Dyspnea: difficult or labored breathing• Cheyne-Stokes respiration: period of dyspnea followed by periods of apnea• Stertorous: snoring-like respirations• Rales (crackles): moist respirations; air has to bypass mucus / wet passage ways; common

in dying pt• Wheezing: difficult breathing by whistling or sighing sound due to narrowing of bronchioles

(ex. asthma)

What to look for p. 325• Check respirations for:

• Rate: number of respirations per minute• Rhythm: should be regular/ even• Symmetry: chest should expand and retract equally• Volume: depth of respiration• Character: regular, irregular, shallow, deep, labored (difficult)• Normal: even, unlabored

• Rate: see norms in Table 19-2 p. 326• Normal for adult: 12-20 respirations per minute• Accelerated: over 25 respirations per minute• Too slow: under 12 per minute• Report: accelerated or too slow breathing (i.e. Over 25 or under 12)• Affected by:

• Illness

• Emotions

• Elevated temp

• Gender

• Age

• Exercise

• Position

• Drugs

How to measure p. 325• Procedure 39 p. 326

• Continue counting respirations after pulse, without letting pt know you are counting respirations

• Record rate, depth and regularity eg. 18 respirations per minute, unlabored, regular

How to record:Ex. 22 breaths per minute, even, unlabored

_____________________/minute, ____________, _______________

1. Introduce yourself by name, call pt by name, explain that you will measure her/his pulse, lock bed/WC if in bed or WC

2. Privacy curtain

3. Wash hands, get supplies (eg. Paper, pen, watch)

4. Wash hands before touching pt

5. Position pt’s arm comfortably, palm down

6. Position your fingertips on radial artery

7. Use 2nd hand on watch, say start, count pulse for 1 full minute (remember number), say stop

8. Immediately, count respirations for 1 full minute, say stop

9. Call bell in reach? Pt feels ok or needs anything else?

10.Privacy curtain open

11.Wash hands

12.Record pulse and respirations as:1. Pulse: ____________ beats per minute, regular, strong

2. Respirations: _______________breaths per minute, even, unlabored

Homework:

Textbook: Read Unit 19

Workbook: p. 119 read Unit Summary, Nursing Assistant Alert; Vocabulary Exercise, True/False