Assessing the Apical Pulse
Equipment for apical pulse
1. Stethoscope 2. Wristwatch with second hand or digital display 3. Pen, vital sign flow sheet, or patient's electronic health record 4. Alcohol swab, to clean diaphragm and earpiece
Delegation of Apical Pulse
Can be delegated to nursing assistive personnel (NAP) if the patient is stable and not at high risk for acute or serious cardiac problems
17
Check to see if patient is comfortable. -Sense of well being
20
Compare readings with previous baseline and or acceptable range of heart rate for patient's age. (can verbalize) -Evaluates for change in condition and alterations.
15
Determine pattern, as regular or irregular. If irregular, describe pattern of irregularity. -Irregular heart rate indicates dysrhythmia. Regular occurrence of dysrhythmia within 1 minute indicates inefficient contraction of heart and alteration in cardiac output.
24
Document the skill
21
Evaluate patient response to procedure. If abnormal response/readings are noted, notify your instructor and the staff nurse assigned to the patient
12
Locate the apical pulse at the fifth intercostal space (ICS) in the midclavicular line (MCL). - This anatomical landmark allows correct placement of stethoscope over the apex of the heart, enhancing ability to hear sounds clearly. -If unable to palpate point of maximal impulse (PMI), reposition patient to left side. -In the presence of serious heart disease, OMI is located to left of the MCL or at 6th ICS.
25
Maintain patient confidentiality.
Mandatory Skills 1-10
Mandatory Skills 1-10
19
Observe and document finding appropriately, note the rhythm and intensity.
23
Perform hand hygeine. 24
13
Place diaphragm of stethoscope in palm of hand for 5 - 10 seconds. -Prevents pt from becoming startled due to cold stethoscope
14
Place diaphragm of stethoscope over PMI and auscultate for normal S1 and S heart sounds (lub-dub) for a full minute. -Normal S1 and S2 sounds are high pitched and best heard with a diaphragm
11
Position patient properly in supine position or sitting position and expose chest area. Move aside bed linen is possible.
22
Record pulse rate, rhythm, and strength and patient response. (can verbalize)
16
Replace patient's gown and bed linen. Return patient to a comfortable position if necessary. -Restore comfort for patient
18
Wash hands and cleans stethoscope (diaphragm and earpiece). -Reduce microorganisms
