How to check the arterial pulse

Rationale and key points

This How to module aims to help healthcare professionals to check the arterial pulse. It focuses on the radial pulse, and also briefly considers the brachial and carotid pulses. The arterial pulse provides information about the patient’s condition and is therefore a vital sign. Checking the pulse is an essential clinical skill for healthcare professionals.

• Palpating the pulse tells us the patient’s heart rate.
• It also provides information on the regularity, volume and character of the pulse.

Keywords

arterial pulse, clinical procedures, clinical skills, observations, pulse, signs and symptoms, vital signs

Learning objectives

After reading this module, you should be able to:

• Describe the arterial pulse.
• Identify the requirements and measures to be taken before and after checking the arterial pulse.
• Name the common sites for palpating the pulse.
• Describe methods to obtain a pulse rate.
• Identify the information obtained in the assessment of the pulse.

Preparation and equipment

• To check the arterial pulse, the following are required:
  • Facilities to wash your hands before and after contact with the patient.
  • Sight of a watch or clock with a second hand, for timing the pulse.
• After the pulse is checked, it should be recorded in the patient record as soon as possible, for example on their observation chart. This will allow comparison with other measurements.

Equipment

Procedure
Explain to the patient why you want to check the radial pulse, and gain their verbal consent to do so. If you need to check another pulse, explain this and gain consent.	In most cases you will want to check the resting pulse, in which case it is best to allow the patient sufficient time to recover after exertion or emotional upset.
Wash your hands before touching the patient, in line with your organisation’s infection control policy.	Figure 1 Using the first and second fingers of your hand, feel for the patient’s radial pulse. What we feel as we check the arterial pulse is not a bolus of blood in the artery, but the effects of the contraction of the heart on the wall of the artery at the pulse check site (Levick 2010). The radial pulse is usually easy to find if you palpate a few centimetres back from the tip of the base of the thumb, around a third of the way across the wrist (Figure 1).
Sometimes, you may not feel the pulse straightaway. Ensure you are pressing firmly enough on the patient’s wrist. If you still cannot feel the pulse, alter the location of your fingers slightly until you can feel it. In the unlikely event you still cannot feel the pulse, ask a colleague to check for you. If neither of you can feel the pulse, seek a medical review. This should be done urgently if additional signs of lack of blood flow such as cold or cyanosed fingers are present (Douglas et al 2013).	Check the pulse, once located, for long enough that you can determine whether it is regular or irregular. If it is irregular, attempt to determine if it is regularly irregular, which may be a heart block, regular ectopic beats or electrical alternans, or whether it is irregularly irregular, which is most likely to be atrial fibrillation. It is not possible to determine the cardiac rhythm from the pulse alone; therefore, if a new abnormality in the regularity of the pulse is found, an electrocardiogram is necessary to investigate this further. There can be slight variations in the regular rhythm depending on the respiratory cycle, as the heart slows during expiration.
Count how many beats occur in 1 minute to calculate the heart rate. Alternatively, you can count the beats in 30 seconds and double the number, or count for 15 seconds and quadruple the number. If you count for less time, there is a greater potential for error when the count is multiplied; therefore, it is good practice to count for 1 minute.	Attempt to feel the character and volume of the pulse. Character and volume are difficult to check at the radial site, but easier to determine at the brachial or carotid sites. The character of the pulse could be a normal up and down stroke, or the pulse might be prolonged, collapsing or jerky, which are usually linked to aortic valve problems. The volume of the pulse is not a direct measure of the stroke volume, but nonetheless informs you whether the pulse is normal, weak or abnormally strong.
If the patient has an irregular pulse, then it may be that not all the beats are being felt at the radial site. This is because if a beat is early it will have had a less forceful contraction, since the volume of blood in the left ventricle will have been smaller. If some beats are not felt at the radial site, then the heart rate will be underestimated. Therefore, if a patient has an irregular pulse at the radial site, it is good practice to check a brachial or carotid pulse, or feel or listen to the heart beat over the apex of the heart.	Figure 2 Figure 3 The pulse can be easily checked at the brachial and carotid arteries (Figures 2 and 3). The carotid artery is nearest to the heart and useful in emergencies, when peripheral arteries may not be palpable. The carotid and brachial arteries give the best information on the volume and character of the pulse. The carotid artery must not be checked if the patient is standing up, because of the risk of collapse. Both carotid arteries should not be palpated simultaneously.
Wash your hands after checking the pulse. Let the patient know you have finished so they can readjust their clothing as necessary. Record the results in the patient record immediately and follow your organisation’s policy for reporting abnormal findings and taking action, if required.