Question

SKILLNAME Palpate Apical Pulse REVIEW MODULE CHAPTER Description of Skill Indications CONSIDERATIONS Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing interventions

Answer 1

Apical pulse is located in 5th intercoastal space of chest.

Description of the skill:

• To locate and palpate apical pulse, first palpate 2nd intercoastal space.
• 2nd intercoastal space can be identified by initial palpation the space or notch above the sternum
• From there move down ward and you can palpate a notch.
• Then move to the left of the patient and there you can find 2nd intercoastal space.
• Then move to the 5th intercoastal space down where we can locate apical pulse.
• Then place a stethoscope and listen with the help of diaphragm
• Record the nature of the pulse whether it is strong or weak
• Count the pulse for 1 full minute.

Indications : Digioxin administration and Arrythmias

Nursing actions through out the procedure

Pre : Explain in detail about the procedure, indications and steps of the procedure.

Ask the patient to be on bare chest, in case of females privacy must be maintained.

Make stethescope ready for the procedure.

Intra: Communicate with the patient through out the procedure.

Explain every step of the procedure

Also speak about the findings noted during the procedure

Palpate and make sure you are locating the correct site

Note all the findings

Post: After the procedure make the patient to feel comfortable.

Allow the patient to speak , and clarify all the concerns

Explain all the findings in detail

Out comes or the Evaluation are the findings notified from the procedure.

Client education is based up on findings of the pulse, the nature , rhythm and frequencies e.g.. AFIB, sinus tachycardia, RVR etc.

Potential complications: Hypotension, inadequate blood supply because of fear and anxiety etc.