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

  1. Gather your supplies:
    • Gloves
    • Stethoscope
    • Clock or watch with seconds displayed, or a second hand
    • Alcohol swabs
  2. Introduce yourself to the patient, perform hand hygiene, and clean the bell of the stethoscope with an alcohol swab.
  3. Ensure patient privacy by closing the curtain or door.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. Replace the patient’s clothing and bed covers.
  10. Perform hand hygiene and clean the bell of your stethoscope with an alcohol swab.
  11. 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

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 äóìstraight up.äó Semi-Fowlers is sitting äóìhalf-way up,äó and is used when patients cannot be laid flat, but wishes to be in a more relaxed position than Fowler’s.

Applying Restraints

Restraints have very strict guidelines for use due to the number of complications that can result. Use of restraints is associated with increased physical and psychosocial health issues. Restraints are only considered necessary when restraint-free alternatives have failed and the patient or others are at risk of harm without the restraints. It is illegal to use restraints for the staff’s convenience or to punish the patient.

Applying Elastic Support Hose

Elastic stockings are worn to prevent deep vein thrombosis (DVT) and reduce the pooling of blood in vessels. Many hospitals and care facilities use elastic stockings in patients with reduced mobility, such as surgical patients and/or the elderly. There are a few risks in wearing elastic stockings; however, these risks can be prevented with proper application and care.

Tympanic Membrane Temperature with Electronic Thermometer

A tympanic membrane thermometer uses an infrared sensor to measure the temperature of the tympanic membrane (ear drum). This type of thermometer is considered an accurate and reliable predictor of a patient’s core temperature because the tympanic membrane’s blood supply is sourced from the carotid artery, which is the same artery that carries blood to the hypothalamus in the brain.

Measuring the Radial Pulse

The radial artery, located in the wrist, is easy to feel and an efficient location to measure heart rate. Changes to the rhythm or strength of the radial pulse can indicate heart disease, damage to the arm, or body fluid status. It is important to remember to check the radial pulse on both sides as differences between left and right can indicate injury or disease processes.

Rectal Temperature with Electronic Thermometer

A rectal temperature provides the most accurate core body temperature reading compared to other non-invasive methods. This makes a rectal temperature desirable; however, this procedure comes with more patient discomfort and more safety risks (bowel perforation, mucosal damage, and/or vagus nerve stimulation) than the other temperature measurement methods.