NURS 200 COMMUNITY
HEALTH NURSING EXAM 2
STUDY GUIDE COMPLETE
LATEST UPDATED RATED A
NEVADA STATE COLLEGE
, CARDIO
ASSESSMENT
Pulses
The pulse is a wave of blood created by contraction of the left ventricle of the heart. When
taking pulse, note the rate, rhythm, volume, arterial wall elasticity, and presence of absence of
bilateral equality.
Pulse sites:
• Temporal: where temporal artery passes over the temporal bone of
head.
• Carotid: at the side of neck where the carotid artery runs between
the trachea and the sternocleidomastoid muscle; most commonly
auscultated pulse
• Apical: at the apex of heart
• Adult: left side of chest, ~3 into the left of sternum, at the fifth
intercostal space
• Elderly: may be further left if enlarged heart
• Children <4: apex is left of midclavicular line
• Children 4-6: apex is at midclavicular line
• Children 5-9: located at 4-5 intercostal space
• Brachial: at the inner aspect of biceps muscle of arm
• Radial: where radial artery rungs alongside radial bone
• Femoral: where the femoral artery passes alongside the inguinal ligament.
• Popliteal: where popliteal artery passes behind the knee.
• Posterior tibial: on medial surface of the ankle where posterior tibial artery passes
behind the medial malleolus.
• Dorsalis pedis: where the dorsalis pedis artery passes over the bones of foot, on an
imaginary line drawn from middle of ankle to the space between big and second
toes.
Pulse 4-Point Scale:
• 0 – absent
• 1+ - palpable, but thready and weak, easily obliterated
• 2+ - normal, easily identified
• 3+ - increased pulse, moder ate pressure for obliteration
• 4+ - full, bounding; cannot o bliterate
Tachycardia: An excessively fast heart rate (110/min or higher)
Bradycardia: A heart rate of less than 60/min
Apical Pulse
Apical pulse should be assessed for clients whose peripheral pulse is irregular or unavailable
and for clients with known cardiovascular, pulmonary, or renal diseases. It is commonly
assessed prior to administering medications that affect heartrate. Also, it is used for newborns,
infants, and children up to 3 years old.
• CANNOT be delegated to UAP
• Pulse deficit = difference between apical and radial pulse
Heart Sounds and Location for Auscultation
Heart sounds & corresponding description:
• S1- dull, high pitched, sounds like “lub”
• S2 - higher pitch, sounds like “dub”
• Systole- normally silent interval between S1 and S2 - ventricles are contracting
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