Assessing Apical Pulse

Which action would take priority if a patient's apical pulse has an irregular rhythm? A. Reassess the pulse for 1 full minute. B. Assess the patient's peripheral pulses. C. Wait 5 minutes, and then reassess the apical pulse. D. Review documentation regarding an irregular rhythm.

A. Reassess the pulse for 1 full minute. A second measurement confirms the initial findings of an irregular heart rate. Irregular rate is more accurately assessed when measured over a longer interval. Peripheral pulse assessment is not a priority. Apical pulse is the most accurate pulse site. An irregular apical pulse already indicates an alteration in cardiac output. Waiting 5 minutes to reassess the apical pulse is not a priority action and could be dangerous in some unstable cardiac conditions. Reviewing documentation regarding an irregular rhythm is not the priority action, because establishing a history of irregular heartbeat is not essential.

Expected Outcomes

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

Assessment

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. 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.

What is the primary purpose of initially assessing an apical pulse? A. Assessment of the patient's cardiac function B. Establishment of a baseline as part of the patient's vital signs C. Assessment of the patient's risk for cardiovascular disease D. Determination of oxygen saturation

B. Establishment of a baseline as part of the patient's vital signs The primary purpose for initially assessing an apical pulse is establishing a baseline for the patient against which future assessments of apical pulse rate can be compared. The apical pulse rate provides some information about the patient's cardiac function; however, obtaining such information is not the primary goal of conducting this assessment at this time. Measuring the apical pulse rate does not adequately assess the patient's risk for cardiovascular disease. Other factors (such as age, smoking, dietary patterns, and exercise habits) contribute to the risk for cardiovascular disease. Pulse oximetry is the measurement of arterial blood oxygen saturation, not an apical pulse.

The nurse can best determine the effect of crying on a patient's apical pulse by doing what? A. Measuring the patient's apical pulse before and after crying B. Assessing the patient's apical pulse 30 minutes after crying C. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate D. Measuring the patient's pulse deficit after cryingD. Measuring the patient's pulse deficit after crying

C. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate The comparison of apical pulse rates at these times is the best means of evaluating the effect of crying on the patient's apical pulse rate. These values would be available data to compare. It is unlikely that the nurse will have the opportunity to measure the patient's apical pulse before and after crying. The time interval of 30 minutes is too long to effectively assess the effect of the crying on the apical pulse. Pulse deficit indicates alterations in cardiac output, not the effect of the emotional reaction.

Which statement demonstrates an understanding of the importance of communicating changes in the patient's apical pulse rate? A. "The patient's apical pulse is recorded as you asked." B. "The apical pulse is more difficult to hear when the patient is sitting up." C. "The apical pulse is usually slower in the morning than it is in the afternoon." D. "The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom."

D. "The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom." This statement identifies a significant change in the patient's apical pulse rate and the reason for the deviation in the rate. Recording the patient's apical pulse pertains to documentation, not to changes in apical pulse rate. While sitting up may make it more difficult to hear the apical pulse this may be true for an individual patient, it does not pertain to changes in the patient's apical pulse rate. The general statement that the apical pulse is usually slower in the morning than it is in the afternoon may or may not be accurate; it does not pertain to a significant change in the patient's apical pulse rate.

What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient's apical pulse? A. Document the patient's pulse rate and rhythm. B. Place the patient in the right lateral position before measuring the apical pulse. C. Review the patient's previous apical pulse measurements. D. Place your stethoscope at the fifth intercostal space over the left midclavicular line.

D. Place your stethoscope at the fifth intercostal space over the left midclavicular line. These anatomical landmarks allow correct placement of the stethoscope over the apex of the heart. Documenting the patient's pulse rate and rhythm pertains to documentation, not technique. The patient may assume a sitting or supine position before measuring the apical pulse. The heart is located to the left of the sternum. If unable to locate the point of maximal impulse (PMI), reposition the patient on the left side to hear the sounds more clearly. Reviewing the patient's previous apical pulse measurements does not pertain specifically to the technique or procedure itself.

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.

Risk Factors

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.

Documentation

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.

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.

Gerantological considerations

The PMI is often difficult to palpate in some older adults because the anterior-posterior 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.

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. Breath holding in an infant or child affects apical pulse rate.

T/F The apical pulse is the most reliable noninvasive way to assess cardiac function.

True

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 pulse is irregular.

Procedure

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. 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. Help the patient into a supine or sitting position, and expose the sternum and the left side of the chest. 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. 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. Feel the PMI as a light tap about 1 to 2 centimeters in diameter, reflecting the apex of the heart. 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. Remember where you felt the PMI: over the apex of the heart in the fifth intercostal space at the left midclavicular line. Warm the diaphragm of the stethoscope. When it feels warm, clean it with alcohol and allow it to dry for 30 seconds. Place the warmed diaphragm on the patient's chest over the PMI, and auscultate for the normal S1 and S2 heart sounds of "lub-dub." Once you can hear S1 and S2 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. Replace the patient's gown and bed linen, help the patient into a comfortable position, and discuss your findings if appropriate. Clean the earpieces and diaphragm of the stethoscope with an organization-approved equipment cleaner. 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. 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. Document and report the patient's response and expected or unexpected outcomes.

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.

The five major parts of the stethoscope are the

earpieces, binaurals, tubing, bell, and diaphragm.

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, S1 and S2. S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systole begins. S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.