Measuring the Apical Pulse

Written by Amanda R. McDaniel, MS, BSN, RN
Amanda is a BSN/RN with a MS in Physiology and a BA in English. She worked as a medical writer in the pharmaceutical industry for 11 years before pursuing a career in nursing. She now works as a nurse on a NeuroTelemetry unit and continues to write and edit on a freelance basis. Amanda’s LinkedIn

The apical pulse rate is the most accurate non-invasive measurement of heart rate because it is measured directly over the apex of the heart. Apical pulse is preferred in cases when the radial pulse is difficult to palpate, when the pulse is irregular, greater than 100 beats per minute, or less than 60 beats per minute when measured by other means (electronic, radial, etc.).

Measuring the Apical Pulse

Gather your supplies:
- Gloves
- Stethoscope
- Clock or watch with seconds displayed, or a second hand
- Alcohol swabs
Introduce yourself to the patient, perform hand hygiene, and clean the bell of the stethoscope with an alcohol swab.
Ensure patient privacy by closing the curtain or door.
The patient should be sitting or lying supine. Adjust the bed covers and/or the patient’s clothing so that the sternum and left side of the chest are exposed.
Place the bell of the stethoscope at the fifth intercostal space, at the left midclavicular line. This is the location of the apex of the heart.
- To find the correct location, first locate the sternal notch at the top of the sternum. Directly beside this is the second intercostal space. Count down three more to reach the fifth intercostal space.
- The midclavicular line is an imaginary line drawn straight down from the middle of the clavicle (in this case, the left clavicle).
- Place your stethoscope where the imaginary line and the fifth intercostal space intersect. This is generally just below the breast tissue.
- It is kind to warm the stethoscope in your hands before placing it on the patient to avoid an unexpected chill.
Listen for the “lub-dub” of normal heart sounds. These are the S1 and S2 heart sounds. You may need to adjust your stethoscope a bit to the right or left, or down to the sixth intercostal space to account for normal anatomical variances or serious heart disease.
Once you regularly hear the pulse, note the second and begin counting the beats (“lub” or “dub”, not both, as they are parts of the same beat), for one full minute.
Observe if the pulse rhythm is regular or irregular, such as occasionally or regularly skipped beats or delays between “lub” and “dub” on some beats.
Replace the patient’s clothing and bed covers.
Perform hand hygiene and clean the bell of your stethoscope with an alcohol swab.
Document the pulse rate and pattern in the patient’s record, and inform the nurse of any rate or rhythm abnormality or significant change from the previous measurement per institutional or unit protocol.

Amanda R. McDaniel, MS, BSN, RN

References

Fetzer, S. J. (2014). Vital signs and physical assessment. In A. G. Perry, P. A. Potter, and W. R. Ostendorf (Eds), Clinical nursing skills & techniques (8th ed., pp. 81-85). St. Louis, MO: Mosby Elsevier.

More Resources

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Many factors can interfere with obtaining an accurate blood pressure. The most common mistakes that lead to inaccurate blood pressures are a result of improper technique, including: not supporting the patient’s arm, using the wrong sized cuff, positioning the cuff too low on the patient’s arm, improper positioning of the cuff’s artery marker, and attempting to measure blood pressure through clothing.

Fowler’s Position

Fowler’s position is used when a patient is eating, is having difficulty breathing, or is ordered by a doctor. This position is easily recognized because the patient will be sitting “straight up.” Semi-Fowler’s is sitting “half-way up,” and is used when patients cannot be laid flat, but wish to be in a more relaxed position than Fowler’s.

Orthopneic Position

Patients with respiratory illnesses such as chronic obstructive pulmonary disease (COPD) find ways to help themselves breathe more easily. This can include sleeping with extra pillows to keep them propped up or leaning forward to ease the work of breathing. The orthopneic position is one forward-leaning position used to help patients breathe comfortably when they are having difficulty.

Putting on Personal Protective Equipment

Personal protective equipment is worn to protect the mouth, nose, eyes, clothing, and skin from unwanted pathogens. In the health care setting, a patient’s condition often prompts the use of personal protective equipment; however, a health care worker is able to wear personal protective equipment whenever he or she deems it is necessary (e.g., during procedures with the potential for excessive contact with bodily fluids).

Measuring the Respirations

Respiration is a vital sign that is measured frequently in the healthcare setting. Taking this measurement requires no equipment and relatively little time. However, it is a measurement that must be taken accurately, as a change in respiration may indicate the worsening of a patient’s condition.

Partial Bed Bath

Bathing is an important part of a patient’s health routine. A partial bed bath focuses on bathing sensitive areas that cause discomfort if not cleansed frequently, such as the face, hands, axillae, back, and perineum. Though patients receiving a bed bath are typically confined to the bed, some are able to wash themselves and should be encouraged to do so to promote independence.

Measuring the Apical Pulse