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Skill

Vital Signs: Pulse: Apical & Radial

Prerequisite Skills

Concepts of Communication

Critical Element Criteria

Students must meet criteria of Critical Elements to safely perform the skill based on evidence-based practice. Score can be pass/fail, letter grade, or point assignment. Only acceptable score for Critical Elements is 100%

Critical Elements

  • Understanding of the importance and variations that can occur with the pulse assessment.
  • Create appropriate physical environment.
  • Provide privacy.
  • Explain procedure.
  • Clean equipment prior to use.
  • Wash hands.

Procedure

Prior to Treatment: (Critical Thinking)

  • Gather appropriate physical assessment equipment: stethoscope, 70% alcohol, watch with second hand.
  • Consider age related variations for exam.

Patient Interaction: (Safety)

  • Patient identifiers.
  • Create appropriate physical environment.
  • Provide privacy.
  • Explain procedure.
  • Clean equipment prior to use.
  • Wash hands.

Procedure: (Patient Centered Care)

Apical Pulse:

  1. Assist patient to a supine or sitting position.
  2. Clean stethoscope with 70% alcohol if not already done.
  3. Locate apical location – 5th intercostal space at the midclavicular line.
  4. Warm stethoscope in the hands for 10 seconds.
  5. Use diaphragm over the PMI.
  6. Count heart rate for 60 seconds noting rate, rhythm, and quality.
  7. Again clean stethoscope with 70% alcohol.

Radial Pulse:

  1. Palpate radial pulse.
  2. Count heart rate for 60 seconds noting rate, rhythm, and quality.

After Procedure (Patient Centered Care, Safety)

  • Provide appropriate nursing management for abnormal findings.

Documentation (Informatics, Communication)

  • Outcome of assessment.
  • Interventions used for nursing management of care.
  • Patient"s response to interventions.