Assessing an Apical Pulse

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Assessing an Apical Pulse
Purposes
·         To obtain the heart rate of newborns, infants, and children 2 to 3 years old or an adult with an irregular peripheral pulse.
·         To establish baseline data.
·         To determine whether the cardiac rate is within normal range and rhythm is regular.
·         To monitor clients with cardiac, pulmonary or renal disease and those receiving medication to improve heart action.
Assessment
·         Clinical signs of cardiovascular alterations (e.g. dyspnea, fatigue, weakness, pallor, cyanosis, syncope
·         Factors that may alter pulse rate (e.g. emotional status, activity level and medications that affect heart rate such as digoxin, beta blockers or calcium channel blockers
Steps
Rationale
Introduce self and verify the clients identify

Perform hand Hygiene

Provide for client privacy

Position the client appropriately in a comfortable supine position or in a sitting position. Expose the area of the chest over the ap ex of the heart.

Locate the apical impulse. This is 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 of the 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

Auscultate and count heart beats
·         Use antiseptic wipes to clean the earpieces and diaphragm of the stethoscope
·         Warm the diaphragm of the stethoscope by holding it in the palm of the hand for a moment
·         Insert the earpieces of the stethoscope into your ears in the direction of the ear canals or slightly forward
·         Tap your finger lightly on the diaphragm to be sure it is the active side of the head
·         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
The diaphragm needs to be cleaned and disinfected if soiled with body substances.
The metal of the diaphragm is usually cold and can startle the client when placed immediately on the chest
To facilitate hearing
The heartbeat is normally loudest over the apex of the heart. Each lub dub is counted as one heartbeat.
The two heart sounds are produced by closure of the heart valves.
The S1 sound (lub) occurs when the



         If you have difficulty hearing the apical pulse ask the supine client to roll onto his or left side or the sitting client to lean slightly forward
         If the rhythm is regular, count the heartbeats for 39 seconds and multiply by 2. If the rhythm is irregular or giving certain medications such as digoxin count the beats for 60 seconds
atrioventricular valves close after the ventricles have been sufficiently filled. The S2 heart sound (dub) occurs when the semilunar valves close after the ventricles empty.
Positioning moves the apex of the heart closer to the chest wall
A 60 second count provides a more accurate assessment of an irregular pulse than a 30 second count
Assess the rhythm and the strength of the heart rate

Document the pulse site, rate, and rhythm in the client record.













Special Considerations

  • Any medication that could affect the heart rate.
  • Any baseline data about the normal heart rate for the client. For. E.g. a physically fit athlete may have a heart rate below 60 BPM.
  • Pulse should not be taken immediately after exercise in emotional stress and immediate after painful treatment.
  • Before measuring the pulse, review the client's baseline rate for comparison.
  • Keep client in comfortable position.
  • Do not apply too much pressure over the arteries.
  • Do not use thumb for palpation.
  • Record immediately.

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notes.nursium.com: Assessing an Apical Pulse
Assessing an Apical Pulse
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