ASSESSING OF APICAL PULSE

DEFINITION:
The central pulse located at the apex of the heart. It is indicated for clients/patients whose peripheral pulse
is irregular as well as for clients with known cardiovascular, pulmonary, and renal disease.

PURPOSES:
 To determine adequacy of peripheral circulation or presence of pulse deficit
 To establish baseline data for subsequent evaluation.
 To determine whether the cardiac rate is within normal range and rhythm is regular.
 To monitor the client with cardiac disease and those receiving medications to improve heart
action.

PRINCIPLES:
 Observe professional ethics and cleanliness.
 Count in one full minute.
 Wash hands before and after the procedure

EQUIPMENT:
 Clock or watch with a sweep second hand or digital indicator
 Stethoscope
 Antiseptic wipes

STEPS: RATIONALE:
1. Wash your hands aseptically. To prevent the spread of microorganism.

2. Prepare the equipment. For organization and to prevent the nurse from
leaving the client to get equipment.

3. Identify the client (ask the complete name,
check the wristband, and bed tag) and explain
the procedure.
Identifying the client ensures the right client
receives the right intervention/procedure and helps
prevent errors. (Lynn, 2015) Discussion and
explanation encourage the client’s understanding,
and participation and reduce apprehension. (Lynn,
2015)

4. Provide client's privacy. For the client to be comfortable and ease anxiety.

5. Clean the earpieces and diaphragm of the Prevent contamination and spreading of
stethoscope with cotton balls soaked with microorganism.
alcohol.

6. Position the client in a comfortable position This ensures an accurate comparative measurement.
(supine or sitting position).

7. Warm the diaphragm of the stethoscope with The metal is cold and can startle the client when
your hands. Expose the area of the chest over place immediately on chest.
the apex of the heart.
8. Locate the site, on the left mid-clavicular line in This is done to evaluate for changes in condition
between the 5th and 6th ICS and place the and alterations.
diaphragm correctly.
9. Auscultate and count heartbeats and assess any To have accurate result.
observable characteristics for one-full minute.
10. Record the apical pulse rate. For documentation
11. Replace client's clothing and fix the top linen. To make client comfortable and for the client to be
relax.

12. Make client comfortable. To have fast recovery of the client and for the client
to be relax.

13. Wash your hands. To prevent the spread of microorganism.

REFERENCE:
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017a). Fundamentals of Nursing. Elsevier
Gezondheidszorg.
Berman, A. T., Snyder, S., & Msn Rn, F. G. E. (2020). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice (11th ed.). Pearson.