Assessment: Apical Pulse

Measuring the Apical Pulse
  1. Assess for factors that influence apical pulse rate and rhythm: age, exercise, position changes, medications, temperature, and sympathetic stimulation.
  2. Perform hand hygiene and ensure patient privacy.
  3. Expose supine or seated patient's sternum and left side of chest.
  4. Palpate for PMI at fifth intercostal space in left midclavicular line. Feel for light tapping in 1- to 2-cm area at PMI.
  5. Place warmed diaphragm of stethoscope over PMI, and auscultate for normal S1 and S2 heart sounds.
  6. While looking at watch's second hand, count the apical rate, starting with zero.
  7. If apical rate is regular, count for 30 seconds and multiply by 2.
  8. If apical rate is irregular or if patient takes cardiovascular medication, count for a full 60 seconds. Also note regularity of any dysrhythmia.
  9. Perform hand hygiene. Clean earpieces and diaphragm of stethoscope with alcohol.
  10. Document apical pulse rate and compare to previous measurements, if any.
 
Measuring the Apical-Radial Pulse
  1. Determine need to assess for pulse deficit. Indications include irregular heart rate, dyspnea, fatigue, chest pain, and palpitations.
  2. Perform hand hygiene and ensure patient privacy.
  3. Expose supine or seated patient's sternum and left side of chest.
  4. Locate apical and radial pulse sites. One nurse auscultates the apical pulse (as above), and one nurse palpates the radial pulse.
  5. The nurse measuring the radial pulse and holding the watch says, "Start."
  6. Both nurses count the pulse rate simultaneously. After 60 seconds, the nurse taking the radial pulse says, "Stop," and the count ends.
  7. Subtract the radial rate from the apical rate to obtain the pulse deficit (number of ineffective cardiac contractions per minute).
  8. If pulse deficit is noted, assess for other signs and symptoms of decreased CO.
  9. Perform hand hygiene. Clean earpieces and diaphragm of stethoscope with alcohol.,
  10. Record the apical pulse, the radial pulse and site, and the pulse deficit in the nurses' notes. Inform the nurse in charge or physician of the presence of a pulse deficit.
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