Assessing an Apical Pulse
Purposes
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To obtain the heart rate of newborns, infants,
and children 2 to 3 years old or an adult with an irregular peripheral pulse.
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To establish baseline data.
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To determine whether the cardiac rate is within
normal range and rhythm is regular.
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To monitor clients with cardiac, pulmonary or
renal disease and those receiving medication to improve heart action.
Assessment
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Clinical signs of cardiovascular alterations
(e.g. dyspnea, fatigue, weakness, pallor, cyanosis, syncope
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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
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Steps
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Rationale
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Introduce
self and verify the clients identify
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Perform
hand Hygiene
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Provide
for client privacy
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Position
the client appropriately in a comfortable supine position or in a sitting
position. Expose the area of the chest over the ap
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Locate
the apical impulse. This is point over the apex of the heart where the apical
pulse can be most clearly heard.
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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.
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Slide your index finger just to the left of
the sternum and palpate the second intercostal space.
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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
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Auscultate and count heart beats
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Use antiseptic wipes to clean the earpieces
and diaphragm of the stethoscope
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Warm the diaphragm of the stethoscope by
holding it in the palm of the hand for a moment
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Insert the earpieces of the stethoscope into
your ears in the direction of the ear canals or slightly forward
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Tap your finger lightly on the diaphragm to be
sure it is the active side of the head
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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
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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
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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
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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
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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
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Assess
the rhythm and the strength of the heart rate
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Document
the pulse site, rate, and rhythm in the client record.
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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.
COMMENTS