Measuring Pulse and Respirations

The pulse is the wave of blood you can feel each time the heart beats. Respirations are breaths in and out. Both can change quickly when someone is sick, in pain or in danger, and they often change before blood pressure does. You can measure them with just your fingers, your eyes and a watch with a second hand.

What You Will Be Able to Do

• Find and count a radial pulse.
• Take an apical pulse with a stethoscope.
• Describe pulse rate, rhythm and strength.
• Count respirations without changing how the person breathes.
• Recognize patterns that need reporting.

Normal Ranges at Rest

Ranges for children vary by age and source, so use the ones in the care plan. Trained athletes may have a resting pulse in the 50s, and many medicines change the pulse too. Compare with what is normal for this person.

Two words you should know are bradycardia, a pulse under 60, and tachycardia, a pulse over 100 in a resting adult.

Taking a Radial Pulse

The radial pulse, on the thumb side of the wrist, is the site most often used for routine checks.

1. Clean your hands and explain what you are doing. Have the person rest for a few minutes.
2. Place the pads of your index and middle fingers on the inside of the wrist, just below the base of the thumb.
3. Press gently until you feel the beat. Pressing too hard can stop it.
4. Count for 60 seconds, starting with "one" on the first beat you feel. Many workplaces allow 30 seconds times two for a regular pulse. Count a full 60 seconds for any irregular or abnormal pulse.
5. Note the rate, the rhythm and the strength.

Warning: Never use your thumb to take a pulse. It has its own pulse, and you may count your own heartbeat instead of the patient's.

Rate, Rhythm and Strength

A good report says more than the number.

Do not try to name the rhythm or decide what is wrong. Simply document it as irregular and report it.

Taking an Apical Pulse

An apical pulse is taken over the heart with a stethoscope. It is often ordered for people with heart problems, those with an irregular pulse, infants and those taking certain heart medicines.

1. Clean the stethoscope's earpieces and diaphragm, and warm the diaphragm in your hand.
2. Provide privacy, and uncover only the left side of the chest.
3. Place the diaphragm at the fifth intercostal space on the midclavicular line, which is the space between the ribs on a line straight down from the middle of the collarbone. On many adults that is just below the left nipple.
4. Listen for the "lub-dub" and count each pair as one beat.
5. Count for a full 60 seconds.
6. Record it as apical. For example: "Apical pulse 76, irregular."

If the nurse asks you to compare radial and apical pulses, two people may count at the same moment. A difference between them, with the apical higher, needs to be reported.

Other Pulse Sites

Press on only one carotid at a time, and press lightly. Pressing both can reduce blood flow to the brain.

Counting Respirations

One respiration equals one breath in and one breath out. People change their breathing when they know you are watching, so count without announcing it.

1. Right after you finish the pulse, keep your fingers on the wrist as though you are still counting.
2. Watch the chest or stomach rise and fall.
3. Count for 60 seconds. Some employers allow 30 seconds times two when breathing is regular.
4. Note the rate, the depth, the rhythm and how hard the person is working to breathe.

Do not skip counting and write 18 by habit. A made-up number can hide a dangerous change.

What to Watch For

When to Report

Report right away:

• Adult resting pulse under 60 or over 100, unless the care plan gives other limits.
• A new irregular pulse, or a pulse that is very weak.
• Respirations under 12 or over 20 at rest, or labored, noisy or uneven breathing.
• Blue or gray lips, skin or nails.

Warning: Call 911 for severe trouble breathing, chest pain, a person who is unresponsive or a person who cannot speak in full sentences because they are out of breath.

Common Mistakes

Check Your Understanding

1. As you count, the beats come in a rhythm that keeps changing, with a few pauses. How do you handle it?

Count for a full 60 seconds, document it as irregular and report it. Do not guess the cause.

2. How can you count respirations without the person noticing?

Keep your fingers on the wrist after counting the pulse, and watch the chest rise and fall.

3. A resting adult's radial pulse is 118. Is that normal?

No. It is over 100, so it is tachycardia. Recheck it, note how they look and report it to the nurse.

4. A nurse asks you to count a resident's heartbeat directly over the heart. Where does the stethoscope go?

On the left side of the chest, at the fifth intercostal space on the midclavicular line, often just below the left nipple.

Key Takeaways

• Adult pulse at rest is 60 to 100, and respirations are 12 to 20.
• Use two fingers, not your thumb, for a radial pulse.
• Describe rate, rhythm and strength.
• An apical pulse is counted for a full 60 seconds at the fifth intercostal space.
• Count breaths quietly, because people change their breathing when watched.
• Blue lips or severe trouble breathing means call 911.