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

Description of skill- apical pulse is the strong rythymic pulsation felt in the apex of the heart. It is the noninvasive method of assessing the function of the heart. It should be assessed for one minute,should check both number and quality of the beat.

Needed skills are:

- skill to locate the 5th intercostal space

- knowledge of using stethoscope. Diaphragm region of the stethoscope is used for auscultation of apical pulse. In palpaton apical pulse, person should have the skill to locate 5th inter coastal space.

Indicators for palpation of apical pulse-

-for checking the cardiac function .

- for checking the functions of valves in the heart.

Nursing intervention in apical pulse palpation:

Pre:

- take history of patient like any cardiac disease or congenital abnormalities,or family history because all these factors can influence the apical pulse.

-provide privacy

-provide comfortable position(usually supine position is given if not medically contraindicated)

-explain the procedure to the patient.

- arrange equipments like stethoscope,wrist watch, pen/pencil, record form,alcohol swab

Intra:

-run the fingers gently through the ribs and locate 5th intercostal space and keep the stethoscope over the area and auscult the pulse.

-if the patient is obese or have large breast then advice patient to lean a little towards left side this will enhance accurate palpation.

Post:

-cover the patient if chest is exposed for palpation.

-explain the outcome of the procedure.

-provide comfortable position.

- record the findings. And report and abnormal findings to the concern doctors or charge nurse.

Outcome of apical pulse palpation (adults)are:

- pulse>100 means tachycardia

-pulse <100 means bradycardia

-irregular pulse

Client education skills:

-if the patient has any abnormal findings then advice patient to follow doctors order like taking medication on time, if needed and lifestyle modification like exercise and diet change then refer patient to dietician.

Complications of palpation of apical pulse: there is no such complications.