Assessing the Apical Pulse by Auscultation

Skill 2-5

Assessing the Apical Pulse by Auscultation

An apical pulse is auscultated (listened to) over the apex of the heart, as the heart beats. Heart sounds, which are produced by closure of the valves of the heart, are characterized as “lub-dub.” The apical pulse is the result of closure of the mitral and tricuspid valves (“lub”) and the aortic and pulmonic valves (“dub”). The combination of the two sounds is counted as one beat. Pulse rates are measured in beats per minute. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats per minute. Pulse rhythm is also assessed. Pulse rhythm is the pattern of the beats and the intervals between them. Pulse rhythm is normally regular; the “lub-dubs” and the pauses between occur at evenly spaced intervals. An irregular rhythm occurs when the beats and pauses between beats occur at unequal, varied intervals.

An apical pulse should be assessed when a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid. An apical pulse is also assessed when administering medications that alter heart rate and rhythm. In adults, the apical pulse is counted for 1 full minute. Apical pulse measurement is the preferred method of pulse assessment in children less than 2 years of age (Jarvis & Eckhardt, 2020; Kyle & Carmen, 2021).

Patients with irregularities in pulse rhythm may have a resulting pulse deficit . Assessment of the apical-radial pulse may be indicated. See the accompanying Skill Variation on page 72 for a description of the procedure for assessing the apical-radial pulse to identify a pulse deficit.

Delegation Considerations

The assessment of an apical pulse is not delegated to assistive personnel (AP). The measurement of an apical pulse may be delegated to a licensed practical/vocational nurse (LPN/LVN). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Watch with second hand or digital readout
Stethoscope
Alcohol swab
Electronic record or pen and paper or flow sheet
Nonsterile gloves, if appropriate; additional PPE, as indicated

Assessment

Assess for factors that could affect pulse characteristics, such as the patient's age, physical activity, fluid balance, medications, body temperature, and presence of disease and/or health conditions. Note baseline or previous pulse measurements.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Altered tissue perfusion
Impaired Cardiac Output
Fluid Imbalance

Outcome Identification and Planning

The expected outcomes to achieve when measuring an apical pulse rate are that the patient's pulse is assessed accurately without injury, and the patient experiences minimal discomfort. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

Implementation

Action	Rationale
1. Check prescribed interventions or plan of care for frequency of pulse assessment. More frequent pulse measurement may be appropriate based on nursing judgment. Identify the need to obtain an apical pulse measurement.	Provides for patient safety and appropriate care.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient's ability to assist with the procedure.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation.
5. Put on gloves, if indicated.	Gloves are not usually worn to obtain a pulse measurement unless contact with blood or body fluids is anticipated. Gloves prevent contact with blood and body fluids.
6. Use an alcohol swab to clean the diaphragm of the stethoscope. Use another swab to clean the earpieces, if necessary.	Cleaning with alcohol deters transmission of microorganisms.
7. Assist the patient to a sitting or reclining position and expose the chest area.	This position facilitates identification of the site for stethoscope placement.
8. Move the patient's clothing to expose only the apical site.	The site must be exposed for pulse assessment. Exposing only the apical site keeps the patient warm and maintains their dignity.
9. Hold the stethoscope diaphragm against the palm of your hand for a few seconds.	Warming the diaphragm promotes patient comfort.
10. Palpate the space between the fifth and sixth ribs (fifth intercostal space), and move to the left midclavicular line. Place the stethoscope diaphragm over the apex of the heart (Figures 1 and 2).	Position the stethoscope over the apex of the heart, where the heartbeat is best heard.
11. Listen for heart sounds (“lub-dub”). Each “lub-dub” counts as one beat.	These sounds occur as the heart valves close.
12. Using a watch with a second hand, count the heartbeat for 1 minute.	Counting for a full minute increases the accuracy of assessment.
13. Note the rhythm of the beats.	Provides additional assessment data regarding the patient's cardiovascular status.
14. Clean the diaphragm of the stethoscope with an alcohol swab. Remove gloves. Perform hand hygiene.	Cleaning deters transmission of microorganisms.
15. Cover the patient and help them to a position of comfort.	Covering and positioning the patient ensures patient comfort.
16. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient's apical pulse has been assessed accurately without injury, and the patient experienced minimal discomfort.

Documentation

Guidelines

Record pulse rate and rhythm in the electronic record or flow sheet. Communicate abnormal findings to the appropriate person. Identify site of assessment.

Sample Documentation

Practice documenting the apical pulse and other vital signs in Lippincott DocuCare.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

If the apical rate is irregular, assess the patient for other symptoms, such as lightheadedness, dizziness, shortness of breath, or palpitations. Communicate findings to the appropriate health care provider.

Special Considerations

Infant and Child Considerations

Assess the apical pulse just above and outside the left nipple of the infant at the third or fourth intercostal space. As the child ages, the location for assessment moves to a more medial and slightly lower area until 7 years of age. In children 7 years of age or older, assess the apical pulse at the fourth or fifth intercostal space at the midclavicular line (Jensen, 2019).
The apical pulse rate is most reliable for infants and children younger than 2 years of age. Count the rate for 1 full minute in infants and children (Jensen, 2019; Silbert-Flagg & Pillitteri, 2018).
Allow the young child to examine or handle the stethoscope to become familiar with the equipment.
Assess the apical rate if the child has a cardiac problem or congenital heart defect.

Assessing the Apical-Radial Pulse Deficit

Measurement of the apical-radial pulse deficit may be utilized to assess the effectiveness of the contractions of the heart, specifically the left ventricle. Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse deficit. Comparison of these two pulse rates provides an indirect evaluation of the ability of each heart contraction to eject enough blood into the peripheral circulation to create a pulse (Jensen, 2019). A difference between the apical and radial pulse rates is called the pulse deficit and indicates that not all the heartbeats are reaching the peripheral arteries or are too weak to be palpated (Taylor et al., 2023). Two nurses are required to perform this skill; one listens with a stethoscope over the apex of the heart for the apical heart rate and the other counts the pulse rate at the radial artery.

Refer to Steps 1-10 in Skill 2-5.
One watch with a sweep second hand is placed so that both nurses can read it simultaneously.
The nurses determine where they can best hear and feel the pulse and decide on a time to start counting, such as when the second hand on the watch is at a specified place (e.g., the number 12).
Both nurses count for 1 full minute and record their counts. The difference between the apical and radial pulse rates is the pulse deficit.
Clean the diaphragm of the stethoscope with an alcohol swab. Remove gloves, if used. Perform hand hygiene.
Cover the patient and help them to a position of comfort.
Remove additional PPE, if used. Perform hand hygiene.

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Skill 2-5