The practical nurse (PN) palpates a client’s radial pulse and notes that the pulse disappears when light pressure is applied.
How should the PN document this finding?
A.
Thready pulse volume
B.
Missing pulse.
C.
Light pressure applied to pulse
D.
Pulse skips beats
The Correct Answer and Explanation is:
The correct answer is A. Thready pulse volume.
Explanation:
In clinical practice, the description of a pulse is essential for accurately documenting a patient’s cardiovascular status. When a practical nurse (PN) palpates a client’s radial pulse and notes that the pulse disappears upon applying light pressure, this typically indicates a pulse that is weak and easily obliterated. This finding is most appropriately documented as a thready pulse volume.
Pulse Volume Classification:
- Thready Pulse Volume:
- Description: A thready pulse is one that is weak, thin, and easily compressible. It can be felt with difficulty and may disappear with slight pressure.
- Clinical Significance: This type of pulse suggests a low volume of blood flow or decreased cardiac output. It can be associated with conditions such as shock, severe blood loss, or heart failure.
- Missing Pulse:
- Description: This term would imply that the pulse is entirely absent, which is a more severe finding and indicates that no pulse is palpable at all. It is less specific than “thready” and may not accurately convey the pulse’s status under varying pressure conditions.
- Light Pressure Applied to Pulse:
- Description: While this is a factual statement about the method used, it does not describe the quality or strength of the pulse. Documenting the pulse status in this way does not provide an adequate assessment of the pulse’s condition.
- Pulse Skips Beats:
- Description: This term would refer to an irregular pulse where beats are missed intermittently, such as in arrhythmias. It does not describe the pulse’s strength or ability to be felt under pressure.
Why Thready Pulse Volume is Appropriate:
- Clarity and Specificity: Describing the pulse as “thready” provides clear information about its quality and helps clinicians understand the potential underlying issue. It indicates that the pulse is weak and can be easily lost with light pressure, which is crucial for assessing the client’s hemodynamic status.
- Consistency in Documentation: Using established terms like “thready” helps maintain consistency in patient records, allowing for accurate communication among healthcare providers and ensuring that appropriate interventions can be planned.
In summary, documenting a pulse that disappears with light pressure as “thready pulse volume” accurately reflects its weak, easily compressible nature and provides essential information about the patient’s cardiovascular condition.