Download - Assessing Apical Pulse

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Earpiece

Binaurals

Tubing

BellChestpiece

Diaphragm

FIG 5-8 Acoustic stethoscope.

The apical pulse is the most reliable noninvasive way to assess cardiac function. The apical pulse rate is the assessment of the number and quality of apical sounds in 1 minute. Each apical pulse is the combination of two sounds, S1 and S2. S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular fi lling, just before systolic contraction begins. S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

You will use a stethoscope to auscultate sound waves of the api-cal pulse (Fig. 5-8). The stethoscope is a closed cylinder that am-plifi es sound waves as they reach the body’s surface. The fi ve major parts of the stethoscope are the earpieces, binaurals, tubing, bell, and diaphragm.

The plastic or rubber earpieces should fi t snugly and comfort-ably in your ears. Binaurals should be angled and strong enough so the earpieces stay fi rmly in place without causing discomfort. The earpieces follow the contour of the ear canal, pointing toward the face when the stethoscope is in place.

SKILL 5-3 Assessing Apical PulseBasic Skills / Vital Signs / Assessing the Apical Pulse Vital Signs Module / Lesson 3NSO

Ch05_0064-0105-A05289.indd 80Ch05_0064-0105-A05289.indd 80 1/23/09 10:22:53 AM1/23/09 10:22:53 AM

Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

movement of blood. Hold the bell lightly against the skin for sound amplifi cation.

Delegation ConsiderationsOften you measure the apical pulse when you suspect an irregular-ity in the radial pulse or when a patient’s condition requires a more accurate assessment. In this situation, pulse assessment cannot be delegated to NAP. When measurement of apical pulse is a routine practice, you can delegate it to NAP. The nurse directs the NAP about:• Specifi c factors related to the patient history, usual values, or

risk for abnormally slow, rapid, or irregular pulse.• Frequency of assessment needed• Need to report any abnormalities in rate or rhythm to the nurse.

Equipment❑ Stethoscope❑ Wristwatch with second hand or digital display❑ Pen, pencil, vital sign fl ow sheet or record form❑ Alcohol swab

The polyvinyl tubing should be fl exible and 30 to 45 cm (12 to 18 inches) in length; longer tubing decreases sound transmission. The tubing should be thick walled and moderately rigid to elimi-nate transmission of environmental noise and to prevent kinking. Stethoscopes can have one or two tubes.

The chestpiece consists of a bell and diaphragm that you rotate into position depending on which part you choose to use. To test, lightly tap to determine which side is functioning. Some stetho-scopes have one chestpiece that combines features of the bell and diaphragm. When you apply light pressure, the chestpiece is a bell, whereas exerting more pressure converts the bell into a diaphragm.

The diaphragm is a circular fl at-surfaced portion of the chest-piece covered with a plastic disk. It transmits high-pitched sounds created by high-velocity movement of air and blood. Position the diaphragm to make a tight seal against the patient’s skin. Exert enough pressure to complete the seal, leaving a temporary red ring on the patient’s skin after you remove the diaphragm.

The bell is the cone-shaped portion of the chestpiece usually sur-rounded by a rubber ring to avoid chilling the patient during place-ment. It transmits low-pitched sounds created by the low-velocity

STEP RATIONALE

ASSESSMENT 1 Determine need to assess apical pulse: a Assess for any risk factors for apical pulse alteration:

• Heart disease• Cardiac dysrhythmias• Onset of sudden chest pain or acute pain from any site• Invasive cardiovascular diagnostic tests• Surgery• Sudden infusion of large volume of IV fl uid• Internal or external hemorrhage• Administration of medications that alter heart function

Certain conditions place patients at risk for pulse alterations.

b Assess for signs and symptoms of altered cardiac function such as dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, cyanosis or pallor of skin (see Chapter 6).

Physical signs and symptoms indicate alteration in cardiac output or stroke volume.

c Assess for factors that normally infl uence apical pulse rate and rhythm:

Allows nurse to anticipate factors that will alter apical pulse, en-suring an accurate interpretation.

(1) Age Infant’s heart rate at birth ranges from 100 to 160 beats per minute at rest; by age 2, pulse rate slows to 90 to 140 beats per minute; by adolescence, rate varies between 60 and 100 beats per min-ute and remains so throughout adulthood.

(2) Exercise Physical activity increases HR; a well-conditioned patient may have a slower-than-usual resting HR that returns more quickly to resting rate after exercise.

(3) Position changes Heart rate increases temporarily when changing from lying to sit-ting or standing position.

(4) Medications Antidysrhythmics, sympathomimetics, and cardiotonics affect rate and rhythm of pulse; large doses of narcotic analgesics can slow HR; general anesthetics slow HR; central nervous system stimu-lants such as caffeine can increase HR.

(5) Temperature Fever or exposure to warm environments increases HR; HR de-clines with hypothermia.

(6) Sympathetic stimulation Emotional stress, anxiety, or fear results in stimulation of the sym-pathetic nervous system, which increases HR.

2 Determine previous baseline apical rate (if available) from patient’s record.

Allows nurse to assess for change in condition.

3 Determine any report of latex allergy. If patient has latex al-lergy, ensure that stethoscope is latex free.

SKILL 5-3



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NURSING DIAGNOSES

STEP RATIONALE

• Activity intolerance • Decreased cardiac output • Ineffective tissue perfusion

Individualize related factors based on patient’s condition or needs.

PLANNING 1 Expected outcomes following completion of procedure:

• Apical heart rate is within acceptable range. Adults average 60 to 100 beats per minute.• Rhythm is regular. Cardiovascular status is stable.

2 Explain to patient that you will assess apical pulse rate. Encour-age patient to relax, and ask patient not to speak. If patient has been active, wait 5 to 10 minutes before assessing pulse. If pa-tient has been smoking, wait 15 minutes before assessing pulse.

Anxiety, activity, and smoking elevate heart rate. Patient’s voice interferes with nurse’s ability to hear sound when measuring apical pulse. Assessing apical pulse rate at rest allows for objec-tive comparison of values.

IMPLEMENTATION 1 Perform hand hygiene. Reduces transmission of microorganisms. 2 If necessary, draw curtain around bed and/or close door. Maintains privacy and minimizes embarrassment. 3 Assist patient to supine or sitting position. Move aside bed

linen and gown to expose sternum and left side of chest.Exposes portion of chest wall for selection of auscultatory site.

4 Locate anatomical landmarks to identify the point of maximal impulse (PMI), also called the apical impulse (see Chapter 6). Heart is located behind and to left of sternum with base at top and apex at bottom. Find Angle of Louis just below suprasternal notch between sternal body and manubrium; it feels like a bony prominence (see illustration A). Slip fi ngers down each side of angle to fi nd second intercostal space (ICS) (illustration B). Carefully move fi ngers down left side of sternum to fi fth ICS and laterally to the left midclavicular line (MCL) (illustration C). A light tap felt within an area 1 to 2 cm (1⁄2 to 1 inch) of the PMI is refl ected from the apex of the heart (illustration D).

Use of anatomical landmarks allows correct placement of stetho-scope over apex of heart. This position enhances ability to hear heart sounds clearly. If unable to palpate the PMI, reposition patient on left side. In the presence of serious heart disease, you may locate the PMI to the left of the MCL or at the sixth ICS.

A B

C D

STEP 4 A, Nurse locates sternal notch. B, Nurse locates second intercostal space. C, Nurse locates fi fth intercostal space. D, Nurse locates point of maximal impulse at intercostal space at the midclavicular line.



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5 Place diaphragm of stethoscope in palm of hand for 5 to 10 seconds.

Warming of metal or plastic diaphragm prevents patient from be-ing startled and promotes comfort.

6 Place diaphragm of stethoscope over PMI at the fi fth ICS, at the left MCL, and auscultate for normal S1 and S2 heart sounds (heard as “lub-dub”) (see illustrations).

Allow stethoscope tubing to extend straight without kinks that would distort sound transmission. Normal sounds S1 and S2 are high pitched and best heard with the diaphragm.

PMI

123

4

56

7

8

910

A B

STEP 6 A, Location of point of maximal impulse (PMI) in adult. B, Stethoscope over PMI.

7 When you hear S1 and S2 with regularity, use second hand of watch and begin to count rate: when sweep hand hits number on dial, start counting with zero, then one, two, and so on.

Apical rate is determined accurately only after you are able to auscultate sounds clearly. Timing begins with zero. Count of one is fi rst sound auscultated after timing begins.

8 If apical rate is regular, count for 30 seconds and multiply by 2. You can assess regular apical rate within 30 seconds. 9 If heart rate is irregular, or patient is receiving cardiovascular

medication, count for a full 1 minute (60 seconds).Irregular rate is more accurately assessed when measured over lon-

ger interval (Evans and others, 2004). 10 Note regularity of any dysrhythmia (S1 and S2 occurring early

or late after previous sequence of sounds; e.g., every third or every fourth beat is skipped).

Regular occurrence of dysrhythmia within 1 minute indicates inef-fi cient contraction of heart and potential alteration in cardiac output.

11 Replace patient’s gown and bed linen; assist patient in return-ing to comfortable position.

Restores comfort and promotes sense of well-being.

Critical Decision Point If apical rate is abnormal or irregular, repeat measurement or have another nurse conduct measurement. Original measurement may be incorrect. Second measurement confi rms initial fi ndings of abnormal HR.

12 Discuss fi ndings with patient as needed. Promotes participation in care and understanding of health status. 13 Perform hand hygiene. Reduces transmission of microorganisms. 14 Clean earpieces and diaphragm of stethoscope with alcohol

swab routinely after each use.Stethoscopes are frequently contaminated with microorganisms.

Regular disinfection can control nosocomial infections.

EVALUATION 1 If assessing pulse for the fi rst time, establish apical rate as base-

line if it is within an acceptable range.Used to compare future pulse assessments.

2 Compare apical rate and character with patient’s previous baseline and acceptable range of heart rate for patient’s age.

Allows nurse to assess for change in patient’s condition and for presence of cardiac alteration.

STEP RATIONALE

SKILL 5-3



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Unexpected Outcomes Related Interventions1 Apical pulse is greater than 100 beats per minute (tachycardia). • Identify related data, including fever, pain, fear or anxiety, recent

exercise, low BP, blood loss, or inadequate oxygenation.• Observe for signs and symptoms associated with abnormal cardiac

function, including dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of body parts, cyanosis, or dizziness.

2 Apical pulse is less than 60 beats per minute (bradycardia). • Assess for factors that decrease heart rate, such as digoxin and antiarrhythmic drugs.

• Observe for signs and symptoms associated with abnormal cardiac function, including dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations, edema of body parts, cyanosis, or dizziness.

• Have another nurse assess apical pulse.• Report fi ndings to nurse in charge and/or health care provider. It may

be necessary to withhold prescribed medications that alter heart rate until the health care provider can evaluate the need to alter the dosage.

3 Apical rhythm is irregular. • Assess for pulse defi cit (see Procedural Guideline 5-1).• Report fi ndings to nurse in charge and/or health care provider, who

may order an electrocardiogram to detect cardiac conduction alteration.

Recording and Reporting• Record apical pulse rate and rhythm on vital sign fl ow sheet

(see Fig. 5-6) or nurses’ notes.• Document measurement of apical pulse rate after administra-

tion of specifi c therapies in nurses’ notes.• Report abnormal fi ndings to nurse in charge or health care

provider.

Teaching Considerations• Teach caregivers of patients taking prescribed cardiotonic or

antidysrhythmic medications to assess apical pulse rates to de-tect side effects of medications.

Pediatric Considerations• Point of maximal impulse of an infant is usually located at the

third to fourth ICS near the left sternal border.• In infants and children younger than 2 years, an apical pulse is

more reliable and you should count it for 1 full minute because of possible irregularities in rhythm.

• Breath holding in an infant or child affects apical pulse rate.

Gerontological Considerations• The PMI is often diffi cult to palpate in some older adults be-

cause the anterior-posterior diameter of the chest increases with age, and the heart becomes repositioned because of left ven-tricular enlargement.

• When assessing older adult women with sagging breast tissue, gently lift the breast tissue and place the stethoscope at the fi fth ICS or the lower edge of the breast.

• Heart sounds are sometimes muffl ed or diffi cult to hear in older adults because of an increase in air space in the lungs.

• The older adult has a decreased heart rate at rest (Ebersole and others, 2008).

Home Care Considerations• Assess home environment to determine which room affords a

quiet environment for auscultation of apical rate.



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