Measurement of heart rate through the pulse in the arteries.
Objectives:
– To assess pulse rate, rhythm and volume. – To assess blood flow in a given area.
Equipment:
– Watch with second hand. – Stethoscope. – Blue pen.
Material:
– Nursing records.
Procedure:
– Perform hand washing. – Prepare the material. – Check the correct functioning of the stethoscope. – Preserve the patient’s privacy. – Inform the patient. – Request the collaboration of the patient and family. – Before measuring the heart rate, make sure that the patient has not performed any significant physical or emotional activity. If so, let the patient rest for 5-10 minutes before measuring.
– Provide a quiet and comfortable environment. – Choose the site or artery for the measurement: radial, apical, femoral or other peripheral pulses. – If apical pulse: place phonendoscope over cardiac apex: 5th left intercostal space and mid-clavicular line (adults), 4th left intercostal space and mid-clavicular line (children up to 4 years). – If palpation of an artery, place the 2nd and 3rd fingers (index and middle) on the chosen artery (preferably the radial artery), pressing lightly. – Count the pulsations for one minute. – Record in the nursing documentation with blue pen: number of pulsations, rhythm, intensity and time.
Observations:
– If there is any significant alteration in the first measurement, look for another artery and compare if they are symmetrical and of equal heart rate. – The apical pulse gives a more accurate assessment of heart rate and rhythm. – Do not use the thumb in the measurement, as it has its own beat. Characteristics to be assessed: Heart rate: no. of heartbeats that occur in one minute 2. Normal values:
AGE BEATS PER MINUTE Newborn 120-170 Young infant 120-160 Older infant 110-130 Children 2 to 4 years 100-120 Children 6-8 years 100-115 Adult 60-80
2. Rhythm: the normal rhythm is regular. 3. If the rate is lower than normal it is called bradycardia and if it is higher, it is called tachycardia. 4. Quality or amplitude: intensity or strength of the pulse. We speak of normal amplitude when the pulse is easily palpable, does not disappear intermittently and all pulses are symmetrical.
Commenti