Purpose

• The apical pulse is over the heart. The apex (apical) of the heart is at the tip of the heart, just below the left nipple. This pulse is taken with a stethoscope.
• A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and other body organs. When using a stethoscope:
  • Place ear-pieces in your ears. The bend of the tips points forward. Ear-pieces should fit snugly to block noise. They should not cause pain or discomfort.
  • Tap the diaphragm gently. If you do not hear the tapping, turn the chest piece at the tubing. Gently tap again. Proceed if you hear the tapping. Check with the nurse if you do not.
  • Place the diaphragm over the pulse site and hold it in place.
  • Prevent noise. Do not let anything touch the tubing. Ask for silence.
• The pulse rate is the number of heartbeats or pulses felt or heard in 1 minute.
  • The pulse rate is affected by many factors, including activity, drugs, and pain.
  • The adult pulse rate is between 60 and 100 beats per minute. A rate of less than 60 or more than 100 is abnormal. Report abnormal pulses at once.
• The pulse rhythm should be regular. That is, pulses are felt in a pattern. The same interval occurs between beats. An irregular pulse occurs when the beats are not evenly spaced or beats are skipped.
• You will take radial and apical pulses. You must count, report, and record accurately.
• The apical pulse is on the left side of the chest slightly below the nipple. Use a stethoscope and count the pulse for 1 minute. The heartbeat normally sounds like lub-dub. Count each lub-dub as one beat.
• Apical pulses are taken on persons who:
  • Have heart disease.
  • Have irregular heart rhythms.
  • Take drugs that affect the heart.

Equipment

Roll cursor over items to see labels. For the purposes of clearly depicting the equipment, a barrier is not shown in this photo. When providing care, a barrier should always be placed on the surface before placing the equipment.

Stethoscope

Antiseptic wipes

Delegation

• Follow delegation guidelines. Before taking an apical pulse, obtain this information from the nurse and care plan:
  • What pulse to take for each person—radial or apical
  • When to take the pulse
  • What other vital signs to measure
  • How long to count the pulse—1 minute for an apical pulse
  • If the nurse has concerns about certain patients or residents
  • What observations to report and record
  • When to report the pulse rate
  • What patient or resident concerns to report at once

Preparation

• Observe quality-of-life measures.
• Review the information under Delegation and Safety and Comfort.
• Practice hand hygiene.
• Collect a stethoscope and antiseptic wipes.
• Identify the person. Check the ID bracelet against the assignment sheet. Also call the person by name.
• Provide for privacy.

Safety

• Stethoscopes are in contact with many persons and staff. You must prevent infection. Wipe the ear-pieces and diaphragm with antiseptic wipes before and after use.

Comfort

• Stethoscope diaphragms tend to be cold. Warm the diaphragm in your hand before applying it to the person. Cold diaphragms can startle the person.

Follow-up Care

• Provide for comfort.
• Place the call light within reach.
• Unscreen the person.
• Complete a safety check of the room.
• Clean the ear-pieces and diaphragm with the wipes.
• Return the stethoscope to its proper place.
• Practice hand hygiene.

Reporting/Recording

• Report and record your observations, including:
  • The pulse site
  • The pulse rate—report at once a pulse rate less than 60 (bradycardia) or more than 100 (tachycardia) beats per minute
  • If the pulse is regular or irregular
  • Pulse force—strong, full, bounding, weak, thready, or feeble
• Record the pulse rate with Ap for apical.