Vital Signs
Assessing Apical Pulse
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- » Taking a Temperature
- » Assessing Radial Pulse
- » Assessing Apical Pulse
- » Assessing Apical-Radial Pulse
- » Assessing Respiration: Rate, Rhythm, and Effort
- » Obtaining Blood Pressure by the One-Step Method
- » Obtaining Blood Pressure by the Two-Step Method
- » Measuring Oxygen Saturation with Pulse Oximetry
- » Assessing Pain
- » Measuring Height and Weight
Take the Review Test:
Safety
- Use Standard Precautions when assessing an apical pulse.
- If the apical rate is abnormal or irregular, repeat the assessment or have another nurse do it. The second assessment can confirm your findings or identify an error.
- If the pulse is irregular, assess for a pulse deficit, which may indicate an alteration in cardiac output. (For details, see Assessing Apical-Radial Pulse.)
- Routinely clean the earpieces and diaphragm of the stethoscope with alcohol after each use.
- Assess the patient for latex allergy. If the patient has a latex allergy, ensure that the stethoscope is latex free.
- Report an apical pulse of less than 60 or more than 100 beats per minute or an irregular rhythm to the health care provider without delay. Immediate intervention may be needed.
Equipment
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Stethoscope
Watch with second hand or digital display
Alcohol swab
PrintableDelegation
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
Preparation
- Determine the need to assess the apical pulse:
- 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.
- Assess for signs and symptoms of altered cardiac function such as dyspnea, 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, exercise, position changes, medication, temperature, and sympathetic stimulation.
- Determine the baseline, or obtain the previous reading of the patient’s apical heart rate.
- Determine any report of latex allergy. If the patient has a latex allergy, ensure that the stethoscope is latex free.
Follow-up
- 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.
- During subsequent assessments, compare the apical rate and character with the patient’s previous baseline and the acceptable range for the patient’s age.
Documentation
- Record apical pulse rate and 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.
Review Questions
1. What is the primary purpose of initially assessing an apical pulse?
Assessment of the patient’s cardiac function
Establishment of a baseline as part of the patient’s vital signs- Assessment of the patient’s risk for cardiovascular disease
- Determination of oxygen saturation
INCORRECT. 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.
CORRECT. This assessment establishes a baseline for the patient against which future assessments of apical pulse rate can be compared.
INCORRECT. 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.
INCORRECT. Pulse oximetry is the measurement of arterial blood oxygen saturation, not an apical pulse.
2. What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient’s apical pulse?
- Document the patient’s pulse rate and rhythm.
- Place the patient in the right lateral position before measuring the apical pulse.
- Review the patient’s previous apical pulse measurements.
- Place your stethoscope at the fifth intercostal space over the left midclavicular line.
INCORRECT. This information pertains to documentation, not technique.
INCORRECT. 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.
INCORRECT. This statement does not pertain specifically to the technique or procedure itself.
CORRECT. These anatomical landmarks allow correct placement of the stethoscope over the apex of the heart.
3. Which action would take priority if a patient’s apical pulse has an irregular rhythm?
- Reassess the pulse for 1 full minute.
- Assess the patient’s peripheral pulses.
- Wait 5 minutes, and then reassess the apical pulse.
- Review documentation regarding an irregular rhythm.
CORRECT. A second measurement confirms the initial findings of an irregular heart rate. Irregular rate is more accurately assessed when measured over a longer interval.
INCORRECT. 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.
INCORRECT. Waiting 5 minutes to reassess the apical pulse is not a priority action and could be dangerous in some unstable cardiac conditions.
INCORRECT. This is not the priority action, because establishing a history of irregular heartbeat is not essential.
4. Which statement demonstrates an understanding of the importance of communicating changes in the patient’s apical pulse rate?
- “The patient’s apical pulse is recorded as you asked.”
- “The apical pulse is more difficult to hear when the patient is sitting up.”
- “The apical pulse is usually slower in the morning than it is in the afternoon.”
- “The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom.”
INCORRECT. This statement pertains to documentation, not to changes in apical pulse rate.
INCORRECT. While this may be true for an individual patient, it does not pertain to changes in the patient’s apical pulse rate.
INCORRECT. This general statement may or may not be accurate; it does not pertain to a significant change in the patient’s apical pulse rate.
CORRECT. This statement identifies a significant change in the patient’s apical pulse rate and the reason for the deviation in the rate.
5. The nurse can best determine the effect of crying on a patient’s apical pulse by doing what?
- Measuring the patient’s apical pulse before and after crying
- Assessing the patient’s apical pulse 30 minutes after crying
- Measuring the patient’s pulse deficit after crying
- Comparing the patient’s post-crying apical pulse rate with her baseline or previous rate.
INCORRECT. It is unlikely that the nurse will have the opportunity to measure the patient’s apical pulse before and after crying.
INCORRECT. The time interval of 30 minutes is too long to effectively assess the effect of the crying on the apical pulse.
INCORRECT. Pulse deficit indicates alterations in cardiac output, not the effect of the emotional reaction.
CORRECT. 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.
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