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

Prone Position

Prone position is not used as commonly as other patient positions. This position allows for full extension of the hips and the knees and gives many bony prominences a break from continuous pressure. However, placing patients in prone position does not come without the risks of pressure ulcers.

Performing the Heimlich Maneuver

The Heimlich Maneuver, also known as abdominal thrusts, is used to remove an object that is blocking a resident’s airway and preventing air from reaching the lungs. It only takes four to six minutes for brain damage to occur from lack of oxygen, so prompt action is vital.

Sim’s Position

The position a patient is placed in is often ordered by the physician, or recommended by a speech, occupational, or physical therapist. The position dictates whether a patient is sitting, lying, standing; or if they are on their side, back, or prone (face-down). Positioning is also determined by the patient’s current needs, such as: Are they eating? Sleeping? Having surgery on their back? Are they receiving nutrition through a nasogastric tube?

Assisting the Resident to Transfer from the Bed to a Chair or Wheelchair

It is important to remember on which side to place the chair when assisting a patient in transferring. Putting the chair on the resident’s unaffected side allows the resident to lead with his or her strong extremity. This eases the procedure for the resident and reduces the risk of falling.

Measuring Blood Pressure

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.

Perineal Care of the Female Resident

Perineal care should be performed during a bath, after using the bedpan, and/or after incontinence. Proper technique is important for maintaining hygiene, preventing infection, and avoiding skin breakdown. Because of the close proximity between a woman’s urethra, vagina, and anus, it is essential to only wipe in a front to back motion. Wiping in the opposite direction is associated with a greater risk for developing a urinary tract infection.

Measuring the Apical Pulse