Nursing Procedure: How to Take an Apical Pulse Rate

Definition:

One method to calculate heart rate (Pulse) using palpation techniques.

Equipment:

• Watch with second hand
• Stethoscope
• Alcohol swabs
• Non Steril Gloves

Goals:

1. To know the number of heart rate
2. To know rhythm

 

Nursing Action (Procedure):

How to take an apical pulse

• Wash hands/hand hygiene. Rationale: Reduces transmission of microorganisms.

• Raise client’s gown to expose sternum and left side of chest. Rationale:Allows access to client’s chest for proper placement of stethoscope.

• Cleanse earpiece and diaphragm of stethoscope with an alcohol swab.Rationale: Decreases transmission of microorganisms from one prescribing practitioner to another (earpiece) and from one client to another (diaphragm).

• Put stethoscope around neck. Rationale: Ensures stethoscope is nearby for frequent use.

• Locate apex of heart:

1. With client lying on left side, locate suprasternal notch. Rationale: Identification of landmarks facilitates correct placement of the stethoscope at the fifth intercostal space in order to hear PMI.
2. Palpate second intercostal space to left of sternum.
3. Place index finger in intercostal space, counting downward until fifth intercostal space is located. Rationale: Ensures correct placement of stethoscope.
4. Move index finger along fourth intercostal space left of the sternal border and to the fifth intercostal space left of the midclavicular line to palpate the point of maximal impulse (PMI)
5. Keep index finger of nondominant hand on the PMI.

• Inform client that his or her heart will be listened to. Instruct client to remain silent. Rationale:  Elicits client support. Stethoscope amplifies noise.

• With dominant hand, put earpiece of the stethoscope in ears and grasp diaphragm of the stethoscope in the palm of the hand for 5 to 10 seconds.Rationale:  Dominant hand facilitates psychomotor dexterity for placement of earpiece with one hand. Heat warms metal or plastic diaphragm and prevents startling client.

• Place diaphragm of stethoscope over the PMI and auscultate for sounds S1 and S2 to hear lub-dub sound. Rationale:  Movement of blood through the heart valves creates S1 and S2 sounds. Listen for a regular rhythm (heartbeats are evenly spaced) before counting.

• Note regularity of rhythm. Rationale:  Establishment of a rhythmic pattern determines length of time to count the heartbeats to ensure accurate measurement.

• Start to count while looking at second hand of watch. Count lub-dub sound as one beat:

1. For a regular rhythm, count rate for 30 seconds and multiply by 2.
2. For an irregular rhythm, count rate for a full minute, noting number of irregular beats.

Rationale:  Ensures sufficient time to count irregular beats.

• Share findings with client. Rationale:  Promotes client participation in care.

• Record by site the rate, rhythm, and, if applicable, number of irregular beats. Rationale:  Record rate and characteristics at bedside to ensure accurate documentation.

• Wash hands/hand hygiene. Rationale:  Reduces transmission of microorganisms.

Nursing tips when taking an apical pulse

• If taking an apical pulse, have the client breathe normally through the nose; breathing through the nose decreases breath sounds and makes the heart sounds easier to hear.

Source : www.nursingprocedure.blogspot.co.id