Question

Skill name:: Palpate apical pulse

All questions must be answered based on the skill listed above:

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

Apical pulse:

The pulsation located at the topmost section of the heart is termed as the apical pulse. It is located on the left side of the chest at the 5th intercostal space (ICS) at the midclavicular line. An apical pulse can be measured by listening over the apex of the heart using a stethoscope.

How to Assess the Apical Pulse:

• Make the patient lie on supine position.
• First, you need to locate the apical pulse. Then you will palpate, listen to it, and count it.
• To find the pulse, do it in these steps:

1. Located the sternal notch. It is located between the clavicles, and it’s literally a notched out area above the sternum.
2. Go down slightly with your index finger and you will feel a “hump”. This is known as the Angle of Louis.
3. Then slide your finger over to the patient’s left to the midclavicular line. Here you will be at the 2nd intercostal space, midclavicular line.
4. Proceed downward and count the intercostal spaces until you reach the 5th ICS. This is the location of the apical pulse.
5. Palpating the Apical Pulse: Place your hand over the site.
6. Note the light thumping sensation…is it regular or irregular, strong, weak?

It is always important to palpate the apical pulse prior to the auscultation to locate the landmark of the apical pulse.

Apical pulse rate is indicated during some assessments, such as when conducting a cardiovascular assessment and when a client is taking certain cardiac medications (e.g., digoxin).

Listening to the apical pulse is basically listening directly to the heart. It’s a very reliable and noninvasive way to evaluate cardiac function. It’s also the preferred method for measuring heart rate in children.

Nursing Intervention

• Before performing the procedure , explain the procedure to the patient.
• Assess for factors that influence apical pulse rate and rhythm: age, exercise, position changes, medications, temperature, and sympathetic stimulation.
• Perform hand hygiene and ensure patient privacy.
• Expose patient's sternum and left side of chest.
• Palpate for PMI at fifth intercostal space in left midclavicular line. Feel for light tapping in 1- to 2-cm area at PMI.
• Check the regularity of pulse.
• Perform hand hygiene.
• Document the findings.