Assessing an apical pulse

Performance

1. Prior to performing the procedure introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do why it is necessary and how he or she can participate. Discuss how the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe appropriate infection prevention procedures. 3. Provide for client privacy. 4. Position the client appropriately in a comfortable supine position or in a sitting position. Expose the area of the chest over the apex of the heart. 5. Locate the apical impulse. This is the point over the apex of the heart where the apical pulse can be most clearly heard. Palpate the angle of louis the angle between the manubrium the top of the sternum and the body of the sternum. It is palpated just below the suprasternal notch and is felt as a prominence Slide your index finger just to the left sternum and palpate the second intercostal space. Place your middle or next finger in the third intercostal space and continue palpating downward until you locate the fifth intercostal space. Move your index finger laterally along the fifth intercostal space toward the MCL. Normally the apical impulse is palpable at or just medial to the MCL. 6. Auscultate and count hearbeats. Use antiseptic wipes to clean the earpieces and diaphragm of the stethoscope. Rationale: the diaphragm needs to be cleaned and disinfected if soiled with body substances. Both earpieces and diaphragms have been shown to harbor pathogenic bacteria. Warm the diaphragm of the stethoscope by holding it in the palm of the hand for a moment. Rationale: The mental of the diaphragm is usually cold and can startle the client when placed immediately on the chest. Insert the earpieces of the stethoscope into your ears in the direction of the ear canals or slightly forward. Rationale: This position facilitates hearing Tap your finger lightly on the diaphragm Rationale: this is to be sure it is the active side of the head if necessary rotate the head to select the diaphragm side Place the diaphragm of the stethoscope over the apical impulse and listen for the normal S1 and S2 heart sounds which are heard as lub- dub. Rationale: the heartbeat is normally loudest over the apex of the heart. Each lub dub is counted as one heartbeat. Rationale: The two heart sounds are produced by closure of the heart valves. The S1 heart sound lub occurs when the atrioventricular valves close after the ventricles have been sufficiently filled. The S2 heart sound dub occurs when the semi lunar valves close after the ventricles empty. If you have difficulty hearing the apical pulse ask the supine client to roll onto his or her left side or the sitting client to lean slightly forward. Rationale: this positioning moves the apex of the heart closer to the chest wall. If the rhythm is regular count the heartbeats for 30 seconds and multiply by 2. If the rhythm is irregular or for giving certain medications such as digoxin, count the beats for 60 seconds. Rationale: a 60 second count provides a more accurate assessment of an irregular pulse than a 30 second count. 7.Assess the rhythm and the strength of the heartbeat. Assess the rhythm of the heartbeat by noting the pattern of intervals between the beats. A normal pulse has equal time period between beats. Assess the strength volume of the heartbeat. Normally the heartbeats are equal in strength and can be described as strong or weak. 8. Document the pulse rate and rhythm and nursing actions in the client record. Also record pertinent related data such as variation in pulse rate compared to normal for the client and abnormal skin color and skin temperature.

Preparation

If using a DUS check that the equipment is functioning normally.

Evaluation

Relate the pulse rate to other vital signs relate the pulse rhythm to baseline data and health status. Report to the primary care provider any abnormal findings such as irregular rhythm reduced ability to hear the heartbeat pallor cyanosis, dyspnea, tachycardia, or bradycardia. Conduct appropriate follow up such as administering medication ordered based on apical heart rate.

SAMPLE DOCUMENTATION

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Purposes

To obtain the heart rate of an adult with an irregular peripheral pulse To establish baseline data for subsequent evaluation. To determine whether the cardiac rate is with in normal rage and the rhythm is regular. To monitor clients with cardiac pulmonary or renal disease and those receiving medications to improve heart action.

Assess

clinical signs of cardiovascular alterations such as dyspnea difficult respiration fatique weakness pallor cyanosis bluish ids coloration of skin and mucous membranes palpitations syncope fainting or impaired peripheral tissue perfusion as evidenced by skin discoloration and cool temperature. Factors that may alter pulse rate emotional status activity level and medications that affect heart rate such as digoxin beta blockers or calcium channel blockers.

Equipment

clock or watch with a sweep second hand or digital seconds indicator stethoscope Antiseptic wipes If using a DUS the transducer probe the stethoscope headset transmission gel and tissues wipes.

Delegation

due to the degree of skill and knowledge required UAP are generally not responsible for assessing apical pulses.