Assessing Apical Pulse

pt 2

2. Wipe the stethoscope with a 70% alcohol or benzalkonium chloride wipe before and after examining the patient. Cleaning can reduce the bacterial count by up to 100%. 3. Palpate the 5th intercostal space at the midclavicular line for the apical pulse. The left ventricle of the heart and the point of maximum impulse lie in this area. The apical pulse is generally best heard at the point of maximum impulse (PMI), over the apex of the heart. a. To locate the 5th intercostal space, slide your finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet). b. Slide your finger over to the left sternal border to the 2nd intercostal space. c. Now place your index or ring finger (depending on which hand you use) in the 2nd intercostal space, and count down to the 5th intercostal space by placing a finger in each of the spaces. d. Slide over to the midclavicular line, keeping your finger in the 5th intercostal space. The apical pulse is generally best heard at the PMI in the 5th intercostal space at the midclavicular line. The PMI is located over the apex of the heart. For an adult, this site is on the anterior chest at 3 inches (8 cm) or less to the left of the sternum, at the 4th, 5th, or 6th intercostal space at the midclavicular line.

pt 3

4. Palpate the apical pulse (also called the point of maximal impulse [PMI]). The pulse area should be about the size of a quarter, without lifts or heaves. A larger than normal pulsation may indicate ventricular hypertrophy. 5. Warm the stethoscope in your hand for 10 seconds. Then place the diaphragm over the PMI, and listen to the normal S1 and S2 heart sounds ("lub dub"). Count each pair of sounds ("lub-dub") as one heartbeat. A cold stethoscope placed on the skin may startle the patient and increase the heart rate. Heart sounds result when blood moves through the valves of the heart. The first heart sound is louder at the apical area and should be audible when the pulse is auscultated. 6. Count the apical heart rate for 1 full minute. Ensures accuracy. Because the apical heart rate is needed as an assessment measure for the administration of some medications (e.g., digoxin), accuracy is essential. Some cardiac conditions cause either slow or irregular rates, both of which must be counted for a full minute to ensure accuracy.

Evaluation

Are the findings within normal limits? Are there other factors supporting the findings? What are the trends over time? Is the skin pink, warm, and dry? Is there any cyanosis?

Pre-Procedure Assessment

Determine why assessment of the apical pulse is indicated. Conditions that require assessment of the apical pulse include digitalis therapy, blood loss, cardiac or respiratory disease, or other conditions that affect oxygenation status. Assess factors that may alter the pulse, such as activity and medications. If the client has been recently active, wait 10 to 15 minutes before obtaining a measurement. Activity can increase the pulse rate. Relate above factors to baseline pulse rate to determine their effect.

Documentation

Document the pulse rate, rhythm, and site. Sample documentation mm/dd/yyyy ———— 0800 ———— Apical pulse regular rhythm, and strong, rate of 64. ———— Janice Jonas, RN

Apical Pulse pt 1

Procedure Steps 1. With the client supine or sitting, expose the left side of the chest, but only as much as necessary. Prevents distortion of sound from the patient's gown rubbing on the stethoscope, while also protecting the patient's privacy.

Equipment

Watch with a second hand or second readout Stethoscope Alcohol wipes (to clean stethoscope)

What if?

What if ... *The apical rate is less than 60 beats/min?* (Note: You may also see "bpm" as an abbreviation for "beats per minute" or for "beats/min.") If the patient is taking cardiac medications, withhold them and consult with a physician about whether to adjust dosage. Certain cardiac medications (e.g., digoxin) are given to slow the heart rate; bradycardia may indicate that blood levels are too high. Assess for chest pain, dizziness, dyspnea. May indicate decreased cardiac output. *The apical rate is greater than 100 beats/min?* Obtain a complete set of vital signs. Assess for pain, anxiety, fever, dehydration, decreased oxygenation, hypotension, and decreased exercise. These factors may increase pulse rate.

Delegation

You can delegate measurement of the apical pulse to the nursing assistive personnel (NAP) if you conclude that the patient's condition and the NAP's skills allow. First perform the pre-procedure assessments. Then inform the NAP of any special considerations (e.g., to note what the patient's activity has been just before taking the pulse or to mark the time exactly so you can compare it with the patient's ECG). Ask the NAP to record and report the pulse to you, and to report immediately if it is outside normal limits (you must specify what is "normal" for each patient).