Vital Signs
Assessing Apical-Radial 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
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Take the Review Test:
Safety
- Use Standard Precautions when assessing an apical-radial pulse.
- Assess the apical-radial pulse for a full 60 seconds.
- If you detect a pulse deficit, immediately assess for other signs and symptoms of decreased cardiac output.
- 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 the presence of a pulse deficit, irregular pulses, irregular rhythms, or weak strength, or pulse rates of less than 60 or more than 100 beats per minute 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
The skill of assessing apical-radial pulse deficit cannot be delegated to nursing assistive personnel (NAP). Collaboration between the nurse and a second health care provider is required.
Preparation
- Assess for factors that suggest a possible pulse deficit: an irregular heart rate and signs and symptoms of decreased cardiac output, such as dyspnea, fatigue, chest pain, orthopnea, dizziness or syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin.
- Obtain the help of a second health care provider.
Follow-up
- If a pulse deficit is noted, assess for signs and symptoms of decreased cardiac output, such as dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin.
- Discuss your findings with the patient as needed.
- Report the presence of a pulse deficit and any related signs and symptoms to the nurse in charge or to the health care provider.
Documentation
- Record the apical pulse, the radial pulse and site, and the pulse deficit.
- Inform the nurse in charge or the health care provider of the presence of a pulse deficit.
Review Questions
1. What is the major health problem resulting from a pulse deficit?
INCORRECT. Bradycardia is a pulse rate less than 60 beats/minute. This can occur without a pulse deficit.
INCORRECT. Activity intolerance may or may not occur with a pulse deficit.
CORRECT. Decreased cardiac output is the major problem indicated by a pulse deficit. Decreased cardiac output may lead to other problems, such as activity intolerance.
INCORRECT. Impaired tissue perfusion may or may not occur with a pulse deficit. Decreased cardiac output may lead to impaired tissue perfusion. A cardiac dysrhythmia may lead to impaired tissue perfusion, but the impaired perfusion itself is not the most important possible result of the dysrhythmia.
2. What should the nurse do when a pulse deficit is suspected?
Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute.- Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds.
- Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute.
Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.
INCORRECT. To identify pulse deficit, the apical and radial pulses must be measured at the same time.
INCORRECT. To identify pulse deficit, the apical and radial pulses must be measured at the same time. A more accurate measurement is obtained when apical pulse rate is assessed over a longer interval (count 1 full minute).
INCORRECT. To identify pulse deficit, the apical and radial pulses must be measured at the same time.
CORRECT. The nurse counts the apical pulse while another health care provider counts the radial pulse.
3. Which action should the nurse perform after identifying a pulse deficit?
- Reassess the apical-radial pulse in 5 minutes.
- Assess the patient for signs of decreased cardiac output.
- Notify the primary health care provider of the pulse deficit.
- Initiate interventions directed toward managing the patient’s symptoms.
INCORRECT. Reassessing the apical-radial pulse is not necessary, since the pulse deficit has already been identified.
CORRECT. The patient must be assessed for cardiac manifestations of the pulse deficit.
INCORRECT. Notifying the primary health care provider of the pulse deficit is not the priority action. The nurse must first assess for cardiac manifestations of the pulse deficit.
INCORRECT. Symptom management is not the priority action. The nurse must first assess for cardiac manifestations of the pulse deficit before initiating interventions.
4. You have the following information:
Oral temperature—36.8° C;
Radial Pulse—112 weak, thready;
Apical pulse—117 regular;
Respirations—24 regular;
Blood Pressure—104/56 right arm;
Blood Pressure—102/50 left arm.
What is the pulse deficit?
INCORRECT. Pulse deficit is the difference between the apical and radial pulse rates. This is the difference in systolic pressure between the right and left arm.
CORRECT. Pulse deficit is the difference between the apical and radial pulse rates (117 – 112 = 5).
INCORRECT. Pulse deficit is the difference between the apical and radial pulse rates. This is the difference in diastolic pressure between the right and left arm.
INCORRECT. Pulse deficit is the difference between the apical and radial pulse rates. This is the difference between the systolic and diastolic pressure in the right arm, known as the pulse pressure.
5. Which of the following is an early manifestation of decreased cardiac output?
CORRECT. Fatigue is an early indicator of cardiac insufficiency.
INCORRECT. Substernal pain can be caused by a variety of disease processes (such as respiratory diseases or esophageal reflux) and does not necessarily indicate decreased cardiac output. Chest pain may occur as a later symptom of decreased cardiac output.
INCORRECT. Nail bed cyanosis can occur with respiratory or hematology diseases and does not necessarily indicate decreased cardiac output.
INCORRECT. Shortness of breath can be caused by a variety of disease processes (such as respiratory and hematology diseases) and does not necessarily indicate decreased cardiac output.
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