Vital Signs, Height, and Weight 357 What Is a Pulse? When you take (measure) a pulse, you are feeling or hearing the pressure of blood against the wall of an artery as the heart beats. Pulse is an important vital sign because it shows how well the cardiovascular system is working. It is very important if a resident has a heart or respiratory condition. Pulse Locations There are several locations in which an artery comes close enough to the surface of the skin that you can feel a pulse (Figure 16.14). These are the three pulses most commonly used: 1. Radial pulse: taken by feeling the radial artery located at the wrist (thumb side of the hand) on bare skin. Two fingers are gently placed on the radial artery to take the pulse. If a resident has an IV in one arm, do not use that arm when taking the pulse. 2. Apical pulse: taken by listening to the apical artery located at the apex of the heart. It is usually taken if radial pulse is difficult to count or if a resident is unconscious. This pulse is taken using a stethoscope, or a medical device for listening to sounds in the body through bare skin. Best Practice: Disposable gloves are worn only if required for infection prevention and control. 12. Position the resident comfortably. 13. Help or have the resident turn so that his forehead faces you. 14. Start the thermometer and wait until it shows it is ready. 15. Place the probe in the middle of the resident’s forehead (Figure 16.13A). Then slowly move the thermometer across the forehead toward the ear, stopping in front of the ear (Figure 16.13B). Figure 16.13 A B 16. Wait until you see or hear the signal that the temperature is complete. 17. Wash your hands or use hand sanitizer to ensure infection control. 18. Document the temperature on a pad, on a form, or in the electronic record. 19. If the resident is in bed, check to be sure the bed wheels are locked. Then reposition the resident and lower the bed. 20. Follow the plan of care to determine if the side rails should be raised or lowered. 21. Clean and store the temporal artery thermometer according to the facility policy. Follow-Up 22. Make sure the resident is comfortable and place the call light and personal items within reach. 23. Conduct a safety check before leaving the room. The room should be clean and free from clutter or spills. 24. Wash your hands or use hand sanitizer before leaving the room. Reporting and Documentation 25. Report any specific observations, complications, or unusual responses to the licensed nursing staff. Images courtesy of Wards Forest Media, LLC Carotid pulse Brachial pulse Radial pulse Radial pulse Apical pulse Temporal pulse Popliteal pulse (behind knee) Dorsalis pedis pulse Dorsalis pedis pulse Femoral pulse © Body Scientifi c International Figure 16.14 Pulse can be measured at all of the locations shown here. Copyright Goodheart-Willcox Co., Inc.