Assessing Apical-Radial Pulse

Expected Outcomes

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

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.

Report presence of

A pulse deficit, irregular pulses, irregular rhythms, or weak strength, or pulse rates of less than 60 or more than 100 beats per minute to the health care provider without delay. Immediate intervention may be needed.

Which of the following is an early manifestation of decreased cardiac output? A. Fatigue B. Substernal pain C. Nail bed cyanosis D. Shortness of breath

A. Fatigue Fatigue is an early indicator of cardiac insufficiency. Substernal pain can be caused by a variety of disease processes (such as respiratory diseases or esophageal reflux) and does not necessarily indicate decreased cardiac output. Chest pain may occur as a later symptom of decreased cardiac output. Nail bed cyanosis can occur with respiratory or hematology diseases and does not necessarily indicate decreased cardiac output. Shortness of breath can be caused by a variety of disease processes (such as respiratory and hematology diseases) and does not necessarily indicate decreased cardiac output.

Assessment and Preparation

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.

You have the following information: Oral temperature-36.8°C.Radial Pulse-112 weak, threadyApical pulse-117 regularRespirations-24 regularBlood Pressure-104/56 right arm-102/50 left arm What is the pulse deficit? A. 2 B. 5 C. 6 D. 48

B. 5 Pulse deficit is the difference between the apical and radial pulse rates (117 - 112 = 5). The answer 2 is the difference in systolic pressure between the right and left arm. The answer 6 is the difference in diastolic pressure between the right and left arm. The answer 48 is the difference between the systolic and diastolic pressure in the right arm, known as the pulse pressure.

Which action should the nurse perform after identifying a pulse deficit? A. Reassess the apical-radial pulse in 5 minutes. B. Assess the patient for signs of decreased cardiac output. C. Notify the primary health care provider of the pulse deficit. D. Initiate interventions directed toward managing the patient's symptoms.

B. Assess the patient for signs of decreased cardiac output. The patient must be assessed for cardiac manifestations of the pulse deficit. Reassessing the apical-radial pulse is not necessary, since the pulse deficit has already been identified. Notifying the primary health care provider of the pulse deficit is not the priority action. The nurse must first assess for cardiac manifestations of the pulse deficit. Symptom management is not the priority action. The nurse must first assess for cardiac manifestations of the pulse deficit before initiating interventions.

What is the major health problem resulting from a pulse deficit? A. Bradycardia B. Activity intolerance C. Decreased cardiac output D. Impaired tissue perfusion

C. Decreased cardiac output Decreased cardiac output is the major problem indicated by a pulse deficit. Decreased cardiac output may lead to other problems, such as activity intolerance. Bradycardia is a pulse rate less than 60 beats/minute. This can occur without a pulse deficit. Activity intolerance may or may not occur with a pulse deficit. Impaired tissue perfusion may or may not occur with a pulse deficit. Decreased cardiac output may lead to impaired tissue perfusion. A cardiac dysrhythmia may lead to impaired tissue perfusion, but the impaired perfusion itself is not the most important possible result of the dysrhythmia.

What should the nurse do when a pulse deficit is suspected? A. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute. B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds. C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute. D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.

D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse. The nurse counts the apical pulse while another health care provider counts the radial pulse. To identify pulse deficit, the apical and radial pulses must be measured at the same time. A more accurate measurement is obtained when apical pulse rate is assessed over a longer interval (count 1 full minute).

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.

If you detect a pulse deficit

Immediately assess for other signs and symptoms of decreased cardiac output.

Documentation

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.

Pulse Deficit

The difference between pulses assessed from two different sites. Provides information about heart and blood vessel function.

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.

Unexpected Outcomes

Unable to assess apical pulse rate. Apical pulse is greater than 100 bpm (tachycardia). Apical pulse is less than 60 bpm (bradycardia). Apical rhythm is irregular.

Procedure

Verify the health care provider's orders. 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. 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. 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. When the person holding the watch says "Start," both of you should begin counting the pulse rate simultaneously for a full 60 seconds. When the person holding the watch says "Stop," stop counting and compare your findings. 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. Help the patient into a comfortable position. Discuss your findings with the patient as needed. Perform hand hygiene. 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. Report the presence of a pulse deficit and any related symptoms to the nurse in charge or to the health care provider. Help the patient into a comfortable position, and place toiletries and personal items within reach. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. To ensure the patient's safety, raise the appropriate number of side rails and lower the bed to the lowest position. Dispose of used supplies and equipment. Leave the patient's room tidy. Remove and dispose of gloves, if used. Perform hand hygiene. Document and report the patient's response and expected or unexpected outcomes.

Assess the apical-radial pulse for ___________________.

a full 60 seconds