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Andrew Pollack-Gray

Nursing Notes

Measuring Pulse and Respirations

3 min read

When & Why?

Measure the resident’s pulse and respiratory rate to recognize changes in circulation and breathing.

Pulse: Arterial pulsations produced by the heartbeat.

Respiratory Rate: Number of complete breathing cycles per minute.

Before You Start

  • Review the care plan and required measurements.
  • Explain the procedure and provide privacy.
  • Perform hand hygiene.
  • Ensure the resident is comfortably positioned and resting when appropriate.
  • Prepare a watch or timer with a seconds display.
  • Identify any individual reporting parameters.

Steps

Radial Pulse

  1. Position the resident’s arm comfortably with the wrist supported.
  2. Locate the radial artery on the thumb side of the wrist.
  3. Use the pads of the index and middle fingers.
  4. Avoid using your thumb to feel the pulse.
  5. Apply gentle pressure until the pulsations are felt.
  6. Count the beats for 60 seconds, or follow the approved skills procedure.
  7. Observe rhythm and pulse strength as trained.
  8. Document the pulse rate and report irregularities or concerning findings.

Respirations

  1. Keep the resident comfortably positioned.
  2. Observe the movement of the chest or abdomen.
  3. Count one complete rise and fall as one breath.
  4. Count respirations for 60 seconds when required by the skills checklist or when breathing is irregular.
  5. Observe rhythm, depth, effort, and signs of distress.
  6. Record the respiratory rate in breaths per minute.
  7. Report concerning breathing patterns or changes.

Observation Tip: Respirations may change when someone deliberately controls their breathing. When appropriate, observe discreetly after measuring the radial pulse without misleading the resident about the care being provided. Can do this by faking checking pulse.

Safety & Observations

  • Use two fingers rather than the thumb when palpating the radial pulse.
  • Avoid excessive pressure that makes the pulse difficult to detect.
  • Report a newly irregular, unusually weak, or difficult-to-detect pulse.
  • Do not assess respirations by rate alone; observe depth, rhythm, and effort.
  • Severe respiratory distress requires immediate escalation, regardless of the counted respiratory rate.
  • Never delay emergency assistance to complete a full-minute count.

What Should I Remember?

  • Pulse: Rate, rhythm, strength.
  • Respirations: Rate, rhythm, depth, effort.
  • One complete chest rise and fall equals one breath.
  • Commonly taught adult reference ranges:
    • Pulse: 60–100 beats/min.
    • Respirations: 12–20 breaths/min.
  • Always consider symptoms, baseline, and the care plan.

Practice

  • Studied
  • Observed
  • Practiced
  • Passed checkoff

Sources

Flashcards

Where is the radial pulse palpated?01-foundations / clinical-skills
Answer

On the thumb side of the wrist.

Which fingers are used to check the radial pulse?03-application / clinical-skills
Answer

Index and middle fingers.

What counts as one respiration?03-application / clinical-skills
Answer

One complete rise and fall of the chest or abdomen.

What should be observed in respirations beyond rate?03-application / clinical-skills
Answer

Rhythm, depth, effort, and distress.

Why should respirations be observed discreetly?03-application / clinical-skills
Answer

Conscious attention can change breathing patterns.

Graph View

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