Question

Skill name:: palpate apical pulse

what is the Description of this skill?

what are the indicators?

what are the nursing interventions (pre, intra, post)?

what are the outcomes/evaluation?

what is the client education for this skill?

what are the potential complications?

what are the nursing interventions?

Answer 1

Nurses usually perform apical pulse assessment during a head-to-toe assessment and before administering medications like Digoxin. Apical pulse is located on the left side of the chest at the 5th intercostal space (ICS) at the midclavicular line. The point of maximal impulse located at the apex of the heart can be measured by apical pulse assessment.

The normal apical pulse rate is typically between 60-100 beats per minute (bpm) in adults and children have a higher resting pulse rate than adults.

Apical pulse rate assessment is useful when patients are taking certain cardiovascular medications like digoxin.

Procedure for Measuring the Apical Pulse:

Inform the patient about the procedure.

Assess age, exercise, position changes, medications, temperature, and sympathetic stimulation (factors that influence apical pulse rate and rhythm).

Perform proper hand hygiene and maintain patient privacy.

Expose patient's sternum and left the side of the chest, in positions like supine or upright.

Palpate the PMI at fifth intercostal space in the left midclavicular line. Check for light tapping in 1- to a 2-cm area at PMI.

Place diaphragm of the stethoscope over PMI (warm it before applying), and auscultate for normal S1 and S2 heart sounds.

Count the apical rate, starting with zero, while looking at watch's second hand.

Count for a full minute or 60 seconds.

Note regularity of pulse for any dysrhythmia.

Perform hand hygiene after the procedure.

The earpieces and diaphragm of stethoscope must be cleaned with alcohol.

Document apical pulse rate, rhythm and compare to previous measurements, if any.

Special considerations: It is hard to palpate the apical pulse in obese or thick chest patients. Ask the patient to lift the breast if the patient’s large breasts interfere with the pulse checking.

As it is a non-invasive procedure there are no potential complications involved, if the procedure is performed correctly.