((22))PulsePulse

VitalVital signssigns

Dr. Karima ElshamyDr. Karima Elshamy

Faculty of NursingFaculty of Nursing

Mansoura UniversityMansoura UniversityEgypt Egypt

Learning objectives:Learning objectives: --

At the end of this lecture the student should be At the end of this lecture the student should be able to: able to:

1.1. Explain the anatomy and physiology of Explain the anatomy and physiology of circulatory system. circulatory system.

2.2. Define pulse. Define pulse.

3.3. Define blood pressure.Define blood pressure.

4.4. Explain factors controlling blood pressure. Explain factors controlling blood pressure.

5.5. Mention the common sites for palpating pulse.Mention the common sites for palpating pulse.

6.6. Describe assessment of normal and Describe assessment of normal and abnormal pulse rate, rhythm, volumeabnormal pulse rate, rhythm, volumeand force.and force.

7.7. Explain how to record and report pulse.Explain how to record and report pulse.

Anatomy and Physiology of the Anatomy and Physiology of the Circulatory SystemCirculatory System

The human heart is a fourThe human heart is a four --chambered chambered muscular organ, shaped and sized muscular organ, shaped and sized roughly like a man's closed fist with roughly like a man's closed fist with twotwo --thirds of the mass to the left of thirds of the mass to the left of midlinemidline . .

The heart is enclosed in a pericardial sac The heart is enclosed in a pericardial sac that is lined with the parietal layers of a that is lined with the parietal layers of a serous membraneserous membrane. .

The visceral layer of the serous membrane The visceral layer of the serous membrane forms the epicardiumforms the epicardium. .

Layers of the Heart WallLayers of the Heart Wall

Three layers of tissue form the heart wall.Three layers of tissue form the heart wall.

1.1. Epicardium :the outer layer of the heart wallEpicardium :the outer layer of the heart wall

2.2. The myocardium is the middle layer, and The myocardium is the middle layer, and

3.3. The endocardium is the inner layer.The endocardium is the inner layer.

Chambers of the HeartChambers of the Heart

The internal cavity of the heart is divided The internal cavity of the heart is divided into four chambers:into four chambers:

1.1. Right atrium Right atrium 2.2. Right ventricle Right ventricle 3.3. Left atrium Left atrium 4.4. Left ventricle Left ventricle

The two atria are thinThe two atria are thin --walled chambers that walled chambers that receive blood from the veinsreceive blood from the veins . .

The two ventricles are thickThe two ventricles are thick --walled chambers walled chambers that forcefully pump blood out of the heartthat forcefully pump blood out of the heart . .

Differences in thickness of the heart Differences in thickness of the heart chamber walls are due to variations in the chamber walls are due to variations in the amount of myocardium present, which amount of myocardium present, which reflects the amount of force each chamber is reflects the amount of force each chamber is required to generaterequired to generate ..

The right atrium receives deoxygenated The right atrium receives deoxygenated blood from systemic veins; the left atrium blood from systemic veins; the left atrium receives oxygenated blood from the receives oxygenated blood from the pulmonary veins.pulmonary veins.

Valves of the HeartValves of the Heart

Pumps need a set of valves to keep the fluid Pumps need a set of valves to keep the fluid flowing in one direction and the heart is no flowing in one direction and the heart is no exception.exception.

The heart has two types of valves that keep the The heart has two types of valves that keep the blood flowing in the correct direction. blood flowing in the correct direction.

The valves between the atria and ventricles are The valves between the atria and ventricles are called called atrioventricularatrioventricular valves (also called valves (also called cuspidcuspidvalves), while those at the bases of the large valves), while those at the bases of the large vessels leaving the ventricles are called vessels leaving the ventricles are called semilunarsemilunar valves. valves.

The right The right atrioventricularatrioventricular valve is the tricuspid valve is the tricuspid valvevalve..

The left The left atrioventricularatrioventricular valve is the bicuspid, or valve is the bicuspid, or mitralmitral, valve, valve. .

The valve between the right ventricle and The valve between the right ventricle and pulmonary trunk is the pulmonary pulmonary trunk is the pulmonary semilunarsemilunarvalvevalve. .

The valve between the left ventricle and the The valve between the left ventricle and the aorta is the aortic aorta is the aortic semilunarsemilunar valvevalve..

When the ventricles contract, When the ventricles contract, atrioventricularatrioventricular valves close to prevent valves close to prevent blood from flowing back into the atriablood from flowing back into the atria ..

When the ventricles relax, When the ventricles relax, semilunarsemilunarvalves close to prevent blood from valves close to prevent blood from flowing back into the ventriclesflowing back into the ventricles ..

Pathway of Blood through the HeartPathway of Blood through the Heart

While it is convenient to describe the flow of blood While it is convenient to describe the flow of blood through the right side of the heart and then through the through the right side of the heart and then through the left side, it is important to realize that both atria contract left side, it is important to realize that both atria contract at the same time and both ventricles contract at the at the same time and both ventricles contract at the same time. same time.

The heart works as two pumps, one on the right and one The heart works as two pumps, one on the right and one on the left, working simultaneously. on the left, working simultaneously.

Blood flows from the right atrium to the right ventricle, Blood flows from the right atrium to the right ventricle, and then is pumped to the lungs to receive oxygen. and then is pumped to the lungs to receive oxygen.

From the lungs, the blood flows to the left atrium, then to From the lungs, the blood flows to the left atrium, then to the left ventricle. From there it is pumped to the systemic the left ventricle. From there it is pumped to the systemic circulation. circulation.

Blood Supply to the MyocardiumBlood Supply to the Myocardium

The myocardium of the heart wall is a working muscle The myocardium of the heart wall is a working muscle that needs a continuous supply of oxygen and nutrients that needs a continuous supply of oxygen and nutrients to function with efficiency. For this reason, cardiac to function with efficiency. For this reason, cardiac muscle has an extensive network of blood vessels to muscle has an extensive network of blood vessels to bring oxygen to the contracting cells and to remove bring oxygen to the contracting cells and to remove waste products. waste products.

The right and left coronary arteries, branches of the The right and left coronary arteries, branches of the ascending aorta, supply blood to the walls of the ascending aorta, supply blood to the walls of the myocardium. After blood passes through the capillaries myocardium. After blood passes through the capillaries in the myocardium, it enters a system of cardiac in the myocardium, it enters a system of cardiac (coronary) veins. (coronary) veins.

Most of the cardiac veins drain into the coronary sinus, Most of the cardiac veins drain into the coronary sinus, which opens into the right atrium. which opens into the right atrium.

Physiology of the HeartPhysiology of the Heart

The work of the heart is to pump blood to The work of the heart is to pump blood to the lungs through pulmonary circulation the lungs through pulmonary circulation and to the rest of the body through and to the rest of the body through systemic circulationsystemic circulation. .

This is accomplished by systematic This is accomplished by systematic contraction and relaxation of the cardiac contraction and relaxation of the cardiac muscle in the myocardiummuscle in the myocardium. .

Conduction SystemConduction System

An effective cycle for productive pumping of An effective cycle for productive pumping of blood requires that the heart be synchronized blood requires that the heart be synchronized accurately.accurately.

Both atria need to contract simultaneously, Both atria need to contract simultaneously, followed by contraction of both ventricles. followed by contraction of both ventricles.

Specialized cardiac muscle cells that make up Specialized cardiac muscle cells that make up the conduction system of the heart coordinate the conduction system of the heart coordinate contraction of the chambers. contraction of the chambers.

The conduction system includes several The conduction system includes several componentscomponents ..

The first part of the conduction system is the The first part of the conduction system is the sinoatrialsinoatrial node . Without any neural stimulation, node . Without any neural stimulation, the the sinoatrialsinoatrial node rhythmically initiates node rhythmically initiates impulses 70 to 80 times per minute.impulses 70 to 80 times per minute.

Because it establishes the basic rhythm of the Because it establishes the basic rhythm of the heartbeat, it is called the pacemaker of the heartbeat, it is called the pacemaker of the heart. heart.

Other parts of the conduction system Other parts of the conduction system include the include the atrioventricularatrioventricular node, node, atrioventricularatrioventricular bundle, bundle branches, bundle, bundle branches, and conduction and conduction myofibersmyofibers. .

All these components coordinate the All these components coordinate the contraction and relaxation of the heart contraction and relaxation of the heart chamberschambers. .

Cardiac CycleCardiac Cycle

The cardiac cycle refers to the alternating The cardiac cycle refers to the alternating contraction and relaxation of the myocardium in contraction and relaxation of the myocardium in the walls of the heart chambers, coordinated by the walls of the heart chambers, coordinated by the conduction system, during one heartbeat. the conduction system, during one heartbeat.

Systole is the contraction phase of the cardiac Systole is the contraction phase of the cardiac cycle, and diastole is the relaxation phase. cycle, and diastole is the relaxation phase.

At a normal heart rate, one cardiac cycle lasts At a normal heart rate, one cardiac cycle lasts for 0.8 second. for 0.8 second.

Heart SoundsHeart Sounds

The sounds associated with the heartbeat The sounds associated with the heartbeat are due to vibrations in the tissues and are due to vibrations in the tissues and blood caused by closure of the valves. blood caused by closure of the valves.

Abnormal heart sounds are called Abnormal heart sounds are called murmurs. murmurs.

Heart RateHeart Rate

The The sinoatrialsinoatrial node, acting alone, produces a constant rhythmic node, acting alone, produces a constant rhythmic heart rate. heart rate.

Regulating factors are reliant on the Regulating factors are reliant on the atrioventricularatrioventricular node to increase node to increase or decrease the heart rate to adjust cardiac output to meet the or decrease the heart rate to adjust cardiac output to meet the changing needs of the body. changing needs of the body.

Most changes in the heart rate are mediated through the cardiac Most changes in the heart rate are mediated through the cardiac center in the medulla oblongata of the brain.center in the medulla oblongata of the brain.

The center has both sympathetic and parasympathetic components The center has both sympathetic and parasympathetic components that adjust the heart rate to meet the changing needs of the bodthat adjust the heart rate to meet the changing needs of the body. y.

Peripheral factors such as emotions, ion concentrations, and bodPeripheral factors such as emotions, ion concentrations, and body y temperature may affect heart rate. temperature may affect heart rate.

These are usually mediated through the cardiac center.These are usually mediated through the cardiac center.

Definition of pulseDefinition of pulse

An alternate expansion and recoil of an An alternate expansion and recoil of an artery as the wave of blood is forced through artery as the wave of blood is forced through it by the contraction of the left ventricle. it by the contraction of the left ventricle.

It is felt by palpating a superficial artery that It is felt by palpating a superficial artery that has a bone behind it.has a bone behind it.

Counting pulse is an indirect measure to Counting pulse is an indirect measure to assess heart rate.assess heart rate.

Normally pulse rate is equal to heart rate.Normally pulse rate is equal to heart rate.

Common sites for palpating the pulseCommon sites for palpating the pulse

1.1. Radial Artery: At the wrist, is the most commonly Radial Artery: At the wrist, is the most commonly used for palpating the pulse rate, because it is used for palpating the pulse rate, because it is easily accessible and it can pressed against theeasily accessible and it can pressed against theradius bone.radius bone.

2.2. The superficial temporal artery, in the temporal The superficial temporal artery, in the temporal region.region.

3.3. The external carotid artery, in the neck.The external carotid artery, in the neck.

4.4. The The subclaviansubclavian artery behind the inner end of the artery behind the inner end of the clavicle against theclavicle against thefirst rib.first rib.

1.1. The facial artery, about an inch forward of the The facial artery, about an inch forward of the angle of the jaw.angle of the jaw.

1.1. The internal maxillary artery, in front of and The internal maxillary artery, in front of and slightly below the ear.slightly below the ear.

1.1. The brachial artery, on the inner aspect of the The brachial artery, on the inner aspect of the upper arm, about halfway between the upper arm, about halfway between the shoulder and the elbow.shoulder and the elbow.

1.1. The femoral artery, in the mid The femoral artery, in the mid -- groin.groin.2.2. The The poplitealpopliteal artery, behind the knee.artery, behind the knee.3.3. The The dorsalisdorsalis pedispedis artery, below the ankle on artery, below the ankle on

the dorsum of the foot.the dorsum of the foot.

Apical PulseApical Pulse

A more accurate estimate of the heart A more accurate estimate of the heart beat, per minute.beat, per minute.

It is obtained by listening with a It is obtained by listening with a stethoscope over the apex of the heart, stethoscope over the apex of the heart, between fifth and sixth rib about 3 inches between fifth and sixth rib about 3 inches (8 cm) to the left of the median line and (8 cm) to the left of the median line and slightly below the nipple.slightly below the nipple.

Assessment of Pulse;Assessment of Pulse;

II-- Pulse is assessed according to rate 60 Pulse is assessed according to rate 60 --90 beat/minute, (90 beat/minute, (b/mb/m).).

Abnormalities of Pulse Rate:Abnormalities of Pulse Rate:

aa-- Tachycardia:Tachycardia: The pulse rate is abnormally The pulse rate is abnormally rapid.rapid.

An adult is considered to have tachycardia An adult is considered to have tachycardia when his pulse rate is 100 beat/m. or when his pulse rate is 100 beat/m. or more, more,

bb-- Bradycardia:Bradycardia: The pulse rate is abnormally The pulse rate is abnormally slow and below 60 beat/m.slow and below 60 beat/m.

Rhythm of pulse:Rhythm of pulse:refers to the pattern of beats (the interval between each refers to the pattern of beats (the interval between each

beat should be identical). Rhythm of pulse: means that beat should be identical). Rhythm of pulse: means that beats are identical in force and separated by equal beats are identical in force and separated by equal intervals.intervals.

Abnormalities in pulse Rhythm:Abnormalities in pulse Rhythm:--

An irregular pulse rhythm is called arrhythmias.An irregular pulse rhythm is called arrhythmias.aa-- Intermittent pulse: a type of irregular pulse where a beat dropIntermittent pulse: a type of irregular pulse where a beat dropped ped

either irregular or regular i.e. each 4 beats there is a droppedeither irregular or regular i.e. each 4 beats there is a dropped beat or beat or in the form of periods of normal rhythm broken by periods of in the form of periods of normal rhythm broken by periods of abnormal rhythm. abnormal rhythm.

bb-- BigeminalBigeminal; ; It consists of two regular beats followed by a longer than It consists of two regular beats followed by a longer than normal pause with no beat, and then two regular beats again normal pause with no beat, and then two regular beats again followed by a pause.followed by a pause.

Common sites Common sites for palpating the for palpating the

pulsepulse

1.1. Axillary pulseAxillary pulse : located inferiorly of the : located inferiorly of the lateral wall of the axilla lateral wall of the axilla

2.2. Brachial pulseBrachial pulse : located on the inside of : located on the inside of the upper arm near the elbow, frequently the upper arm near the elbow, frequently used in place of carotid pulse in infants used in place of carotid pulse in infants ((brachial arterybrachial artery) )

3.3. Radial pulseRadial pulse : located on the lateral of : located on the lateral of the wrist (the wrist (radial arteryradial artery). It can also be ). It can also be found in the found in the anatomical snuff boxanatomical snuff box. .

Upper limbUpper limb

5.5. Ulnar pulseUlnar pulse : located on the medial of the : located on the medial of the wrist (wrist (ulnar arteryulnar artery). ).

6.6. Front of right upper extremity :Front of right upper extremity :ChineseChinesemedicine has focused on the pulse in the medicine has focused on the pulse in the upper limbs for several centuries. upper limbs for several centuries.

7.7. The concept of The concept of Pulse DiagnosisPulse Diagnosis is is essentially a treatise based upon essentially a treatise based upon palpation and observations of the radial palpation and observations of the radial and and ulnarulnar volarvolar pulses at the readily pulses at the readily accessible wrist.accessible wrist.

Lower limbLower limb

1.1. Femoral pulseFemoral pulse : located in the inner thigh, at the mid: located in the inner thigh, at the mid--inguinal inguinal point, halfway between the pubic symphysis and anterior superiorpoint, halfway between the pubic symphysis and anterior superioriliac spine (iliac spine (femoral arteryfemoral artery).).

2.2. Popliteal pulsePopliteal pulse : Above the knee in the popliteal fossa, found by : Above the knee in the popliteal fossa, found by holding the bent knee. The patient bends the knee at holding the bent knee. The patient bends the knee at approximately 124approximately 124°°, and the physician holds it in both hands to , and the physician holds it in both hands to find the popliteal artery in the pit behind the knee (find the popliteal artery in the pit behind the knee (Popliteal Popliteal arteryartery). ).

3.3. Dorsalis pedis pulseDorsalis pedis pulse : located on top of the foot, immediately : located on top of the foot, immediately lateral to the extensor of hallucis longus (lateral to the extensor of hallucis longus (dorsalis pedis arterydorsalis pedis artery). ).

4.4. Tibialis posterior pulseTibialis posterior pulse : located on the medial side of the ankle, : located on the medial side of the ankle, 22 cm inferior and 2cm inferior and 2 cm posterior to the medial malleolus (cm posterior to the medial malleolus (posterior posterior tibial arterytibial artery). It is easily palpable over ). It is easily palpable over Pimenta's PointPimenta's Point. .

Head/neckHead/neckCarotid pulseCarotid pulse : located in the neck (: located in the neck (carotid arterycarotid artery). The ). The carotid artery should be palpated gently and while the carotid artery should be palpated gently and while the patient is sitting or lying down. Stimulating its patient is sitting or lying down. Stimulating its baroreceptors with low palpitation can provoke severe baroreceptors with low palpitation can provoke severe bradycardiabradycardia or even stop the heart in some sensitive or even stop the heart in some sensitive persons. Also, a person's two carotid arteries should not persons. Also, a person's two carotid arteries should not be palpated at the same time. Doing so may limit the be palpated at the same time. Doing so may limit the flow of blood to the head, possibly leading to flow of blood to the head, possibly leading to faintingfainting or or brain brain ischemiaischemia. It can be felt between the anterior border . It can be felt between the anterior border of the sternocleidomastoid muscle, above the hyoid bone of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage. and lateral to the thyroid cartilage. Facial pulseFacial pulse : located on the mandible (lower jawbone) : located on the mandible (lower jawbone) on a line with the corners of the mouth (on a line with the corners of the mouth (facial arteryfacial artery). ). Temporal pulseTemporal pulse : located on the : located on the templetemple directly in front directly in front of the ear (of the ear (superficial temporal arterysuperficial temporal artery).).

Pulse RatePulse Rate

Pulse rate is the number of contractions over Pulse rate is the number of contractions over a peripheral artery in 1 minute.a peripheral artery in 1 minute.

Regulated by the autonomic nervous system Regulated by the autonomic nervous system through cardiac through cardiac sinoatrialsinoatrial nodenode

Parasympathetic stimulation Parasympathetic stimulation -- decrease heart decrease heart raterate

Sympathetic stimulation Sympathetic stimulation -- increases heart rateincreases heart rate

The normalThe normal heart rate in adult is heart rate in adult is

( 60 ( 60 –– 100 beat/min.)100 beat/min.)

TachycardiaTachycardia : is a rapid pulse rate , : is a rapid pulse rate ,

greater than 100 beat /min.greater than 100 beat /min.

BradycardiaBradycardia : is a pulse rate below : is a pulse rate below

60 beats / min. in adults.60 beats / min. in adults.

Factors Contribute to Increase Factors Contribute to Increase

Pulse RatePulse Rate

Pain.Pain.

Fever.Fever.

Stress.Stress.

Exercise .Exercise .

Bleeding.Bleeding.

Decrease in blood pressure .Decrease in blood pressure .

Some medications as (adrenalin, Some medications as (adrenalin,

aminophylline)aminophylline)

Age; as age increases, the pulse rate gradually Age; as age increases, the pulse rate gradually decreases.decreases.

Exercise; the pulse rate normally increase with Exercise; the pulse rate normally increase with activityactivity

Fever; the pulse rate increases in response to the Fever; the pulse rate increases in response to the lowered blood pressure that results from peripheral lowered blood pressure that results from peripheral vasodilatation associated with elevated temperature vasodilatation associated with elevated temperature and because of the increased metabolic rate.and because of the increased metabolic rate.

Factors May Slow The PulseFactors May Slow The Pulse

Rest .Rest .

Increasing age.Increasing age.

People with thin body size .People with thin body size .

Medication as ( digitalis ).Medication as ( digitalis ).

Thyroid gland disturbances . Thyroid gland disturbances .

PULSE SITES PULSE SITES

Temporal pulseTemporal pulseCarotid pulse Carotid pulse Brachial pulseBrachial pulseRadial pulseRadial pulseFemoral pulseFemoral pulsePopliteal pulsePopliteal pulsePosterior tibial pulsePosterior tibial pulseDorsalis pulse.Dorsalis pulse.Auscultation apical pulse with stethoscopeAuscultation apical pulse with stethoscope

Normal Pulse Per Minute At Various Normal Pulse Per Minute At Various

AgeAge

808060 60 -- 100100Adolescence to adult Adolescence to adult

959575 75 –– 1101106 year 6 year -- 12 year 12 year

10010075 75 –– 1201202 year 2 year -- 6 year6 year

11011080 80 –– 13013012 months 12 months –– 2 year2 yearss

12012080 80 –– 1401401 month 1 month -- 12 months12 months

140140120 120 –– 160160NewbornNewborn–– 11

monthmonth

AverageAverageRangeRangeAgeAge

Pulse RatePulse Rate

The normal The normal pulse for healthy pulse for healthy adults ranges adults ranges from from 60 60 -- 100100beats per beats per minute. minute.

Pulse ratePulse rate

The pulse rate may The pulse rate may fluctuate and increase fluctuate and increase with with exercise, illnessexercise, illness, , injuryinjury, and , and emotionsemotions. . Girls ages Girls ages 12 12 and and older andolder and womenwomen, in , in general, tend to have general, tend to have fasterfaster heart rates than heart rates than do boys and men. do boys and men.

Pulse ratePulse rate

Athletes, such as Athletes, such as runnersrunners, may , may have heart rates have heart rates in the in the 40's 40's and and experience no experience no problems.problems.

How to check your pulseHow to check your pulse

You feel the You feel the beatsbeats by by firmly pressingfirmly pressing on the on the arteries, which are arteries, which are located located close to the close to the surfacesurface of the skin at of the skin at certain points of the certain points of the body. body.

How to check your pulseHow to check your pulse

The pulse can be The pulse can be found on the found on the side side of the lower neckof the lower neck, , on the on the inside of the inside of the elbowelbow, or at the, or at thewristwrist. .

PulsePulse

Place thePlace the tips tips of your of your index index andand middle middle fingersfingers just proximal just proximal to the patients wrist to the patients wrist on the on the thumb sidethumb side, , orienting them so that orienting them so that they are both over the they are both over the length of the vessel. length of the vessel.

PulsePulse

Push lightly at first,Push lightly at first,adding pressure if adding pressure if there is a lot of there is a lot of subcutaneous fat or subcutaneous fat or you are you are unable to unable to detect a pulsedetect a pulse. If you . If you push too hardpush too hard, you , you might might occlude the occlude the vesselvessel and mistake and mistake your own pulseyour own pulse for for that of the patient. that of the patient.

PulsePulse : Quantity: Quantity

Measure the rate of Measure the rate of the pulse (recorded in the pulse (recorded in beats per minute). beats per minute). Count for Count for 30 seconds30 secondsand multiply by 2 (or and multiply by 2 (or 15 seconds x 415 seconds x 4). ).

PulsePulse : Quantity: Quantity

If the rate is If the rate is particularly particularly slow or slow or fastfast, it is probably , it is probably best to measure for best to measure for a a full 60 secondsfull 60 seconds in in order to minimize order to minimize the error. the error.

PulsePulse : Regularity: Regularity

Is the time Is the time between beats between beats constantconstant?. ?. Irregular Irregular rhythmsrhythms, are , are quite quite commoncommon. .

PulsePulse : Volume: Volume

Does the pulse Does the pulse volumevolume feel normal? This feel normal? This reflects changes in reflects changes in stroke volumestroke volume. In . In hypovolemiahypovolemia, the pulse volume is relatively , the pulse volume is relatively low low

THANK THANK TOUTOU