Download Patient Assessment VS Pulse - Los Angeles County Fire Department

EMS SKILL
PATIENT ASSESSMENT / VITAL SIGNS
PULSE
PERFORMANCE OBJECTIVES
Demonstrate competency in performing an accurate pulse assessment.
CONDITION
Perform an accurate pulse assessment for the primary and secondary assessment. The examiner assesses the opposite radial or brachial
pulse to determine the accuracy of the assessment. Necessary equipment will be adjacent to the patient or brought to the field setting.
EQUIPMENT
Live model, timing device, stethoscope, goggles, mask, gown, gloves.
PERFORMANCE CRITERIA
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Items designated by a diamond () must be performed successfully to demonstrate skill competency.
Items identified by double asterisks (**) indicate actions that are required if indicated.
Items identified by (§) are not skill component items, but should be practiced.
Reading must be within +/- 4 beats/minute of examiner’s determination.
PREPARATION
Skill Component
Key Concepts
 Take body substance isolation precautions
 Mandatory (minimal) personal protective equipment – gloves
§ Locate the most common arterial points:
 Students should be able to locate and palpate all major arterial
points.
 Peripheral
- brachial
- radial
- ulnar
- popliteal
- tibial (posterior tibial)
- pedal (dorsalis pedis)
 An auscultated apical pulse should be taken on pediatric patients,
trauma patients with no detectable pulse, and on patients who are to
be pronounced dead in the field.
 Central pulses should be palpated if unable to palpate peripheral
pulses.
 If patient is critical, peripheral and central pulses should be palpated
simultaneously.
 Central
- carotid
- femoral
- apical
 Palpate pulse with 2 fingers. DO NOT use thumb to palpate due to
the possibility of feeling one’s own pulse.
 Femoral pulses are palpated in the inguinal fold - avoid inference of
impropriety.
 Pedal pulses (10-15%) are often difficult to find. Check other signs
of circulation. Mark pulses with an AX@ if located.
PRIMARY ASSESSMENT
Skill Component
Key Concepts
 Assess pulse:
 Rate (normal, fast, slow)
 Rhythm (regularity)
 Quality (strength)
 Rate - determine if fast or slow. The actual beats per minute are
not counted during the primary assessment.
** Consider cardiac monitor - if pulse is irregular
- regular rhythm - consistent interval between beats
- irregular rhythm - a beat may be early, late or missed. The
rhythm may be either regularly-irregular or irregularly-irregular.
* All irregular rhythms are abnormal rhythms.
 Quality (strength) - determines the feel of the pulse and described
as: strong (normal), full or bounding (stronger than normal), weak
or thready (difficult to feel).
Patient Assessment – Vital Signs – Pulse
 Rhythm (regularity) - heart rhythm may be either regular or
irregular.
© 2013, 2010, 2009, 2002
Page 1 of 3
SECONDARY ASSESSMENT
Skill Component
Key Concepts
 Assess pulse:
 Rate (beats/minute)
 Rhythm (regularity)
 Quality (strength)
 Rate can be calculated by counting for 30 seconds and
multiplying by 2.
- A 15 second count may be inaccurate and irregular rhythms
may be missed.
- A 6 second pulse count is NOT acceptable due to inaccuracy of
the count, missing irregular rhythms and mathematical errors.
** Consider cardiac monitor - if pulse is irregular
 An irregular pulse should be counted for 1 full minute.
 DO NOT rely on monitor rate indicator. The monitor may pick up
various wave forms and count as a pulse if the gain is too high or
may not pick up the pulse if the gain is too low.
REASSESSMENT
(Ongoing Assessment)
Skill Component
Key Concepts
§ Repeat pulse assessment:
 Every 5 minutes for priority patients
 Every 15 minutes for stable patients
' Re-assess pulse:
 Rate (beats/minute)
 Rhythm (regularity)
 Quality (strength)
** Consider cardiac monitor - if pulse is irregular
PATIENT REPORT AND DOCUMENTATION
Skill Component
Key Concepts
 If patient is placed on a monitor, run at least two (2) 6 second strips
and attach one strip to the provider copy and one strip to the
receiving copy of the EMS form.
§ Verbalize/Document:
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Rate (beats/minute)
Rhythm (regularity)
Quality (strength)
ECG reading - if applicable
 If the monitor is applied, document the palpated pulse and the pulse
rate on the monitor. DO NOT rely just on the monitor read out .
 Documentation must be on either the Los Angeles County EMS
Report form or departmental Patient Care Record form.
Developed: 3/02 Revised 12/09, 1/13
Patient Assessment – Vital Signs – Pulse
© 2013, 2010, 2009, 2002
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PATIENT ASSESSMENT / VITAL SIGNS
PULSE
Supplemental Information
DEFINITIONS:

Rate - number of heart beats per minute:
- Initial assessment - determine if fast or slow, rate is not counted during the initial assessment
- Focused/Ongoing assessment - rate can be calculated by counting for 30 seconds and multiplying by 2
- A 6 second pulse count is NOT acceptable due to inaccuracy of the count and mathematical errors
- A 15 second pulse count should not be used due to missing an irregular rhythm that may be present

Rhythm (regularity) - heart rhythm may be either regular or irregular. The rhythm may be either regularly-irregular or irregularly-irregular.
- Regular rhythm - consistent interval between beats
- Irregular rhythm - a beat may be early, late or missed. An irregular pulse should be counted for 1 full minute.
* All irregular rhythms are considered abnormal rhythms until proven otherwise. The young and athletes have commonly
regularly-irregular pulses as a normal event called sinus arrhythmia. Pulse accelerates with inspiration and slows with expiration.

Quality (strength) - determines the feel of the pulse and described as: strong, full or bounding, weak or thready
Note:

10-15% of pedal pulses are difficult to find. Check other signs of circulation. Mark pulses with an “X” if located.
Normal Pulse Rate
Adult
Adolescent
11-14 years
School Age
6-10 years
Preschool
3-5 years
Toddler
1-3 years
Infant
6-12 months
Infant
0-5 months
Newborn
(Neonate)
0-28 days
Pulse Quality/Strength
Palpated Pulse in Relation to Blood Pressure
60-100
Strong
normal
Adult blood pressures
60-105
Full/bounding
stronger than normal
Radial
Weak/thready
difficult to feel
Brachial approximately > 70 Systolic
70-110
approximately > 80 Systolic
Femoral approximately > 70 Systolic
80-120
Carotid
approximately > 60 Systolic
80-130
(pressure is lost in the order indicated -- from radial
to the carotid pulse)
80-140
90-140
120-140
COMMON CAUSES OF ABNORMAL PULSE RATE OR RHYTHM
Tachycardia
Exercise
Hypoxia
Fever
Infection
Hypovolemia
Hyperthyroidism
Emotional upset
Stimulating drugs/medications
Myocardial infarction
Pain
Hyperthermia
Bradycardia
Heart disease
Organophosphates
Calcium channel or beta blocking agents
Vagal response
Myocardial infarction
Pain
Intracranial pressure
CNS depressing drugs/medications
Athletic conditioning
Hypothermia
Patient Assessment – Vital Signs – Pulse
© 2013, 2010, 2009, 2002
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Irregular Rhythm
Electrolyte imbalance
Conduction defects
Cardiac damage (MI)
Drug/Chemical ingestion or exposure
Medications
Hypoxia
Abnormal body temperature