Pulse assessment is crucial to identifying life- and limb-threatening injuries and illnesses. Character and quality of pulses can be affected by several different factors, and early identification and intervention is paramount to good patient outcomes.

The general approach to assessment includes a systematic examination of the pulses, distally to proximally. This allows for the most objective assessment of pulses from their weakest point to the strongest. The quality of the pulses, size of the arteries, and symmetry is important to note.

The radial and brachial arteries in the arms and dorsalis pedis, post tibial, popliteal and femoral arteries in the legs should be included. Normal pulses are graded 2+. Bounding pulses are graded 3+, and diminished pulses 1+. Absent pulses are assigned a grade of 0.

The radial pulse should be assessed by taking the pads of your fingers and placing them on the flexor aspect of the wrist. The brachial pulse is assessed just medial to the biceps tendon in the antecubital fossa. Comparison should be made with the opposite arm. Any discrepancy should be reported to the provider for further evaluation.

The dorsalis pedis is assessed by placing the pads of your fingers on the dorsum of the foot just lateral to the extensor tendon of the great toe. The posterior tibial pulse is located behind/distal to the medial malleolus of the ankle. The popliteal artery is located behind the knee deeply in the popliteal space and may be found more easily if the knee is flexed slightly. The femoral pulse is deep within the inguinal region and may be more easily found using two hands with deep palpation.

Generally, when a pulse rate is taken the radial artery is used. The patient should be seated comfortably, and wrist supported on the exam table or chair arm. The artery is palpated, and pulse counted for 30 seconds and multiplied by 2, or for a full minute if irregular. If there is an irregular heart rate, this should be reported to the provider for further evaluation.

Remember…

• Examining the patient with the next provider during care transitions helps to eliminate discrepancies in the quality assessments of pulses and maintains continuity of examination findings.
• Cyanosis, pallor, or lack of hair growth on an extremity may be concerning for arterial insufficiency.
• Bounding radial and femoral pulses may indicate aortic regurgitation.
• Pulsus parvus refers to weak pulses and may indicate atherosclerotic disease.
• Femoral pulses with a bruit should be reported to a provider for further evaluation for possible aneurysm.

Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.

 

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