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

Assisting the Resident to Sit on the Side of the Bed

Having the resident sit on the side of the bed is otherwise referred to as dangling. When a resident quickly changes position, especially from lying to sitting or standing, there can be a rapid drop in the resident’s blood pressure. This drop in blood pressure may cause dizziness or lightheadedness.

Removing Personal Protective Equipment

It is important to follow the correct procedure while removing personal protective equipment to avoid contaminating your skin or clothing. The most common source of contamination in this process stems from improper removal of gloves. Gloves are often the most soiled piece of equipment. To avoid contaminating your skin or the other equipment worn, gloves should always be removed first. Then remove the goggles, gown, and mask, in that order.

Axillary Temperature with Electronic Thermometer

Compared to other temperature measurement methods, the axillary measurement is considered the least reliable. An axillary temperature measurement typically reads 0.5 to 1 degree Fahrenheit lower than an oral temperature reading [1]. For this reason, it is recommended to use this method only when other methods are contraindicated or when taking an axillary temperature is the safest method for the patient.

Putting on Personal Protective Equipment

Personal protective equipment is worn to protect the mouth, nose, eyes, clothing, and skin from unwanted pathogens. In the health care setting, a patient’s condition often prompts the use of personal protective equipment; however, a health care worker is able to wear personal protective equipment whenever he or she deems it is necessary (e.g., during procedures with the potential for excessive contact with bodily fluids).

Logrolling the Resident

Logrolling is a technique used to roll a resident onto their side without the resident helping, and while keeping the resident’s spine in a straight line. This is especially important for residents who have had spinal surgery or injury.

Using a Gait / Transfer Belt to Assist the Resident to Ambulate

Walking (aka, ambulating) helps residents maintain mobility and independence, and prevents complications. However, ambulation must be done safely so that the resident does not have a fall or injury. A gait or transfer belt, when properly used, can increase resident safety. Gait belts can vary between facilities, so make sure you know how to use the one in your facility.

Measuring the Apical Pulse