Peripheral pulses - I'm not entirely convinced they exist!

[seconddegreebsn]

Hey everyone,

I finished my assessment class this summer and I'm out doing med surg clincals, using the skills I learned there. My problem: I cannot for the life of me find a popliteal, posterior tibial or dorsalis pedis pulse. I've tried on at least 30 people now and have never felt it once. And now that I'm caring for postsurgical hip replacement surgery patients, it's important to find these on the affect side. What am I doing wrong?

[MendedHeart]

NO NO NO!!!! You should NEVER be able to hear a pulse!!!! That was drilled into our head by our assessment instructor. If you HEAR a pulse, something is seriously wrong (stenosis of the artery)!!! Think about taking BP. You don't hear the brachial artery until you constrict the arm, right? You have to feel them or use a Doppler. YouTube videos helped me find landmarks.

Thank you for clarifying, when I read that I was like ummm, I dont think you should be able to hear that with a stethoscope, bruit is not a good thing, turbulence.

[libby11]

I am curious, you say you've tried on at least 30 people? Realistically how long did you try? 5 seconds? 10 seconds? 1 minute? 5 minutes? The reason I ask, is because I wanted to say it is OK to take 5 minutes to find a pulse--especially if you're new. Taking 5 minutes to find it, is better than not finding it or pretending you found it. Yes, you might feel like an idiot palpating someone's foot for 5 minutes--it is actually a really long time, BUT you will demonstrate integrity and eventually learn to find those pulses!

I agree with many of the other comments about palpating too deeply or not deeply enough. For me, I often was pushing down so hard that i was basically stopping the blood flow and would be unable to feel a pulse. I know other students that touched so lightly, they wouldn't feel a pulse unless the patient was bounding or had paperthin skin.

It is typical to feel for a pulse with the index and middle finger, you can also try variations such as ring and middle OR pinky, ring and middle, OR ring, middle and index. When I first began and was struggled a teacher suggested to me to use ring, middle and index; this helped me for a while until I got really comfortable. There were times I really couldn't find it until someone showed me right where it was. Even when they place my hand exactly where it was I couldn't feel it. They asked 'Can you feel it?' I wanted to just say, 'yes.' I knew I'd never get anywhere doing that and that someday I'd be on my own and couldn't fake feeling a pulse. They teacher wiggled my hand around, said 'push harder' and 'don't push so much.' It seemed I'd never find the pulse. It felt like forever had gone by each time, but I found the pulses eventually. Most of the patients were nice and now I find them in just a few seconds--usually.

Keep trying & keep us updated.

[WordWrangler]

I was instructed this previous semester to palpate the DP bilaterally at the same time, as well, to judge differences in quality of each. Sometimes it's hard to find those pedal pulses in sick patients, but keep at it. They know you're learning.

[FineAgain]

I found them hard at first as well. I finally realized that (at least for me) I was pressing too hard and occluding the pulse. I usually start at the top of the foot for the DP and feel around lightly. If it is really hard to find I mark it for next time, or next person! I think the PT is easier to find and I use the same technique as akulahawk describes. Keep practicing, you will get it!

[nurseprnRN, BSN, RN]

The anesthesiologists where I had my first critical care job told me that 15-20% do not have palpable DP/PT. If they are there I can find 'em, but when you remember that diabetes mellitus is getting really, really common and one of its hallmarks is (ta-da!) obliterative arterial disease, it's not hard to understand why they are hard or impossible to find.

What I have not seen in this entire thread is the idea that if you can't find the pulses, you never stop there. Remember why we are going to all this trouble: looking at blood flow.

You go to the Plan B to assess and document peripheral perfusion: capillary refill time. To do that, you blanch a toe or fingertip (make it white, from the French "blanch/blanche," white) by squeezing it, and count the number of seconds it takes to pink up. Less than 2-3 seconds is normal (try this on your own fingers and toes if your SO is too ticklish). Do all the toes pink up at the same rate, or are some slower to recover?

Don't forget to note warmth over the skin from ankle to toes, feeling with the backs of your fingers (does it feel cooler the more distal you get?) and overall color.

[seconddegreebsn]

I've been so embarassed to admit that I can't find them - it's kept me from asking for help, which only make the problem continue longer. I spoke with two nurses that I work closely with and they've agreed they're going to help me find them on every patient we assess together, so hopefully that will help out a lot. Thanks everyone for the suggestions, much appreciated!

[morte, LPN, LVN]

are you old enough that you may have sensory def of your own? Do you smoke? good luck

I've been so embarassed to admit that I can't find them - it's kept me from asking for help, which only make the problem continue longer. I spoke with two nurses that I work closely with and they've agreed they're going to help me find them on every patient we assess together, so hopefully that will help out a lot. Thanks everyone for the suggestions, much appreciated!

[seconddegreebsn]

are you old enough that you may have sensory def of your own? Do you smoke? good luck

I do not have a "sensory deficit", nor am I smoker - I already stated that my patients are all elderly people with DM, some of whom postsurgical. Not exactly the easiest bunch.

[morte, LPN, LVN]

absolutely! just covering all the bases.

I do not have a "sensory deficit", nor am I smoker - I already stated that my patients are all elderly people with DM, some of whom postsurgical. Not exactly the easiest bunch.