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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 a medical setting, at home, at the scene of a medical emergency, or anywhere. Vital signs are essential as the morbidity and mortality of cardiovascular diseases are well-known.
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.
- Before and after interventions performed by nurses can affect vital signs.
- If the patient observes in their general health condition non-specific symptoms.
Checking circulation
There are various methods for checking the patients’ circulation, such as:
1. Taking a patient’s history can reveal risk factors for cardiovascular diseases.
2. Cardiovascular risk assessment and scoring is needed.
3. In specific cases, when further examinations are necessary.
2. Cardiovascular risk assessment and scoring is 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, edema, jugular vein distension, difficulty breathing
- Palpitation
- Transient loss of consciousness (syncope)
- Gärtner sign – loss of hand circulation can occur with arms raised heart level (except in heart failure).
- The development, nourishment, physique, size of the extremities, the color 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 (sudden or gradual?), how frequently it occurs, and how long it has been. 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, immunization, previous injuries, surgeries, blood type, allergy, 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 other specialists' involvement necessary in patient care?
- Physical examinations:
measurement of body weight, height, abdominal circumference and blood pressure are always performed depending on the general condition of the patient.
- 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 stabilized the detailed patient examination can be performed.
2. Cardiovascular risk assessment and scoring
Waist circumference
- It is beneficial for patients who are within the normal or overweight range based on the 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 riskModerate riskSevere 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 characterized by fat accumulation in the body's central part, resulting in an apple body shape (fat occupies mostly 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 dyslipidemia. 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-shapedpattern of body fatAbove the waits
Below the waits
The Framingham Risk Score is a sex-specific algorithm used to estimate the 10-year cardiovascular risk of an individual.
MenWomenAgeScoreAgeScoreTotal cholesterol(mmol/L)AgeAgeHDL ch.
(mmol/L)ScoresHDL ch.
(mmol/L)ScoresNon-smoker
SmokerSyst RR
(mmHg)UntreatedTreatedTotal score10-year
riskTotal score10-year
riskAgeScoreAgeScoreTotal cholesterol
(mmol/L)AgeAgeNon-smokerSmokerHDL ch.
(mmol/L)ScoresHDL ch.
(mmol/L)ScoresSyst RR
(mmHg)UntreatedTreatedTotal score10-year
riskTotal score10-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 an age group between 40 and 65.
WomenMenNon-smokerSmokerNon-smokerSmokerNon-smokerSmokerNon-smokerSmokerSystolic blood pressure (mmHg)Age1%and lower2%3%-4%5%-9%10%-14%15%
and higherCardiovascular risk within 10 years (fatal and non-fatal)Total cholesterol statusDiabeticNon-diabeticNon-diabeticDiabetic12345
3. Other tests
Inspection
- Inspection of patients is vital to assess their cardiac status. Still, in most cases, only the signs and symptoms of severe heart failure (dyspnea, cyanosis, edema, 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, observation of the internal jugular vein can provide information on the venous pulse.
Palpation
- Palpation in the case of the heart is relatively less critical.
- Changes in places where heart sounds can be heard indicate altered heart position.
- In patients with chest complaints, especially young patients, we should also consider problems with the chest muscles and joints, as the complaint might result from a previous major physical strain.
- In such cases, detailed palpation of the chest muscles to look for tender or painful areas of the chest might provide more information on 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 the heart sounds takes place at specific points (listening points) according to each particular 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.
PCPLCarotid artery examination
- Gives more information about the heart’s status compared to the peripheral vessels.
- These arteries deliver blood to the head and neck.
- Generally, the carotid artery is examined while the patient is sitting or their head is elevated.
- Auscultation of the carotid artery can be performed as well.
- 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 lies across the sternocleidomastoid muscle, directed toward the mandible.
- Jugular veins can be observed well if the patient is lying; however, these vessels cannot be observed to be distended when the patient is lying with his head elevated.
- Hepatojugular reflux: the distension of the neck veins precipitated by the maneuver of firm pressure over the liver.
Signs of peripheral circulatory failure
If arteries are affected, the following symptoms might 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 might occur:
- heavy or achy legs
- paresthesia
- leg cramps (especially at night)
- spider veins
- along with varicose veins
- normal or blue colorization
- tight sensation, swelling
- edema, leg swelling
- thickened skin
- hyperpigmentation, discoloration around the ankle
- scars of healed ulcers, scarring without ulceration
- leg ulcers (ulcus cruris)
The 5 P's of circulation assessment
Can youmove?Not really.You are
pale!OUCH!Do you feel
this?Not really.PainPulsePallorParesthesiaParalysisPulseParesthesiaPainPallorParalysis
Pulse check
- A pulse is an intense throbbing felt over one of the arteries in the body.
- The number of times each minute that the heart beats 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 is when the heart beats faster than the palpable pulse at 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 mobilization, 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:
- Hypovolemia – 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 enhances)
- 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) 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 arteryRadialarteryFemoral
arteryDorsalis pedis
arteryCarotid arteryPopliteal
arteryPosterior 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 medio-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 | 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, 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 (this information is gathered from the patient or former regular measurements). It is important to know this because although there are generally accepted ranges for all parameters, they should continually be assessed concerning each patient. For example, an athlete's heart rate of 45 beats per minute is bradycardia in a non-athletic, healthy person, which is a normal rate for them.
- 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 pulseA 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 to measure pulse is the capillary refill time (CRT). It is a valuable and rapid metric in determining the intravascular volume status of ill patients, particularly those with conditions that arise or result from hypovolemia. 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 ten seconds and then released. The amount of time, in seconds, that transpires before reperfusion occurs and normal color returns 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 fast and purple, thus 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 color 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, hypovolemia), 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.
Impressum
Impressum
Assessment of vital signs – Pulse rate
Authors: Veronika Rajki, PhD, Pál Bakó
Authors: Veronika Rajki, PhD, Pál Bakó
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Reference number: 630029
Mozaik Education, 2024
Mozaik Education, 2024
