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Assessment of vital signs – Pulse rate

Authors: Veronika Rajki, PhD, Pál Bakó

The first set of clinical examinations is the evaluation of the patient's vital signs. Healthcare providers routinely take patients’ vital signs, which include:

Blood pressure
Pulse
Respiratory rate
Body temperature

Vital signs help identify or monitor health problems and can be measured in clinical settings, at home, at the scene of a medical emergency, or in virtually any environment. They are essential, particularly given the well-established morbidity and mortality associated with cardiovascular diseases.

When should we check vital signs?

At the admission of the patient.
At a physician's office visit.
Before and after surgical interventions.
Before and after any medical interventions.
Before and after applying medications that can affect the cardiovascular and respiratory system or thermoregulation.
If there is a change in the patient’s general health condition.
Nurse-performed interventions, both before and after, can affect vital signs.
If the patient reports non-specific symptoms in their general health.

Checking circulation

1. Taking a patient’s history can reveal risk factors for cardiovascular diseases.
2. Cardiovascular risk assessment and scoring are needed.
3. In specific cases, when further examinations are necessary.

1. Medical history

Several types of heart disease do not produce symptoms at the beginning and remain unnoticed.
Most frequent symptoms of heart diseases:

Chest pain or discomfort
Cyanosis, oedema, jugular vein distension, difficulty breathing
Palpitation
Transient loss of consciousness (syncope)
Gärtner sign – loss of hand circulation can occur with arms raised to heart level (except in heart failure).
The development, nourishment, physique, size of the extremities, the colour of the patient’s body, state and pulsation of the blood vessels, finger clubbing or “drumstick fingers.”

Taking a medical history involves the following:

Recording personal data:

Date of birth, sex, address, marital status, next of kin, phone number, profession, and religion.

Family health history:

A record of the diseases and health conditions in the patient’s family and relatives (people in their blood-related family who have or had a serious health condition).

Cause of medical care needed:

The main problems, complaints, and information are given either by the patient (auto-anamnesis) or by other people who know the person or caregivers who can provide suitable information (in this case, it is sometimes called hetero-anamnesis). It is essential to know when the complaint started (suddenly or gradually?) and how often it occurs, as well as for how long. Were there any triggering factors? Has the patient tried something to stop the problem recently or in the past, and has it helped?

Previous medical history:

Childhood diseases, immunisation, previous injuries and surgeries, blood type, allergies, and previous medications.

Social history:

Family connections and ethnic background (these might influence patient compliance).

Mother language: Ensure the patient understands all the provided information, including occupation/profession (current and past). Could this cause the underlying medical situation? Financial conditions (employment status): Can the patient allow possible lifestyle changes and provide therapies? Social support: Is the involvement of other specialists necessary in patient care?

Physical examinations:

Measurement of body weight, height, abdominal circumference, and blood pressure is always performed based on the patient's general condition.

Lab tests

A. total LDL and HDL cholesterol

B. triglyceride level

C. fasting blood glucose level

Individual risk factors

Smoking (coughing, sputum, chest pain, frequent pneumonia, bronchitis); dietary habits; physical inactivity.

In severe, life-threatening conditions such as circulatory arrest, priority is given to rapid intervention, and only after the patient’s state has been relatively stabilised can the detailed patient examination be performed.

2. Cardiovascular risk assessment and scoring

Waist circumference

It is beneficial for patients with a normal or overweight Body Mass Index (BMI).
It is measured at a point halfway between the bottom of the ribs and the top of the anterior superior iliac spine. Not at the navel level, but about 2–3 cm above the navel. It has to be measured in a relaxed state, in exhalation, using a tape measure, with an accuracy of 0.1 cm.

Abdominal obesity as risk factor

Subcutaneous
(SBC) fat

Visceral (VSC) fat

Rertoperitoneal (RTP) fat

Subcutaneous fat
(SBC)

Visceral fat
(VSC)

Retroperitoneal fat
(RTP)

Subcutaneous fat
(SBC)

Visceral (VSC)

Retroperitoneal fat
(RTP)

Low risk

Moderate risk

Severe risk

Illustration of the subcutaneous and visceral fat layer

Risk / very high risk*

In men: above 94 / 102 cm, in women: above 80 / 88 cm

Based on the recommendations of the National Cholesterol Education Program Adult Treatment Panel III (2001) and the International Diabetes Federation (IDF) (2005).

There are two main types of obesity: central and peripheral. The central type of obesity (android obesity) is characterised by fat accumulation in the body's central region, resulting in an apple-shaped body (fat accumulates mainly in the abdominal region). Regional adiposity, on the other hand, is when fat is collected around the midsection, such as in the chest, neck, and face. This type predisposes to heart disease, diabetes, and dyslipidaemia. In the peripheral (pear-shaped or gynoid) type, fat deposits are most prominent in the lower abdomen, buttocks, and thighs, often leading to aesthetic problems and joint and varicose vein complaints.

Apple and pear-shaped
pattern of body fat

Above the waits

Below the waits

The Framingham Risk Score is a sex-specific algorithm used to estimate an individual's 10-year cardiovascular risk.

Men

Women

Age

Score

Age

Score

Total cholesterol
(mmol/L)

Age

HDL ch.
(mmol/L)

Scores

HDL ch.
(mmol/L)

Scores

Non-smoker

Smoker

Syst RR
(mmHg)

Untreated

Treated

Total score

10-year
risk

Total score

10-year
risk

Age

Score

Age

Score

Total cholesterol
(mmol/L)

Age

Non-smoker

Smoker

HDL ch.
(mmol/L)

Scores

HDL ch.
(mmol/L)

Scores

Syst RR
(mmHg)

Untreated

Treated

Total score

10-year
risk

Total score

10-year
risk

The original SCORE model was developed for low-risk (Western European countries) and high-risk (Central and Eastern European countries) regions. SCORE risk tables or charts also show the probability of fatal cardiovascular events (coronary, cerebrovascular, and peripheral vascular events) within 10 years. It is recommended that the model be applied to the age group 40–65.

Women

Men

Non-smoker

Smoker

Non-smoker

Smoker

Non-smoker

Smoker

Non-smoker

Smoker

Systolic blood pressure (mmHg)

Age

1%
and lower

2%

3%-4%

5%-9%

10%-14%

15%
and higher

Cardiovascular risk within 10 years (fatal and non-fatal)

Total cholesterol status

Diabetic

Non-diabetic

Diabetic

1

2

3

4

5

3. Other tests

Inspection

Patient inspection is vital for assessing cardiac status. Still, in most cases, only the signs and symptoms of severe heart failure (dyspnea, cyanosis, oedema, bulging of the external jugular vein) can be easily detected.
However, signs and symptoms of pressure changes in the large vessels near the heart can help us diagnose.
In addition to palpating the arterial pulse, observing the internal jugular vein can provide information about the venous pulse.

Palpation

Palpation of the heart is relatively less critical.
Changes in places where heart sounds can be heard indicate an altered heart position.
In patients with chest complaints, especially young patients, we should also consider chest muscle and joint problems, as the complaint may result from a prior significant physical strain.
In such cases, detailed palpation of the chest muscles to identify tender or painful areas may provide more information about the patient’s condition.

Auscultation

This is one of the oldest and most frequently used examination types in cardiology.
The ability to accurately identify different heart sounds, among other things, helps to assess the patient's condition quickly and efficiently.
Listening to heart sounds occurs at specific points (listening points) for each part of the heart.

Heart sounds/Auscultatory areas (Punctum maximum)

Aortic valve/aortic area: The second right intercostal space near the upper sternal border (due to the aortic arch, it has to be examined on the right side).
Tricuspid valve/tricuspid area: in the 5th intercostal space at the border of the sternum.
To the left of the sternum at the 3rd and 4th costosternal articulation is the so-called Erb's point. (Mitral valve)
Pulmonary valve area: the second left intercostal space near the upper sternal border.
The apex of the heart or mitral valve area: in the fifth left intercostal space, 1–2 cm medially to the midclavicular line.
Epigastric region or tricuspid valve area: the fourth and fifth intercostal spaces near the lower sternal border.

A: aortic area (aortic auscultatory area)

P: pulmonary valve area (auscultatory area of the pulmonary valve)

E: Erb’s point (auscultatory area of the mitral valve)

T: tricuspid valve area (auscultatory area of the tricuspid valve)

M: mitral valve area (auscultatory area of the mitral valve)

Points of auscultation for the heart – POV

Cardiac percussion

Heart percussion can help estimate the patient’s heart size, borders, dislocation, and pericardial effusion.

This method helps approximate the heart’s position in the chest; however, it is not suitable for determining its actual size.

A pleximeter is a device used in medical percussion as part of a clinical examination that absorbs the energy generated by the strike from the plexor. During percussion, the middle finger of the examiner's hand is used as a pleximeter.

PC

PL

Carotid artery examination

Provides more information about the heart’s status than the peripheral vessels do.
These arteries deliver blood to the head and neck.
Generally, the patient's carotid artery is assessed while they are seated or with their head elevated.
Auscultation of the carotid artery can also be performed.
Palpate only one carotid artery at a time.

Examination of the jugular veins

The jugular venous examination is essential for assessing a patient's volume status.
The external jugular vein runs across the sternocleidomastoid muscle, directed toward the mandible.
Jugular veins are well visible when the patient is lying; however, they are not distended when the patient is lying with his head elevated.
Hepatojugular reflux: the distension of the neck veins precipitated by the manoeuvre of firm pressure over the liver.

Signs of peripheral circulatory failure

If arteries are affected, the following symptoms may occur:

cyanosis, pallor
pain, intermittent claudication, difficulty in walking
cold extremities
weak or absent pulse
leg cramps, numbness
thin, brittle, shiny skin, hair loss, thickened toenails
trophic changes, ulceration, gangrene

If veins are affected, the following symptoms may occur:

heavy or achy legs
paraesthesia
leg cramps (especially at night)
spider veins
along with varicose veins
normal or blue colourisation
tight sensation, swelling
oedema, leg swelling
thickened skin
hyperpigmentation, discolouration around the ankle
scars of healed ulcers, scarring without ulceration
leg ulcers (ulcus cruris)

The 5 P's of circulation assessment

Can you
move?

Not really.

You are
pale!

OUCH!

Do you feel
this?

Not really.

Pain

Pulse

Pallor

Paresthesia

Paralysis

Pulse

Paraesthesia

Pain

Pallor

Paralysis

Pulse check

A pulse is an intense throbbing felt over an artery in the body.
The number of times the heart beats per minute is the bpm.
Pulse can be central or peripheral.
Taking the patient's pulse is one of the oldest physical examination techniques.
It is an essential part of the general medical examination.
It can be easily performed.
It has a crucial role in cardiac examination.
Stroke volume = blood pumped from the left ventricle (60–70 mL) through the aortic valve.
Cardiac output = the blood volume the heart pumps per minute: pulse (number of ventricular contractions in 1 minute) x stroke volume = cardiac output.
Pulse wave = the speed at which the pulse wave travels through the arterial system, which depends on the flexibility and stiffness of the vessel. The blood creates the pulse wave pushed from the left ventricle into the aorta during a heart contraction.
Pulse rate, also known as heart rate, is the number of times the heart beats (periodic) per minute.
A pulse deficit occurs when the heart beats faster than the palpable pulse at the distal and apical pulses. That is, if the peripherally palpable pulse is less than the frequency of ventricular contractions heard with a stethoscope.
Heart rate reflects the work of the heart, the condition of blood vessels, and blood pressure.

Assessment of pulse deficit

Normal resting heart rate by age

Normal resting heart rate by age defined by the National Institutes of Health:

Age	Normal resting heart rate (bpm: beats per minute)
Neonate (28 days or younger)	70–190 bpm
Infant (1 month to 11 months)	80–160 bpm
Infant (1 to 2 years)	80–130 bpm
Infant (3 to 4 years)	80–120 bpm
Infant (5 to 6 years)	75–115 bpm
Infant (7 to 9 years)	70–110 bpm
Children older than 10 years, adults and elderly	60–100 bpm
Athletes	40–60 bpm

Average maximum heart rate for adults and the target heart rate zones by age (based on the American Heart Association's recommendations):

Age	Target heart rate zones	Average maximum heart rate
20 years	100–170 bpm	200 bpm
30 years	95–162 bpm	190 bpm
35 years	93–157 bpm	185 bpm
40 years	90–153 bpm	180 bpm
45 years	88–149 bpm	175 bpm
50 years	85–145 bpm	170 bpm
55 years	83–140 bpm	165 bpm
60 years	80–136 bpm	160 bpm
65 years	78–132 bpm	155 bpm
70 years	75–128 bpm	150 bpm

Factors affecting pulse rate

Age
Sex
Fitness or physical activity
Hormones
Temperature
Emotions
Medications
Bleeding, fluid loss (initially compensatory tachycardia, then bradycardia)
Change of posture or body position (before patient mobilisation, checking pulse and blood pressure is mandatory)
Pulmonary/cardiac factors
Stress
Pain
Coffee consumption and/or smoking

Quantitative characteristics of the pulse

Frequency:

Fast
Weak

Normocardia: in adults, when the pulse is between 60–100 bpm

Tachycardia: in adults, when the pulse is above 100 bpm

Causes:

Hypovolaemia – because of temporary compensatory mechanisms
High body temperature
Stress
Heart disease, heart failure, myocarditis, hyperthyroidism
Infection
Short physical activity
The acute phase of pain
Anxiety, stress
Positive chronotropes (e.g., atropine)
Bleeding (as a compensatory mechanism, sympathetic activity is enhanced)
Change in posture and/or position (standing, sitting)
Pulmonary factors (low oxygen level, compensatory mechanism)

Bradycardia: in adults when the pulse is below 60 bpm

Causes:

Increasing parasympathetic activity
Heart failure
Conduction disorder
Permanent physical exertion, competitive sports
Hypothermia
Lying down
Chronic severe pain (parasympathetic activation)
Relaxation
Negative chronotropes (e.g., digoxin)
Poisons
Increased intracranial pressure
Hypoxia

Qualitative characteristics of the pulse

Rhythm (regular/normal irregular/arrhythmic)

Regular
Irregular

Normal:

Bigeminy, trigeminy, quadrigeminy, extrasystoles

Irregular:

Extrasystole
Arrhythmia perpetua: complete and persistent irregularity in the magnitude and interval of pulse waves
Arrhythmia absoluta: irregular pulse in atrial fibrillation
Respiratory arrhythmia

Pulse force (strength or volume) or compressibility

Tension low tension pulse (pulsus mollis), the vessel is soft or impalpable between beats. In high tension pulse (pulsus durus), vessels feel rigid even between pulse beats.

Pulse amplitude

High or low
Changing in amplitude or inaequalis: uneven and unsteady pulse

Form

A quickly rising and quickly falling pulse (pulsus celer), a slow rising and slowly falling pulse (pulsus tardus)

Equality

Equal (aequalis)
Unequal (inaequalis)

Pulse measurement

By palpation: on any surface of the body where the artery can be pressed against a bony base (simple, quick method, but not continuous) → pulse points

Pulse points

Brachial artery

Radial
artery

Femoral
artery

Dorsalis pedis
artery

Carotid artery

Popliteal
artery

Posterior tibial
artery

Dorsalis pedis
artery

Pulse point	Area	When to choose this site?
temporal artery	It starts below the ear and runs vertically between the cheekbone and the ear.	In children it can be checked easily.
carotid artery	In the neck at the medial border of the sternocleidomastoid muscle.	If the patient is in shock this area is easily accessible even if other pulse points cannot be palpable.
apex of the heart	In the left medial clavicular line in the 4th or 5th intercostal space.	One of the heart sounds’ auscultation points.
brachial artery	The area of the antecubital fossa is between the biceps and triceps muscles.	An adequate location to assess the circulatory status of the forearm.
radial artery	On the forearm, close to the wrist, on the radial side, i.e., above the thumb, on the volar side.	A place to test peripheral pulse quality and circulation in the hand.
ulnar artery	In the forearm above the wrist on the ulnar side.	An adequate place to assess the circulatory status of the hand (Allen test).
femoral artery	It is located below the inguinal ligament, halfway between the pubic symphysis and the anterior superior iliac spine.	If the patient is in shock, this area is easily accessible, even if other pulse points cannot be palpable, to assess the circulatory status of the lower limb.
popliteal artery	Behind the knee in the popliteal fossa.	An adequate location to assess the circulatory status of the lower leg.
posterior tibial artery	Behind the medial malleolus (the bony prominence on the inside of the ankle).	An adequate location to assess the circulatory status of the foot.
dorsalis pedis artery	On the dorsum of the foot in the first intermetatarsal space, just lateral to the extensor tendon of the great toe.	To examine the circulation of the foot.

Place the tip of the index (first finger) and middle finger on the selected pulse point. The radial pulse is commonly measured using three fingers. Do not use your thumb because it has a pulse that you may feel.
The following can affect pulse check: surgery, injury, illness, and tight clothes.
Low or absent pulse: in atherosclerosis.

Devices for pulse measurement

Noninvasive: stethoscope, ECG, monitor, pulse oximeter, Holter monitor, ABPM, and pulse-doppler ultrasound. These devices were not primarily developed to measure pulses, but they can calculate them during use.
Invasive examination: invasive arterial blood pressure monitoring.

Taking the pulse

Determine the factors affecting the measurement.
Baseline: basal or resting pulse rate (obtained from the patient or from previous regular measurements). It is important to know this because, although there are generally accepted ranges for all parameters, these should be continually reassessed for each patient. For example, an athlete's heart rate of 45 beats per minute is within the normal range for a non-athletic, healthy person.
Providing information about the examiner, the examination's purpose, and the examination's steps.
Body position: in rest, sitting, or lying (in sitting to avoid muscle tension).
Counting up to 60 seconds with a device that can measure seconds.
In addition to the pulse rate, rhythm, and other parameters should be checked.
(Apical pulse rate measurement – pulse deficit, optional)
Documentation

Measuring pulse

A peripheral vascular examination

Abnormal arterial supply
Interfering factors: leg cramps, numbness, cold limbs, swelling, pain, diseases, risk factors.

To check blood flow, another functional, non-invasive test is the capillary refill time (CRT), which measures pulse. It is a valuable, rapid metric for determining intravascular volume status in ill patients, particularly those with conditions that arise or result from hypovolaemia. The performing examiner exerts manual pressure on the ventral surface of the distal phalanx of fingers or toes until the nailbed is blanched. This pressure is maintained for 10 seconds, then released. The time, in seconds, from the onset of reperfusion to the return of normal colour to the digit is the CRT. To avoid venous stasis, the test area (limb) should be at or above the level of the heart. The blood supply to the nail is very good, so in case of circulatory failure, it will turn pale quickly and then purple, providing information about the body as a whole. If pressure is applied to the nail bed briefly, it will turn white, but in healthy people, it will regain its original colour shortly. Suppose the reperfusion is prolonged (more than 2 seconds). In that case, it may indicate a circulatory problem (e.g., shock-reduced tissue perfusion, severe infection, hypovolaemia), severe organ dysfunction, or severe dehydration, so the expected value of capillary reperfusion time is 2 seconds. It is also important to note that a decrease in CRT might be due to a reduction in body temperature or ambient temperature.

Assessment of vital signs – Pulse rate

Authors: Veronika Rajki, PhD, Pál Bakó

Szakápolási feladatok szakmai követelménymodulhoz 55 723 01 OKJ számú Ápoló szakképesítéshez – Dr. Pápai Tibor 2017
Oláh András (szerk.): Az ápolástudomány tankönyve. Medicina Könyvkiadó Zrt, Budapest, 2012
Oláh András (szerk.): Beavatkozások digitális kézikönyve. Medicina Könyvkiadó Zrt, Budapest, 2015
Papp László (szerk.): Tanulási útmutató - Klinikai diagnosztika és döntéshozatal I. SZTE ETSZK Ápolási Tanszék, 2016
SCORE2-OP working group and ESC Cardiovascular risk collaboration, SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions, European Heart Journal, Volume 42, Issue 25, 1 July 2021, Pages 2455–2467,
Antal, Ilyés István, Jancsó, Nánási Anna, Somhegyi, Tamás, Vajer, Vásárhelyi: Kardiometabolikus rizikótenyezők - kardiovaszkuláris rizikóbecsles és kockázatbesorolás – rizikómenedzsment az alapellátásban. 2020
Radnai Balázs: Klinikai propedeutika Ápolás-betegellátás alapszakos hallgatók számára. 2011
Deb Hipp: Normal heart rate by age. 2022.
OMSZ Orvosszakmai Osztály Szakmai Munkacsoportja: Betegvizsgálat a prehospitális ellátásban. Szabványos Eljárásrend. 2020.
Fritúz Gábor: A veszélyeztetett állapotú páciens felismerése és menedzselése. Az ABCDE-gyorsvizsgálat. Csekklista kritikus állapotú páciens esetére. SBAR-segítséghívás / referálás Hatékony kommunikáció kritikus helyzetekben. SE AITK, 2014
Mentéstechnika. 2020.
Magyar Hypertonia Társaság szakmai irányelve – A hypertoniabetegség ellátásnak irányelvei 11., módosított, javított és kiegészített kiadás (2018)
Elizabeth Tenny: What does an ankle-brachial index (ABI) reveal and when is it indicated? 2021.
Oláh András, Fullér Noémi, Sziládiné Fusz Katalin: Vitális paraméterek. PTE ETK,
2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal (2018)
Cheng, Yibang; Li, Yan; Wang, Jiguang: Ambulatory blood pressure monitoring for the management of hypertension. Chinese Medical Journal. 2022
Jacob George, Thomas MacDonald: Home Blood Pressure Monitoring. Eur Cardiol., 2015
Sangita Thapa, Lokendra Bahadur Sapkota: Bacteriological assessment of stethoscopes used by healthcare workers in a tertiary care centre of Nepal. BMC Research Notes, 2017
Gabriele Messina, Sandra Burgassi, Daniele Messina, Valerio Montagnani, Gabriele Cevenini: A new UV-LED device for automatic disinfection of stethoscope membranes. American Journal of Infection Control, 2015
Measuring and Understanding the Ankle Brachial Index (ABI)
Szobota Lívia, Hirdi Henriett Éva: Boka-kar index mérés a foglalkozás-egészségügyi rendelőben. Nővér, 2021
Késmárky G., Koltai K., Biró K., Endrei D., Tóth K.: Alsó végtagi perifériás verőérbetegségek noninvazív diagnosztikája. Cardiologia Hungarica , 2018
Magyar Hypertonia Társaság szakmai irányelve – A hypertoniabetegség ellátásnak irányelvei 11., módosított, javított és kiegészített kiadás (2018)

Reference number: 630029

Mozaik Education, 2024

Kardiovaskulárny systém

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