12.9:
Assessment of apical pulse
Assessing the apical pulse is indicated for children younger than two, cardiac patients, and prior to specific medication administration.
It is auscultated at the left midclavicular line at the fifth intercostal space.
Before the procedure, gather equipment, such as a stethoscope, watch, pen, documentation aids, and alcohol swabs.
Identify and approach the patient.
Explain the procedure and obtain verbal consent.
Perform hand hygiene and provide privacy.
Clean the stethoscope's diaphragm and earpieces with an alcohol swab to reduce the transmission of microorganisms.
Position the patient in a sitting or reclining posture, exposing the chest.
Ensure the stethoscope’s audibility.
Place the stethoscope at the apical site and check for cardiac valve closure sounds, the S1 lub, and the S2 dub sounds.
Check the pulse for one full minute.
Post-procedure, cover the patient and provide a comfortable position.
Replace the equipment, perform hand hygiene, and record the findings.
12.9:
Assessment of apical pulse
Assessing the Apical Pulse
Assessing the apical pulse is a critical nursing procedure, particularly indicated for:
- • Children younger than two years.
- • Cardiac patients.
- • Patients before administering specific medications (e.g., cardiac glycosides like digoxin).
Location: The apical pulse is auscultated at the left midclavicular line. It is located at the 5th intercostal space, where the heart's apex is closest to the chest wall.
Preparation:
- Gather Equipment: Ensure you have a stethoscope, a watch with a secondhand or a timer, a pen, documentation materials, and alcohol swabs.
- Patient Identification and Approach: Properly identify and approach the patient, explaining the procedure to gain their understanding and verbal consent.
- Hand Hygiene and Privacy: Perform hand hygiene according to infection control protocols and ensure adequate privacy for the patient.
- Stethoscope Preparation: Clean the diaphragm and earpieces of the stethoscope with alcohol swabs to minimize the risk of transmitting microorganisms.
Verfahren:
- Position the Patient: Position the patient comfortably, either sitting or reclining, with the chest area exposed for easy access to the apical site.
- Check Stethoscope: Ensure the earpiece audibility is clear to provide accuracy during the assessment.
- Locate and Listen: Place the stethoscope at the apical site. Listen carefully for the heart sounds, notably the S1 'lub' and S2 'dub' sounds, which indicate cardiac valve closure.
- Timing the Pulse: The apical pulse is auscultated for one full minute to accurately measure heart rate and rhythm. This duration helps detect irregularities like missed or extra beats, which may not be noticeable in shorter assessments.
Post-Procedure:
- Patient Comfort: After completing the assessment, cover the patient and assist them in getting back into a comfortable position.
- Equipment and Hygiene: Replace the equipment in its proper place. Perform hand hygiene again to maintain infection control standards.
- Documentation: Record your findings accurately in the patient's medical record, including the rate, rhythm, and any abnormalities of the apical pulse.