Question - having significant doubts about my VS assessment skills

[Jedi of Zen]

Hello all,

I am a student, with a question for all the new nurses out there. I have just finished the third semester of a five-semester associate degree program. I feel that by now, my vital-sign assessment skills should be competent, or at least have improved since the days of my first semester clinicals. I pretty much feel okay with getting temps and counting respirations. However, I find that when I try to assess the pulse rate, I can NEVER seem to find a pulse. I usually try the radial pulse first, and no matter how firmly or gently I press, I just can't seem to locate it, ever. Then I try the brachial, and I have the same problem. Usually the only way I'm ever able to get a pulse rate is by using my stethoscope over the apical pulse - and even then I still have problems finding it sometimes. And often it's difficult to distinguish over lung sounds.

Aside from that, I just leave it up the magic of the vital sign machine. However, I would like to be able to think that I can still get a pulse rate without relying on the vital-sign machine if necessary.

So, my question is - did any of you have this (or a similar) problem when you were this far along in school? If so - since you've started working, do you feel that your assessment skills (along with general confidence in yourself) have improved at all? I really don't want to get into doing precepting, graduating, working, etc (all of which I know is virtually right around the corner) and STILL not be able to get a pulse. I feel too scared and stupid to ask my teachers or another student for help.

Any advice/input is welcome. Thank you for your time!

[KFP83]

I had such a hard time getting pedal pulses in nursing school, but the more you do it the easier it becomes. When you try for a radial pulse, do you move around to find it? Everyone is different, so where you found it in one person, it may be different in another. Practice on non-patients: family members or fellow students. I hope this helps you.

[locolorenzo22, BSN, RN]

I used to have this problem...after working as a CNA for years, and just feeling around, I can get a pulse on just about anyone. I find that a gentler touch works better on most patients...but you should be able to do that by now. Then again, everybody is always better at other clinical skills.

[AddieRN]

I would try moving around and using a gentler touch. I still have trouble finding pedal pulses sometimes. I work on a tele unit, we have a lot of CHF pts. Many patients have edema in their ankles and feet making it difficult to assess the dorsalis pedis and posterior tibial. Once you do find the pulse mark it with a pen, the next time you assess you'll know exactly where to go. As far as the apical pulse is concerned, listen over the 5th intercostal space mid-clavicular. It's very important to get the apical pulse rate in pts. taking Digoxin. Assessment skills just take practice. One more piece of advice, never be afraid to ask questions. Hope this helps.

[NotReady4PrimeTime, RN]

Try finding your own pulses. See how much pressure causes them to disappear. A light touch is enough for about half the population. Use three fingers, not two. If you're having trouble finding pedal pulses, put your index finger in the notch between the tendons at the ankle. You should feel a pulse there and can then follow the artery down over the instep. Posterior tibs can be felt on the medial side of the foot just posterior to the malleolus. For pedal edema, I often guesstimate where I should find a pulse, then apply gentle pressure until my fingers begin to cause a dimple, and I can usually feel a pulse then. Mark them once you find them as suggested previously, but use a Sharpie. It stays on longer than ballpoint.

[mimi13]

I am in a similar situation as you and do not want to graduate without these basic skills. I'm fine with radial, but can NEVER find pedal. I can spend 40 minutes trying to find my husband/childrens' pedal pulses to practice. Extremely frustrating. I also have a hard time with apical on overweight or women with very large breasts. I try to figure out where the intercostal spaces are that I cannot see or feel anywhere. I'm so glad for this forum where we can reveal this info and get support. It's difficult in clinical where most seem to be way beyond this stuff.

[chevyv, BSN, RN]

It's hard to hone skills when you don't often get a chance to do them over and over. Maybe you can try this for a pulse: follow your thumb down towards your wrist and follow the curve where your wrist bends. There is a bone that flares out just a bit in the wrist of the path your following. Use a light touch and you'll find the pusle just about there. I hope this isn't too confusing. Pedal pulses will come the more you do them. It might be more difficult to find on elderly. Go between the great toe and follow a path down (or rather up). Be very gentle and take your time. The inside of the ankle towards the heel is another spot to check. I often tell patients that "this may take me a bit longer and not to worry". I went through a time when I couldn't find pedal pulses to save my life. I told my instructor and went and got her or hit her up when she came to check off for meds and had her find them so I could get a feel for them. It's hard, but once you get it, your good.

[Jedi of Zen]

I actually have no problem at all finding my own radial pulse. Although I find that I actually have to use a little bit of pressure to really get it. It's only on other people that I have problems, for some reason.

I live alone, and don't really have any friends or family to practice on.

I am curious, as I asked in the OP - have any new nurses out there found that your skills have improved at all since you started working? Or, do you feel that you pretty much hit your peak ability in school, and from there it's all been easy coasting?

Thanks again.

[chevyv, BSN, RN]

Your skills will definately improve as you work. I guess the key is to ask questions and don't act like you got it if you don't.

You might not always have those wonderful machines to rely on and vs are a basic assessment skill. The machine can't tell you that pedal pulses aren't palpable bilaterally. It does get better, but please please don't be afraid to ask your instructor. They can make sure you get it down pat.

[jjjoy, LPN]

This might feel a bit risky but it would be great practice not only to learn how to find pulses but to practice admitting when you don't get something and asking for assistance... tell your classmates and clinical instructor that you want to practice finding pulses. Ask if you can practice on each of your classmates patients as well as your own... that will multiply the exposure you get... and maybe one of your classmates will have be able to help you find the pulses. Just say "sometimes I have a hard time finding pulses and would like more practice."

Aim for trying to find the pulse on 30 patients in one week... and then maasure your success in the number of attempts that you make, as opposed to how many pulses that you actually find... that way you have something to congratulate yourself on no matter how the pulse taking goes. With that much practice you probably WILL get it... but even if you don't (highly unlikely), you'll have had wonderful practice at asking for clinical practice (something you'll continue to need to do as a working nurse) and so much more exposure to different patients that you can be proud of yourself and your efforts!!

[Jedi of Zen]

This might feel a bit risky but it would be great practice not only to learn how to find pulses but to practice admitting when you don't get something and asking for assistance... tell your classmates and clinical instructor that you want to practice finding pulses. Ask if you can practice on each of your classmates patients as well as your own... that will multiply the exposure you get... and maybe one of your classmates will have be able to help you find the pulses. Just say "sometimes I have a hard time finding pulses and would like more practice."

Aim for trying to find the pulse on 30 patients in one week... and then maasure your success in the number of attempts that you make, as opposed to how many pulses that you actually find... that way you have something to congratulate yourself on no matter how the pulse taking goes. With that much practice you probably WILL get it... but even if you don't (highly unlikely), you'll have had wonderful practice at asking for clinical practice (something you'll continue to need to do as a working nurse) and so much more exposure to different patients that you can be proud of yourself and your efforts!!

I've found in clinicals, every semester, that my instructor is usually far too busy to be bothered with something that sounds so simple and trivial. Seriously, to ask about something like that would probably be downright offensive to some of the instructors I've had, lol. However, after the fall semester starts, I may try to talk to my new clinical instructor before clinicals even begin and discuss this.

As for 30 patients a week - I don't really get that kind of exposure in clinicals, but that's something that I'll definitely keep in mind. Thanks.

[mcknis]

Yes skills do improve, but as others have said, just practice. I have a hard time with pedal pulses, but some pts need deep palp and others only a light touch. I have found that some pts, with any pressure, will cause you to lose the pedal pulses. I have also found i have complications assessing breakdown staging.