Chapter 14: Observations
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Pre‐procedural considerations
Equipment
Monitoring a pulse may require a stethoscope (if it is necessary to count the apical beat along with palpating the pulse). Alternatively, an electronic pulse measurement device (pulse oximeter) may be used; this is a small electronic device consisting of a probe that is placed onto the end of a finger to record pulse rate and peripheral oxygen saturations.
Specific patient preparation
Ideally a patient should be at rest for 20 minutes before any attempt to obtain an accurate pulse, as strenuous activity can result in falsely elevated readings (Blows [21]).
Procedure guideline 14.1
Pulse measurement
Table 14.2 Prevention and resolution (Procedure guideline 14.1)
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| No pulse palpable | Incorrect positioning of fingers | Refer to Figure 14.4 for palpation sites. | Place two or three fingers over the appropriate artery and lightly depress against the tissue or bone. Try alternative sites such as the brachial or carotid artery. |
| Absent or faint pulse | Poor perfusion | Assess the patient's existing co‐morbidities for further information and identify any possible causes of hypovolaemia ( Lin [104]). | Inform the medical team if the patient is cardiovascularly compromised (RCUK [173]). |
| Obstruction to flow, for example clot, swelling or trauma |
Perform a venous thromboembolism risk assessment on admission and ensure appropriate preventative measures are in place, for example anti‐embolism stockings, mechanical devices applying intermittent pneumatic compression, or pharmacological prophylaxis such as injections of low‐molecular‐weight heparin preparations (
NICE [142]).
Monitor lower lib circulation. |
Perform a neurovascular assessment, assessing all pulse sites to determine the compromised area (
Sprigings and Chambers [189]). Also feel for warmth and sensation and capillary refill to provide further information on the degree of vascular sufficiency (Bickley [18]).
Evaluate the vascularity of the lower limbs (see the section above on assessing lower limb perfusion). | |
| Pulse too fast and irregular to palpate manually | Patient may be in an abnormal rhythm | Conduct a haemodynamic assessment, and monitoring and maintenance of electrolyte balance ( Jackson [86]). | Irregular rhythms should prompt a full set of observations, and it is essential to perform a 12‐lead ECG and have this reviewed by a practitioner competent in ECG interpretation (Adam et al. [2]). |
| ECG, electrocardiogram. |
