Wednesday, January 1, 2014

5 Mistakes to Avoid When Checking a Pulse or Heart Rate

Common Mistakes to Avoid When Checking a Heart Rate - Photo by Thamizhpparithi Maari
A non-invasive pulse check is a basic skill utilized by many physicians, nurses, EMTs, nurse aides, and other caregivers. This data is often collected as part of a person's vital signs, which typically also includes body temperature, blood pressure, and respiratory rate. Other data, such as pain level, intake and output, weight, and other information might also be obtained in order to have a more full picture of the person's health status.

Mistakes when checking the pulse, or heart rate, can result in a variety of negative results because important care decisions may be based on this number. Although checking a pulse requires few steps, each step is important, and avoiding common mistakes can help one to ensure that data collected is trustworthy and may lead to more appropriate care.

Below are five of the more common mistakes when checking a pulse that caregivers should take note to avoid:

Mistake #1: Improper Technique

Manually checking the pulse typically means that the caregiver will palpate the heart rate at the appropriate pulse point on the correct patient, resident, or client. Obviously, checking the pulse on another person would be a serious error. It is also important to identify oneself and one's role and to ask permission before providing care as appropriate.

Some caregivers may palpate the pulse using his or her thumb. This can lead to errors because one's thumb can have a pulse, leading the caregiver to erroneously count his or her own pulse rather than the patient's pulse.

Pressing down too firmly with one's fingers can result in occluding the blood flow, resulting in a pulse that seems to feel weaker and weaker. Learning how to press down the appropriate depth can help prevent this error. On the flip side, some pulses are not able to be accurately palpated with the caregiver's fingers and must be checked by other means, such as with a Doppler or stethoscope. Failing to utilize proper equipment and instead simply recording a pulse of zero or guessing at the pulse could result in major problems and false records.

Those who are inexperienced with checking a pulse might have difficulties when timing the count. A common mistake happens when someone watches the second hand on a watch or clock and begins counting the second hand rather than the resident's pulse. If the palpated heart rate tends to always result in 60 beats/minute, ensure that this is truly patient data rather than simply movement of the second hand on a timing device. When learning, it can help to look away from the clock or watch for a few seconds after starting the pulse check or to set an audible alarm to know when to stop counting.

Mistake #2: Not Checking the Pulse in the Correct Area

Not all pulses on a patient are necessarily equal. If an apical pulse check through a stethoscope is needed, palpating the radial pulse instead would be a mistake. If bilateral dorsalis pedis pulses are needed, checking only one and putting the same number for both could lead to errors in treatment.

Having a working knowledge of medical terminology is very important. If the caregiver does not know what a popliteal or apical pulse is, he or she will have a difficult time locating and checking it.

Checking orthostatic vital signs includes checking the pulse along with other vital signs, when the person is lying, then sitting, then standing. If the vital signs are not timed correctly or obtained in the right order, the data will not be very helpful to the caregiver assessing the information.

Some conditions may affect one side of the body and not the other. For example, if the client has one-sided paralysis, an intravenous line, or a cast on one arm, checking the pulse on the unaffected side of the body would typically be recommended.

If the patient has an amputated arm and the caregiver records a brachial pulse on the affected side, this could be cause for serious concerns regarding one's attention to detail when charting and providing appropriate hands-on care.

Mistake #3: Taking Too Many Shortcuts

Caregivers are often pressed for time. Prioritizing tasks can be extremely challenging. It can be tempting to save time while checking the pulse, but shortcuts with a heart rate check can lead to errors, sometimes errors that are directly proportional to the amount of time supposedly saved.

A pulse check does not mean that the caregiver simply looks at a monitor and records a number from the screen. Although the numbers appearing on the screen may be accurate, the numbers could also be far from correct. For example, a patient who has very high T-waves might have a heart rate appearing on the monitor that is recognizing those T-waves as QRS-waves, resulting in an inaccurate heart rate reading that is approximately two times higher than the true pulse rate. Manually checking a pulse can often quickly dispel any seemingly strange numbers.

A pulse is recorded as the number of heartbeats per minute. A 60-second pulse check tends to be more accurate than checking for a shorter period of time and then multiplying to get a 60-second count. For example, if the caregiver checks a client's pulse for 15 seconds and multiplies that number by four, the result could be significantly higher or lower than the actual heart rate if the client's pulse rate is irregular. If a 60-second pulse check is necessary, checking for a shorter period of time may equal a mistake, sometimes a grave one. Checking the pulse for less than 60 seconds may be safe and appropriate in some circumstances, but it is important to understand when a full minute count is needed.

Nothing saves more time than doing it correctly the first time. If unsure of a patient's pulse, requesting the assistance of another caregiver would be appropriate.

Mistake #4: Not Knowing Normal Limits and Exceptions

A normal pulse for the average adult has a regular rate, is strong, and is between 60 and 100 beats per minute. Pediatric normal ranges are typically based on the child's age. Collecting data is useful, but knowing what is normal and what is not normal is equally important. If the pulse is weak, thready, has pauses, speeds up or slows down, is less than 60 or greater than 100, this is considered abnormal in most cases.

Some people normally fall outside of normal ranges. A marathon runner might have a normal resting heart rate of 50, and this pulse would not be cause for concern. However, if that marathon runner suddenly had a resting heart rate of 96, this might be a notable problem even though the number is technically within normal ranges for an adult. There is a lot to be said for common sense in healthcare.

Sudden and significant changes may indicate a problem, or they may be an expected result of treatment. If in doubt, seek clarification. If the patient complains of chest pain, shortness of breath, a feeling of impending doom, dizziness, or other unexpected symptoms, this would typically warrant a more thorough assessment, even if all vital signs are within normal limits.

Mistake #5: Not Knowing What to Do with the Information

Most caregivers have taken a pulse and then failed to record and/or report that information at some point. Unfortunately, information that is not recorded is not very helpful to a healthcare team. Charting as one completes tasks and double-checking each chart regularly can help caregivers to ensure their charting is complete and accurate.

If working in a facility or for an agency, it is very important to know how to record important information like the pulse rate and location of the pulse in addition to knowing how to make notations such as an irregular rhythm or a pulse that is difficult to palpate. Having accurate and complete records can help to identify trends and may assist in determining decisions for care.

Changes and deviations from normal may also need to be reported to others, whether those others are working together at the time or they are other people on the team who are assuming future care. Forgetting to report important information might result in medication errors and could lead to larger and larger problems for the recipient of care. Recording that you reported this information may be wise in some instances as well. Facility policy can guide caregivers to follow-up with appropriate decisions in most cases.

If a resident refuses to have his or her pulse checked, follow facility policy and notify the appropriate people. Sometimes checking vital signs may become an unwanted burden for a patient who is dying, for example, and altering the plan of care to meet current wishes of the patient can be helpful to everyone involved; however, this should be appropriately discussed and documented.

Not collecting data due to customer refusal is a very different situation than not providing care because the caregiver forgot, was too busy, did not have necessary equipment, or did not understand how to perform the procedure. Clear documentation can help to ensure that everyone knows the situation at any given time.

Tips for Checking a Pulse

Although no caregiver is perfect, being aware of common mistakes may help those who work in healthcare to be more diligent in providing appropriate care. The smart caregiver will learn from his or her own mistakes and perhaps avoid making some errors by learning from other's mistakes as well.

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  1. Question: What are some potential errors that will happen when obtaining vital signs?

  2. Hi Savanna! In addition to the above errors when obtaining VS, if incorrect data is obtained, the patient may receive incorrect treatment. The healthcare team depends on accurate VS in order to direct care. If the information is not properly communicated and the patient is acutely ill with vital signs outside of normal limits, the patient could become sicker and potentially die.


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