Assessing a Peripheral Pulse & Respiration

1. Check physician’s order or nursing care plan for frequency of pulse assessment. More frequent pulse measurement may be appropriate based on nursing judgment.

2. Identify the patient.

3. Explain the procedure to the patient.

4. Close curtains around bed and close door to room if possible.

5. Perform hand hygiene and put on gloves as appropriate.

6. Select the appropriate peripheral site based on assessment data.

7. Move the patient’s clothing to expose only the site chosen.

8. Place your first, second, and third fingers over the artery. Lightly compress the artery so pulsations can be felt and counted.

9. Using a watch with a second hand, count the number of pulsations felt for 60 seconds.

10. Note the rhythm and amplitude of the pulse.

      

11. Cover the patient and help him or her to a position of comfort.

12. Remove gloves, if necessary. Perform hand hygiene.

Assessing Respiration

1. While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations.

2. Note the rise and fall of the patient’s chest.

3. Using a watch with a second hand, count the number of respirations for 60 seconds.

4. Note the depth and rhythm of the respirations.

5. Perform hand hygiene.

6. Document correctly.