Critical care nurses care for patients with various degrees of illness. Unfortunately, a critical illness may be masked by the signs and symptoms of a secondary abnormality, for example, severe abdominal pain masking heart failure. Good assessment skills and clinical knowledge are required to ensure that important findings are not overlooked. One physiological finding that may be overlooked is pulsus alternans.

Pulsus alternans is a cardiovascular phenomenon characterized by alternating strong and weak pulse pressures during a sinus rhythm. This alternation is evident predominantly in the arterial waveform because the amplitude of the systolic beat differs with every other beat. No changes are apparent on electrocardiograms or in diastolic filling time.1,2 Pulsus alternans may indicate severe ventricular failure.3 

Pulsus alternans occurs in aortic and mitral valve stenosis, hypertrophic and congestive cardiomyopathy, effusive pericarditis, and instances in...

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