How to Take an Apical Pulse: A Step-by-Step Guide
Taking an apical pulse is a valuable skill for healthcare professionals and caregivers alike. Unlike radial pulse measurements, which are taken at the wrist, the apical pulse is auscultated (listened to) directly over the apex of the heart. This method provides a more accurate assessment of heart rate and rhythm, particularly in individuals with irregular heartbeats, infants, and those taking certain medications. This comprehensive guide will walk you through the process of taking an apical pulse, step-by-step, ensuring accuracy and patient comfort.
Why Take an Apical Pulse?
Before we dive into the how-to, let’s understand why taking an apical pulse is important:
* **Accuracy in Irregular Rhythms:** When a patient has an irregular heartbeat (arrhythmia), the radial pulse may not accurately reflect the heart’s true rate. Some beats might be too weak to be felt peripherally. The apical pulse, being a direct measurement, captures all heartbeats, providing a more reliable rate.
* **Medication Monitoring:** Certain medications, such as digoxin, affect heart rate. Monitoring the apical pulse is crucial to ensure the medication is within the therapeutic range and to detect any adverse effects like bradycardia (slow heart rate).
* **Infants and Young Children:** In infants and young children, it can be difficult to palpate the radial pulse reliably. The apical pulse is the preferred method for assessing their heart rate.
* **Pre- and Post-Operative Assessment:** The apical pulse is often assessed before and after surgical procedures to establish a baseline and monitor for any cardiac complications.
* **Assessment of Heart Conditions:** It helps in monitoring patients with underlying heart conditions like atrial fibrillation, heart failure or valve disorders.
* **When Radial Pulse is difficult to obtain:** When the radial pulse cannot be reliably palpated or is weak due to medical conditions or injuries, the apical pulse provides an alternative and accurate assessment.
Equipment Needed
To take an apical pulse, you will need the following:
* **Stethoscope:** A good quality stethoscope is essential for clear auscultation of heart sounds.
* **Alcohol Swabs:** To clean the stethoscope earpieces.
* **Watch with a Second Hand or Digital Timer:** For accurate timing of the pulse.
* **Pen and Paper or Electronic Medical Record (EMR):** To document the findings.
* **Privacy Screen or Curtain (Optional):** To ensure patient privacy.
Step-by-Step Guide to Taking an Apical Pulse
Follow these steps carefully to ensure accurate and reliable results:
**1. Preparation:**
* **Gather Your Supplies:** Ensure you have all the necessary equipment readily available.
* **Prepare the Environment:** Provide a quiet and private environment. Close the door or use a privacy screen if necessary. Minimize distractions to accurately hear the heart sounds.
* **Introduce Yourself and Explain the Procedure:** Introduce yourself to the patient, explain what you will be doing, and why. This helps alleviate anxiety and ensures cooperation. For example, “Hello, my name is [Your Name], and I’m going to listen to your heart to check your pulse. This will help us monitor your heart rate.”
* **Hand Hygiene:** Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer to prevent the spread of infection.
* **Clean the Stethoscope:** Clean the earpieces of the stethoscope with an alcohol swab to maintain hygiene.
* **Patient Positioning:**
* Ideally, the patient should be lying supine (on their back). This position allows for optimal access to the chest area.
* If the patient cannot lie flat, they can sit up or lie on their left side (left lateral decubitus position). The left lateral position brings the heart closer to the chest wall, making it easier to hear the apical pulse. Make sure to document the position the patient was in during the assessment.
* Ensure the patient is comfortable and relaxed.
**2. Locating the Apex of the Heart:**
The apex of the heart is typically located at the 5th intercostal space (the space between the 5th and 6th ribs) at the midclavicular line (an imaginary vertical line that runs down from the middle of the clavicle or collarbone).
* **Palpate the Angle of Louis (Sternal Angle):** Locate the bony prominence where the manubrium (upper part of the sternum) joins the body of the sternum. This is the Angle of Louis. Slide your finger laterally to locate the 2nd rib.
* **Locate the Intercostal Spaces:** Move your fingers down from the 2nd rib to identify the 2nd intercostal space, then continue moving down to the 3rd, 4th, and finally the 5th intercostal space.
* **Find the Midclavicular Line:** Palpate the clavicle (collarbone) and imagine a line running vertically downward from its midpoint. This is the midclavicular line.
* **Locate the Apex:** The apex of the heart is typically located at the intersection of the 5th intercostal space and the midclavicular line. This is where you will place the stethoscope.
* *Note: In some individuals, the heart may be displaced due to conditions like cardiomegaly (enlarged heart), pregnancy, or certain lung conditions. If you have difficulty locating the apex, palpate the chest area to identify where the heartbeat is strongest.* If you are still having issues, you may use imaging such as an X-Ray to determine placement.
**3. Auscultation (Listening to the Apical Pulse):**
* **Warm the Stethoscope:** Warm the diaphragm of the stethoscope with your hand to prevent discomfort for the patient.
* **Place the Stethoscope:** Gently place the diaphragm of the stethoscope firmly over the apex of the heart (5th intercostal space at the midclavicular line). Ensure the entire diaphragm is in contact with the skin.
* **Listen Carefully:** Listen for the heart sounds. You will hear the characteristic “lub-dub” sound, which represents the closing of the heart valves.
* “Lub” (S1): The first heart sound, which is produced by the closing of the mitral and tricuspid valves at the beginning of systole (ventricular contraction).
* “Dub” (S2): The second heart sound, which is produced by the closing of the aortic and pulmonic valves at the beginning of diastole (ventricular relaxation).
* **Count the Heartbeats:** Using your watch with a second hand or a digital timer, count the number of heartbeats for one full minute (60 seconds). This is crucial for accuracy, especially if the heart rhythm is irregular. Shorter durations (e.g., 15 or 30 seconds) can be used, but the result should be multiplied accordingly, and any irregularities should prompt a full 60-second count. When timing a pulse, start the timer on the first beat you hear, and count that as “one”.
* **Assess the Rhythm:** While counting, also assess the rhythm of the heartbeats. Note whether the beats are regular (evenly spaced) or irregular (unevenly spaced). If the rhythm is irregular, note the pattern of the irregularity (e.g., occasionally skipped beats, regularly irregular). Document any irregularities observed.
**4. Documentation:**
* **Record the Heart Rate:** Record the apical pulse rate (beats per minute) in the patient’s chart or electronic medical record. Be precise with your documentation.
* **Note the Rhythm:** Document whether the rhythm was regular or irregular. If irregular, describe the pattern.
* **Document Any Abnormalities:** Note any unusual sounds or abnormalities heard during auscultation, such as murmurs, clicks, or rubs. Describe the characteristics of the sound (e.g., location, timing, intensity).
* **Record the Date and Time:** Record the date and time the apical pulse was taken.
* **Document Patient Position:** Note the position the patient was in during assessment (supine, left lateral, sitting, etc.)
* **Your Initials/Signature:** Sign or initial the entry to indicate who performed the assessment.
**Example Documentation:**
“Apical pulse: 72 bpm, regular rhythm. No murmurs or extra heart sounds auscultated. Patient positioned supine. Date: 2024-10-27, Time: 10:00 AM. [Your Initials/Signature]”
**5. Post-Procedure:**
* **Ensure Patient Comfort:** Ensure the patient is comfortable before leaving. Assist them back to their original position if needed.
* **Dispose of Supplies:** Dispose of any used supplies according to facility protocols.
* **Wash Your Hands:** Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer.
* **Report Abnormal Findings:** Report any abnormal findings (e.g., significant changes in heart rate, new murmurs, irregular rhythms) to the appropriate healthcare provider immediately.
Special Considerations
* **Infants and Children:**
* In infants and young children, the apical pulse is often the preferred method for assessing heart rate. Use a pediatric stethoscope with a smaller diaphragm.
* The apical pulse in infants is typically located at the 4th intercostal space, midclavicular line.
* Be gentle and patient when assessing infants and children, as they may be anxious or uncooperative. Use a calm and reassuring tone.
* **Obese Patients:**
* In obese patients, it may be more difficult to locate the apex of the heart due to the increased amount of subcutaneous tissue.
* Palpate carefully to identify the point where the heartbeat is strongest. You may need to press a bit more firmly with the stethoscope to obtain a clear sound.
* Consider using the left lateral position to bring the heart closer to the chest wall.
* **Patients with Chest Deformities:**
* Patients with chest deformities (e.g., scoliosis, pectus excavatum) may have a displaced heart position.
* Palpate carefully to locate the apex of the heart. Use imaging results, if available, to assist.
* **Patients with Lung Disease:**
* Patients with lung diseases like emphysema may have an altered heart position due to lung hyperinflation.
* Auscultate carefully, paying attention to any adventitious lung sounds that may interfere with hearing the heart sounds.
* **Pregnant Women:**
* During pregnancy, the heart is displaced upward and to the left due to the enlarging uterus.
* The apical pulse may be located higher than the 5th intercostal space. Palpate carefully to find the point where the heartbeat is strongest.
* The heart rate in pregnant women is typically slightly higher than in non-pregnant women.
Common Mistakes to Avoid
* **Incorrect Stethoscope Placement:** Placing the stethoscope in the wrong location can lead to inaccurate readings. Always ensure the stethoscope is placed over the apex of the heart.
* **Inadequate Contact:** Not ensuring the entire diaphragm of the stethoscope is in contact with the skin can result in faint or unclear heart sounds. Press firmly but gently.
* **Short Counting Time:** Counting the heartbeats for less than one full minute, especially with irregular rhythms, can lead to inaccurate rate determination. Always count for a full minute.
* **Ignoring Environmental Noise:** Not minimizing environmental noise can make it difficult to hear the heart sounds clearly. Ensure a quiet environment.
* **Failure to Document Thoroughly:** Incomplete documentation can lead to confusion and errors in patient care. Document all relevant findings, including heart rate, rhythm, and any abnormalities.
* **Not washing hands before and after the procedure:** Increases the risk of infection.
Troubleshooting Difficulties
* **Difficulty Hearing Heart Sounds:**
* **Reposition the Patient:** Try repositioning the patient (e.g., left lateral position) to bring the heart closer to the chest wall.
* **Ensure Proper Stethoscope Placement:** Double-check that the stethoscope is placed directly over the apex of the heart and that the entire diaphragm is in contact with the skin.
* **Minimize Environmental Noise:** Reduce noise levels in the environment by closing doors or turning off televisions or radios.
* **Use a Different Stethoscope:** If possible, try using a different stethoscope to rule out any issues with the equipment.
* **Consider Patient Factors:** Be aware that factors such as obesity, lung disease, or chest deformities can make it more difficult to hear heart sounds. Palpate carefully to locate the apex of the heart.
* **Irregular Heart Rhythm:**
* **Count for a Full Minute:** Always count the heartbeats for one full minute when the rhythm is irregular to obtain an accurate rate.
* **Assess the Pattern:** Note the pattern of the irregularity (e.g., occasionally skipped beats, regularly irregular) and document your observations.
* **Consult with a Healthcare Provider:** Report the irregular rhythm to the appropriate healthcare provider for further evaluation and management.
* **Patient Anxiety:**
* **Explain the Procedure:** Clearly explain the procedure to the patient and address any concerns they may have.
* **Create a Calm Environment:** Provide a quiet and comfortable environment to help the patient relax.
* **Use a Reassuring Tone:** Speak in a calm and reassuring tone to alleviate anxiety.
Conclusion
Taking an apical pulse is a fundamental skill that provides valuable information about a patient’s cardiovascular health. By following these detailed steps and considering the special considerations discussed, you can accurately assess heart rate and rhythm. Accurate apical pulse assessment is a cornerstone of patient care, assisting in diagnosis, treatment monitoring, and overall patient well-being. Remember to always document your findings thoroughly and report any abnormalities to the appropriate healthcare provider. Practice and familiarity with the procedure will enhance your confidence and competence in performing this essential skill.
Disclaimer
This guide is for informational purposes only and should not be considered medical advice. Always follow your facility’s policies and procedures, and consult with a healthcare professional for any specific medical concerns or questions.
