80

SKILL 5-3

Assessing Apical Pulse

NSO

Basic Skills / Vital Signs / Assessing the Apical Pulse

Vital Signs Module / Lesson 3

Earpiece

The apical pulse is the most reliable noninvasive way to assess cardiac function. The apical pulse rate is the assessment of the number and quality of apical sounds in 1 minute. Each apical pulse is the combination of two sounds, S1 and S2. S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular lling, just before systolic contraction begins. S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction. You will use a stethoscope to auscultate sound waves of the apical pulse (Fig. 5-8). The stethoscope is a closed cylinder that amplies sound waves as they reach the bodys surface. The ve major parts of the stethoscope are the earpieces, binaurals, tubing, bell, and diaphragm. The plastic or rubber earpieces should t snugly and comfortably in your ears. Binaurals should be angled and strong enough so the earpieces stay rmly in place without causing discomfort. The earpieces follow the contour of the ear canal, pointing toward the face when the stethoscope is in place.

Binaurals

Tubing

Chestpiece

Bell Diaphragm

FIG 5-8
Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Acoustic stethoscope.

SKILL 5-3

The polyvinyl tubing should be exible and 30 to 45 cm (12 to 18 inches) in length; longer tubing decreases sound transmission. The tubing should be thick walled and moderately rigid to eliminate transmission of environmental noise and to prevent kinking. Stethoscopes can have one or two tubes. The chestpiece consists of a bell and diaphragm that you rotate into position depending on which part you choose to use. To test, lightly tap to determine which side is functioning. Some stethoscopes have one chestpiece that combines features of the bell and diaphragm. When you apply light pressure, the chestpiece is a bell, whereas exerting more pressure converts the bell into a diaphragm. The diaphragm is a circular at-surfaced portion of the chestpiece covered with a plastic disk. It transmits high-pitched sounds created by high-velocity movement of air and blood. Position the diaphragm to make a tight seal against the patients skin. Exert enough pressure to complete the seal, leaving a temporary red ring on the patients skin after you remove the diaphragm. The bell is the cone-shaped portion of the chestpiece usually surrounded by a rubber ring to avoid chilling the patient during placement. It transmits low-pitched sounds created by the low-velocity

movement of blood. Hold the bell lightly against the skin for sound amplication.

Delegation Considerations
Often you measure the apical pulse when you suspect an irregularity in the radial pulse or when a patients condition requires a more accurate assessment. In this situation, pulse assessment cannot be delegated to NAP. When measurement of apical pulse is a routine practice, you can delegate it to NAP. The nurse directs the NAP about: Specic factors related to the patient history, usual values, or risk for abnormally slow, rapid, or irregular pulse. Frequency of assessment needed Need to report any abnormalities in rate or rhythm to the nurse.

Equipment
Stethoscope Wristwatch with second hand or digital display Pen, pencil, vital sign ow sheet or record form Alcohol swab

STEP
ASSESSMENT 1 Determine need to assess apical pulse: a Assess for any risk factors for apical pulse alteration: Heart disease Cardiac dysrhythmias Onset of sudden chest pain or acute pain from any site Invasive cardiovascular diagnostic tests Surgery Sudden infusion of large volume of IV uid Internal or external hemorrhage Administration of medications that alter heart function b Assess for signs and symptoms of altered cardiac function such as dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, cyanosis or pallor of skin (see Chapter 6). c Assess for factors that normally inuence apical pulse rate and rhythm: (1) Age

RATIONALE

Certain conditions place patients at risk for pulse alterations.

Physical signs and symptoms indicate alteration in cardiac output or stroke volume.

(2) Exercise

(3) Position changes (4) Medications

(5) Temperature (6) Sympathetic stimulation

2 Determine previous baseline apical rate (if available) from 3

Allows nurse to anticipate factors that will alter apical pulse, ensuring an accurate interpretation. Infants heart rate at birth ranges from 100 to 160 beats per minute at rest; by age 2, pulse rate slows to 90 to 140 beats per minute; by adolescence, rate varies between 60 and 100 beats per minute and remains so throughout adulthood. Physical activity increases HR; a well-conditioned patient may have a slower-than-usual resting HR that returns more quickly to resting rate after exercise. Heart rate increases temporarily when changing from lying to sitting or standing position. Antidysrhythmics, sympathomimetics, and cardiotonics affect rate and rhythm of pulse; large doses of narcotic analgesics can slow HR; general anesthetics slow HR; central nervous system stimulants such as caffeine can increase HR. Fever or exposure to warm environments increases HR; HR declines with hypothermia. Emotional stress, anxiety, or fear results in stimulation of the sympathetic nervous system, which increases HR. Allows nurse to assess for change in condition.

patients record. Determine any report of latex allergy. If patient has latex allergy, ensure that stethoscope is latex free.
Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

82
STEP
NURSING DIAGNOSES Activity intolerance

RATIONALE

Decreased cardiac output

Ineffective tissue perfusion

Individualize related factors based on patients condition or needs.

PLANNING 1 Expected outcomes following completion of procedure: Apical heart rate is within acceptable range. Rhythm is regular. 2 Explain to patient that you will assess apical pulse rate. Encourage patient to relax, and ask patient not to speak. If patient has been active, wait 5 to 10 minutes before assessing pulse. If patient has been smoking, wait 15 minutes before assessing pulse. IMPLEMENTATION 1 Perform hand hygiene. 2 If necessary, draw curtain around bed and/or close door. 3 Assist patient to supine or sitting position. Move aside bed linen and gown to expose sternum and left side of chest. 4 Locate anatomical landmarks to identify the point of maximal impulse (PMI), also called the apical impulse (see Chapter 6). Heart is located behind and to left of sternum with base at top and apex at bottom. Find Angle of Louis just below suprasternal notch between sternal body and manubrium; it feels like a bony prominence (see illustration A). Slip ngers down each side of angle to nd second intercostal space (ICS) (illustration B). Carefully move ngers down left side of sternum to fth ICS and laterally to the left midclavicular line (MCL) (illustration C). A light tap felt within an area 1 to 2 cm (12 to 1 inch) of the PMI is reected from the apex of the heart (illustration D).

Adults average 60 to 100 beats per minute. Cardiovascular status is stable. Anxiety, activity, and smoking elevate heart rate. Patients voice interferes with nurses ability to hear sound when measuring apical pulse. Assessing apical pulse rate at rest allows for objective comparison of values.

Reduces transmission of microorganisms. Maintains privacy and minimizes embarrassment. Exposes portion of chest wall for selection of auscultatory site. Use of anatomical landmarks allows correct placement of stethoscope over apex of heart. This position enhances ability to hear heart sounds clearly. If unable to palpate the PMI, reposition patient on left side. In the presence of serious heart disease, you may locate the PMI to the left of the MCL or at the sixth ICS.

D
STEP 4 A, Nurse locates sternal notch. B, Nurse locates second intercostal space. C, Nurse locates fth intercostal space. D, Nurse locates point of maximal impulse at intercostal space at the midclavicular line.
Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-3

83

STEP
5 Place diaphragm of stethoscope in palm of hand for 5 to

RATIONALE
Warming of metal or plastic diaphragm prevents patient from being startled and promotes comfort. Allow stethoscope tubing to extend straight without kinks that would distort sound transmission. Normal sounds S1 and S2 are high pitched and best heard with the diaphragm.

10 seconds. 6 Place diaphragm of stethoscope over PMI at the fth ICS, at the left MCL, and auscultate for normal S1 and S2 heart sounds (heard as lub-dub) (see illustrations).

1 2 3 4 5 6 PMI 7 8 9 10

A
STEP 6 7

B
A, Location of point of maximal impulse (PMI) in adult. B, Stethoscope over PMI.

8 9 10

11

When you hear S1 and S2 with regularity, use second hand of watch and begin to count rate: when sweep hand hits number on dial, start counting with zero, then one, two, and so on. If apical rate is regular, count for 30 seconds and multiply by 2. If heart rate is irregular, or patient is receiving cardiovascular medication, count for a full 1 minute (60 seconds). Note regularity of any dysrhythmia (S1 and S2 occurring early or late after previous sequence of sounds; e.g., every third or every fourth beat is skipped). Replace patients gown and bed linen; assist patient in returning to comfortable position.

Apical rate is determined accurately only after you are able to auscultate sounds clearly. Timing begins with zero. Count of one is rst sound auscultated after timing begins. You can assess regular apical rate within 30 seconds. Irregular rate is more accurately assessed when measured over longer interval (Evans and others, 2004). Regular occurrence of dysrhythmia within 1 minute indicates inefcient contraction of heart and potential alteration in cardiac output. Restores comfort and promotes sense of well-being.

Critical Decision Point If apical rate is abnormal or irregular, repeat measurement or have another nurse conduct measurement. Original measurement may be incorrect. Second measurement conrms initial ndings of abnormal HR.
12 Discuss ndings with patient as needed. 13 Perform hand hygiene. 14 Clean earpieces and diaphragm of stethoscope with alcohol

swab routinely after each use. EVALUATION 1 If assessing pulse for the rst time, establish apical rate as baseline if it is within an acceptable range. 2 Compare apical rate and character with patients previous baseline and acceptable range of heart rate for patients age.

Promotes participation in care and understanding of health status. Reduces transmission of microorganisms. Stethoscopes are frequently contaminated with microorganisms. Regular disinfection can control nosocomial infections.

Used to compare future pulse assessments. Allows nurse to assess for change in patients condition and for presence of cardiac alteration.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

84
Unexpected Outcomes
1 Apical pulse is greater than 100 beats per minute (tachycardia).

Related Interventions
Identify related data, including fever, pain, fear or anxiety, recent exercise, low BP, blood loss, or inadequate oxygenation. Observe for signs and symptoms associated with abnormal cardiac function, including dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of body parts, cyanosis, or dizziness. Assess for factors that decrease heart rate, such as digoxin and antiarrhythmic drugs. Observe for signs and symptoms associated with abnormal cardiac function, including dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of body parts, cyanosis, or dizziness. Have another nurse assess apical pulse. Report ndings to nurse in charge and/or health care provider. It may be necessary to withhold prescribed medications that alter heart rate until the health care provider can evaluate the need to alter the dosage. Assess for pulse decit (see Procedural Guideline 5-1). Report ndings to nurse in charge and/or health care provider, who may order an electrocardiogram to detect cardiac conduction alteration.

2 Apical pulse is less than 60 beats per minute (bradycardia).

3 Apical rhythm is irregular.

Recording and Reporting

Record apical pulse rate and rhythm on vital sign ow sheet (see Fig. 5-6) or nurses notes. Document measurement of apical pulse rate after administration of specic therapies in nurses notes. Report abnormal ndings to nurse in charge or health care provider.

Breath holding in an infant or child affects apical pulse rate.

Gerontological Considerations
The PMI is often difcult to palpate in some older adults because the anterior-posterior diameter of the chest increases with age, and the heart becomes repositioned because of left ventricular enlargement. When assessing older adult women with sagging breast tissue, gently lift the breast tissue and place the stethoscope at the fth ICS or the lower edge of the breast. Heart sounds are sometimes mufed or difcult to hear in older adults because of an increase in air space in the lungs. The older adult has a decreased heart rate at rest (Ebersole and others, 2008).

Teaching Considerations
Teach caregivers of patients taking prescribed cardiotonic or antidysrhythmic medications to assess apical pulse rates to detect side effects of medications.

Pediatric Considerations
Point of maximal impulse of an infant is usually located at the third to fourth ICS near the left sternal border. In infants and children younger than 2 years, an apical pulse is more reliable and you should count it for 1 full minute because of possible irregularities in rhythm.

Home Care Considerations

Assess home environment to determine which room affords a quiet environment for auscultation of apical rate.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.