Observations : NURSING PROBLEM - Pulse Rate

Case History: Mr. Ellis is a young man and was called to service after a head injury. He was beaten unconscious, but has started to improve.

Problem: Mr.Ellis has an tainted level of awareness.

Objective: rapid changes in a number of neurological order to classify.

Pulse
When the left ventricle of the heart contracts it pushes blood into the aorta and sends a surge through the arterial system that can be felt in the marginal arteries as a pulse.

Evaluation of a patient's wrist is an effective method to assess the state of the heart and circulatory system (Perry and Potter, 1998). There are several pulse points on the body, the most common is the radialpulse. The radialartery is to be found near the radius on the thumbside of the wrist. If the radialpulse is out-of-the-way, or is irregular, listening (auscultation) the wrist at the top of the heart can be used as an alternative or an impulse to the carotid artery may feel that s executes on the side of the trachea (windpipe) in the neck.

Factors that can affect the wrist, the body, the blood comes from hemorrhagic shock m or fluid loss, medicines such as digoxin, or a severe head injury.

Terminology
dysrhythmia in cardiac tachycardia, an abnormally high heart rate (over 100 beats / minute), bradycardia, an abnormally slow heartbeat (less than 60 beats / minute)

When a pulse is palpated, it is important to determine the following:

Tempo - the usual range for adults is 60to100 beats/min.(Potter and Perry1997) rhythm - the rhythm is a standard pulse sequence of normal beats. You should be able to feel if the pulse is regular or amplitude - the strength of the pulse.

The pulse may feel low, low, and "spent", or well-built and bounding.

Intervention: consideration of peripheral pulses

Equipment

• View second hand or digital display.

• Black pen.

Documentation sheets •.

Procedure

• Prepare the equipment.

• Wash your hands.

• Place the procedure to Mr. Ellis.

• Ask Mr. Ellis to sit or lie down. Make no doubt that he is as comfortable and relaxing as possible, rest for a minimum period of five minutes, when it occurs.

• Place the end of the first two or three middle fingers of the groove along the side of the thumb of Mr. Ellis wrist and squeeze gently.

° If the wrist is often count the number of beats in 30 seconds and multiplying the total by 2. If it is irregular, count the pulse for a full minute.

• Examine pulse amplitude and rhythm.

• Wash your hands.

• Record the heart rate graph on observation and the differences in amplitude and rhythm.

More Info Ellis of your results.

• Report discrepancies or changes in observing a more experienced colleague.

TIP
peripheral pulses is irregular! As patient's interpretation the radialartery of the wrist with headvisable theapical to measure up to to determine whether there is a difference. The most accurate method of doing this is the rhythm of two nurses apical and radial pulse measured simultaneously. This is described as a "top-radial recording.

Evaluation of the apical impulse is to listen to heart sounds with a stethoscope placed on the top of the heart. At the same time, the nurse takes half the radial pulse.

Equipment

° stethoscope.
• Sight secondhand or digital display.
Rumen ° in two colors (according to Trust policy).
Documentation sheets

Procedure

• Creation of material: support the application of a fellow nurse.

• Wash your hands.

• Close the curtains around the bed.

• Place the course of action to Mr.Ellis.

• Ask Mr. Ellis.

• Presentation to the left of the sternum and chest. Place the diaphragm of the stethoscope over the apex of the heart. It is located on the fifth intercostal space, in line with the left mid-clavicle.

• Listening sounds double beating heart. The heart sounds are called S1 and S2.

° If your colleague is complete, you begin to count the pulses apical and starts counting the radialpulse. One of you, a regular count of the apex beat, will need to take the lead in starting the counting and timing of the procedure. Count the pulse for a full minute, counting each beat Apex Double (the S1 and S2) as a full beat.

• Assist Ellis dress.

° For hand washing.

Conference record

° observation grid, using different colors for the measures radial and apex, and document the changes in the rhythm.

• Apply to Mr. Ellis to your closing date.

• Report discrepancies or changes in observing a more experienced colleague.