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Apical Pulse      

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Use Standard Precautions when assessing an apical pulse. If the apical rate is abnormal or irregular, repeat the assessment or have another nurse do it. The second assessment can confirm your findings or identify an error. If the pulse is irregular, assess for a pulse deficit, which may indicate an alteration in cardiac output. (For details, see Assessing Apical-Radial Pulse.) Routinely clean the earpieces and diaphragm of the stethoscope with alcohol after each use. Assess the patient for latex allergy. If the patient has a latex allergy, ensure that the stethoscope is latex free. Report an apical pulse of less than 60 or more than 100 beats per minute or an irregular rhythm to the health care provider without delay. Immediate intervention may be needed.

Verify the health care provider’s orders. Gather the necessary equipment and supplies. Perform hand hygiene. Provide for the patient’s privacy. Introduce yourself to the patient and family if present. Identify the patient using two identifiers. Explain the procedure to the patient and ensure that he or she agrees to treatment. 8. Assess for factors that can affect the apical pulse rate and rhythm, such as medical history, disease processes, age, exercise, position changes, medications, temperature, or sympathetic stimulation. Gloves are only worn if nurse will be in contact with bodily fluids or the patient is in protective precautions. 9. Help the patient into a supine or sitting position, and expose the sternum and the left side of the chest. 10. Locate the point of maximal impulse (PMI, or apical impulse). To do this, find the angle of Louis, which feels like a bony prominence just below the suprasternal notch. 11. Slide your fingers down each side of the angle to find the second intercostal space (ICS). Carefully move your fingers down the left side of the sternum to the fifth intercostal space and over to the left midclavicular line. 12. Feel the PMI as a light tap about 1 to 2 centimeters in diameter, reflecting the apex of the heart. 13. If the PMI is not where you would expect, as in a patient whose left ventricle is enlarged, inch your fingers along the fifth intercostal space until you feel the PMI. 14. Remember where you felt the PMI: over the apex of the heart in the fifth intercostal space at the left midclavicular line.

15. Warm the diaphragm of the stethoscope. When it feels warm, clean it with alcohol and allow it to dry for 30 seconds. 16. Place the warmed diaphragm on the patient's chest over the PMI, and auscultate for the normal S and S heart sounds of “lub-dub.” 17. Once you can hear S and S with regularity, look at your watch. When the second hand reaches a number on the dial (or when the digital display reaches a round number), start taking the pulse, counting the first beat you hear as “one.” If the apical pulse is regular, count the rate for 30 seconds and multiply the total by 2. The pulse rate normally ranges from 60 to 100 beats per minute. If the apical pulse is irregular or the patient is taking a cardiovascular drug, count for a full 60 seconds. Also, note the patterns of irregularity with any dysrhythmia, for example, if every third beat is skipped. 18. Replace the patient’s gown and bed linen, help the patient into a comfortable position, and discuss your findings if appropriate. 19. Clean the earpieces and diaphragm of the stethoscope with an organizationapproved equipment cleaner. 20. Place toiletries and personal items within reach. 21. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 22. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. 23. Dispose of used supplies and equipment. Leave the patient’s room tidy. 24. Remove and dispose of gloves, if used. Perform hand hygiene. 25. As part of your follow-up care, compare the patient’s apical pulse rate and rhythm with the baseline and with the acceptable range for the patient’s age. 26. Document and report the patient’s response and expected or unexpected outcomes. 1

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OVERVIEW The apical pulse is the most reliable noninvasive way to assess cardiac function. The apical pulse rate is the assessment of the number and quality of apical sounds in 1 minute. Each apical pulse is the combination of two sounds, S and S . S is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systole begins. S is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction. 1

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You use a stethoscope to auscultate sound waves of the apical pulse. The stethoscope is a closed cylinder that amplifies sound waves as they reach the surface of the body. The five major parts of the stethoscope are the earpieces, binaurals, tubing, bell, and diaphragm. The plastic or rubber earpieces should fit snugly and comfortably in your ears. Binaurals should be angled and strong enough so the earpieces stay firmly in place without causing discomfort. The earpieces follow the contour of the ear canal, pointing toward the face when the stethoscope is in place. The polyvinyl tubing should be flexible and 30 to 45 cm (12 to 18 inches) in length; longer tubing decreases sound transmission. Stethoscopes can have one or two tubes.

At the end of the tubing is the chest piece, consisting of a bell and diaphragm that you rotate into position, depending on which part you choose to use. To test, lightly tap to determine which side is functioning. Some stethoscopes have one chest piece that combines features of the bell and diaphragm. When you apply light pressure, the chest piece is a bell, whereas exerting more pressure converts the bell into a diaphragm. The diaphragm is the larger, circular, flat-surfaced portion of the chest piece. It transmits high-pitched sounds created by high-velocity movement of air and blood. Position the diaphragm to make a tight seal against the patient’s skin. Exert enough pressure to complete the seal, leaving a temporary red ring on the patient’s skin after you remove the diaphragm. The bell is the cone-shaped portion of the chest piece, usually surrounded by a rubber ring to avoid chilling the patient during placement. It transmits low-pitched sounds created by the low-velocity movement of blood. Hold the bell lightly against the skin for sound amplification.

SUPPLIES Click here for a list of supplies.

PATIENT AND FAMILY EDUCATION   

Teach caregivers of patients taking prescribed cardiotonic or antidysrhythmic medications how to assess apical pulse rates to check for adverse effects of medications. Teach the patient and family members not to check the apical pulse right after smoking or exercising. Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION 

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Determine the need to assess the apical pulse: o Note any risk factors for alterations in the apical pulse, including heart disease, cardiac dysrhythmias, sudden onset of chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of a large volume of intravenous (IV) fluid, internal or external hemorrhage, and administration of medications that alter heart function. Assess for signs and symptoms of altered cardiac function such as dyspnea or shortness of breath, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin. Assess for factors that affect the apical pulse rate and rhythm, such as age, smoking, exercise or activity, athletic conditioning, position changes, medication, temperature, sleep, and sympathetic stimulation. Determine the baseline, or obtain the previous reading of the patient’s apical heart rate.

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If the patient has been smoking, or has been active, allow the patient to sit and rest before assessing his or her pulse. Encourage the patient to relax and not to speak during the procedure.

DELEGATION Do not delegate this skill to nursing assistive personnel (NAP) when a pulse abnormality is suspected or when the patient’s condition warrants a more accurate assessment. Before delegating routine performance of this skill, be sure to inform NAP of the following:  

The frequency of measurement and factors related to the patient’s history, such as the risk for an abnormally slow, rapid, or irregular pulse. The patient’s usual pulse values and the need to report to you any abnormalities in rate or rhythm.

PROCEDURE 1. 2. 3. 4. 5. 6. 7.

Verify the health care provider’s orders. Gather the necessary equipment and supplies. Perform hand hygiene. Provide for the patient’s privacy. Introduce yourself to the patient and family if present. Identify the patient using two identifiers. Explain the procedure to the patient and ensure that he or she agrees to treatment. 8. Assess for factors that can affect the apical pulse rate and rhythm, such as medical history, disease processes, age, exercise, position changes, medications, temperature, or sympathetic stimulation. Gloves are only worn if nurse will be in contact with bodily fluids or the patient is in protective precautions. 9. Help the patient into a supine or sitting position, and expose the sternum and the left side of the chest. 10. Locate the point of maximal impulse (PMI, or apical impulse). To do this, find the angle of Louis, which feels like a bony prominence just below the suprasternal notch. 11. Slide your fingers down each side of the angle to find the second intercostal space (ICS). Carefully move your fingers down the left side of the sternum to the fifth intercostal space and over to the left midclavicular line. 12. Feel the PMI as a light tap about 1 to 2 centimeters in diameter, reflecting the apex of the heart. 13. If the PMI is not where you would expect, as in a patient whose left ventricle is enlarged, inch your fingers along the fifth intercostal space until you feel the PMI. 14. Remember where you felt the PMI: over the apex of the heart in the fifth intercostal space at the left midclavicular line.

15. Warm the diaphragm of the stethoscope. When it feels warm, clean it with alcohol and allow it to dry for 30 seconds. 16. Place the warmed diaphragm on the patient's chest over the PMI, and auscultate for the normal S and S heart sounds of “lub-dub.” 17. Once you can hear S and S with regularity, look at your watch. When the second hand reaches a number on the dial (or when the digital display reaches a round number), start taking the pulse, counting the first beat you hear as “one.” If the apical pulse is regular, count the rate for 30 seconds and multiply the total by 2. The pulse rate normally ranges from 60 to 100 beats per minute. If the apical pulse is irregular or the patient is taking a cardiovascular drug, count for a full 60 seconds. Also, note the patterns of irregularity with any dysrhythmia, for example, if every third beat is skipped. 18. Replace the patient’s gown and bed linen, help the patient into a comfortable position, and discuss your findings if appropriate. 19. Clean the earpieces and diaphragm of the stethoscope with an organizationapproved equipment cleaner. 20. Place toiletries and personal items within reach. 21. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 22. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. 23. Dispose of used supplies and equipment. Leave the patient’s room tidy. 24. Remove and dispose of gloves, if used. Perform hand hygiene. 25. As part of your follow-up care, compare the patient’s apical pulse rate and rhythm with the baseline and with the acceptable range for the patient’s age. 26. Document and report the patient’s response and expected or unexpected outcomes. 1

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MONITORING AND CARE  

When assessing the apical pulse for the first time, establish the apical pulse as the baseline. Compare the apical heart rate to the acceptable range for the patient age. Notify the practitioner if it is not within an acceptable range. During subsequent assessments, compare the apical rate and character with the patient’s previous baseline and the acceptable range for the patient’s age. Notify the practitioner if a change has occurred.

EXPECTED OUTCOMES  

Apical pulse is assessed and is within acceptable range. Rhythm is regular.

UNEXPECTED OUTCOMES 

Unable to assess apical pulse rate.

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Apical pulse is greater than 100 bpm (tachycardia).1 Apical pulse is less than 60 bpm (bradycardia).1 Apical pulse is irregular.

DOCUMENTATION Documentation Guidelines:     

Record apical pulse rate and if it is a regular or irregular rhythm. Document the measurement of apical pulse after administration of specific therapies. If the apical pulse is not found at the fifth intercostal space at the left midclavicular line, document the location of the point of maximal impulse. Report abnormal findings to the nurse in charge or to the health care provider. Record unexpected outcomes and related nursing interventions. Record pain assessment and management.

Sample Documentation: 1000 Apical pulse 94 and irregular. Respirations 24, regular. Temperature 36.8° C tympanic. Blood pressure 124/72 right arm, supine. Reports dizziness. Denies dyspnea, nausea, or pain. Skin pale. Physician notified. Orders received. –A. Wahlquist, RN 3/26/19

PEDIATRIC CONSIDERATIONS   

The PMI of an infant is usually located at the fourth to fifth ICS lateral to the left sternal border. In infants and children younger than 2 years, an apical pulse provides the most reliable HR assessment and is counted for 1 full minute because of possible irregularities in rhythm.2 Breath holding in an infant or child affects apical pulse rate.

GERONTOLOGICAL CONSIDERATIONS    

The PMI is often difficult to palpate in some older adults because the anteriorposterior diameter of the chest increases with age and the heart becomes repositioned because of left ventricular enlargement. When assessing older adult women with sagging breast tissue, gently lift the breast tissue and place the stethoscope at the fifth ICS or the lower edge of the breast. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. The older adult has a decreased HR at rest.1

HOME CARE CONSIDERATIONS

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Assess home environment to determine which room affords a quiet environment for auscultation of apical rate.

Apical – Radial Pulse

OVERVIEW The difference between pulses assessed from two different sites, or a pulse deficit, provides information about heart and blood vessel function. When a pulse deficit is assessed between the apical and radial pulses, the volume of blood ejected from the heart may be inadequate to meet the circulatory needs of the tissues, and intervention may be required. To assess for a pulse deficit, the nurse and a second health care provider assess a peripheral pulse rate and the apical pulse rate simultaneously and compare the measurements.

SUPPLIES Click here for a list of supplies.

ASSESSMENT AND PREPARATION 

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Assess for factors that suggest a possible pulse deficit: an irregular heart rate and signs and symptoms of decreased cardiac output, such as dyspnea, fatigue, chest pain, orthopnea, dizziness or syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin. Obtain the help of a second health care provider.

DELEGATION The skill of assessing apical-radial pulse deficit cannot be delegated to nursing assistive personnel (NAP). Collaboration between the nurse and a second health care provider is required.

PROCEDURE 1. Verify the health care provider’s orders. 2. 3. 4. 5. 6. 7.

Gather the necessary equipment and supplies. Perform hand hygiene. Introduce yourself to the patient and family, if present. Provide for the patient’s privacy. Identify the patient using two patient identifiers. Check for factors that suggest a possible pulse deficit, such as an irregular heart rate, dyspnea, fatigue, chest pain, orthopnea, or palpitations. Obtain the help of a second health care provider.

8. Explain to the patient that two people will be assessing heart function at the same time. Help the patient into a supine or sitting position, and expose the sternum and the left side of the chest. 9. Locate the apical and radial pulse sites. If possible, have the second health care provider palpate the radial pulse while you auscultate the apical pulse. 10. When the person holding the watch says “Start,” both of you should begin counting the pulse rate simultaneously for a full 60 seconds. 11. When the person holding the watch says “Stop,” stop counting and compare your findings. 12. Subtract the radial rate from the apical rate. If the difference is more than 2 beats per minute, a pulse deficit exists, reflecting the number of ineffective cardiac contractions in 1 minute. 13. Help the patient into a comfortable position. Discuss your findings with the patient as needed. 14. Perform hand hygiene. 15. As part of your follow-up care for a patient with a pulse deficit, assess for other signs and symptoms of decreased cardiac output, such as edema of dependent body parts, cyanosis or pallor of the skin, and dizziness or syncope. 16. Report the presence of a pulse deficit and any related symptoms to the nurse in charge or to the health care provider. 17. Help the patient into a comfortable position, and place toiletries and personal items within reach. 18. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 19. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. 20. Dispose of used supplies and equipment. Leave the patient’s room tidy. 21. Remove and dispose of gloves, if used. Perform hand hygiene. 22. Document and report the patient’s response and expected or unexpected outcomes.

MONITORING AND CARE   

If a pulse deficit is noted, assess for signs and symptoms of decreased cardiac output, such as dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin. Discuss your findings with the patient as needed. Report the presence of a pulse deficit and any related signs and symptoms to the nurse in charge or to the health care provider.

EXPECTED OUTCOMES  

Apical HR is assessed and is within acceptable range. Rhythm is regular.

UNEXPECTED OUTCOMES  

Unable to assess apical pulse rate. Apical pulse is greater than 100 bpm (tachycardia).

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Apical pulse is less than 60 bpm (bradycardia). Apical rhythm is irregular.

DOCUMENTATION Documentation Guidelines:  

Record the apical pulse, the radial pulse and site, and the pulse deficit. Inform the nurse in charge or the health care provider of the presence of a pulse deficit.

Assessing Pain   

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Never use physiologic responses alone to determine pain therapy. A patient’s selfreport is the gold standard. Identify patients at high risk for adverse opioid-related outcomes (e.g., patients with sleep apnea, receiving continuous IV opioids, or on supplemental oxygen).1 Know the patient’s medical history, types of therapies used, and medications, including over-the-counter (OTC) products. Many patients do not mention having used these because they fear being criticized or havi...