Assessment:
Assess appropriate site to obtain pulse. Check pulse with health status changes. Assess for rate, rhythm, pattern, and volume. Take an apical pulse on patients with irregular rhythms or those on heart medications. Take an apical-radial pulse when deficits occur between apical and radial measurements.
Planning:
To determine if the pulse rate is within normal range and if the rhythm is regular. Evaluate the quality of corresponding arterial pulses. To determine presence of peripheral pulses when palpation is ineffective. To monitor and evaluate changes in the patients health status.
Intervention:
Position the client appropriately. Demonstrate the procedure to child using a stuffed animal or doll, and allow the child to handle the stethoscope before beginning the procedure. Expose the area of the chest over the apex of the heart. Locate the apical pulse. Palpate the angle of Louis (the angle between the manubrium the top of the sternum). Place your index finger just to the left of the client sternum, and palpate the second intercostals space. Place your middle or next finger in the third intercostals space, and continue palpating downward until you locate the apical pulse, usually about the fifth intercostals space. Auscultate and count heartbeats. Use antiseptic wipes to clean the earpiece and diaphragm of the stethoscope if their cleanliness is in doubt. Warm the diaphragm of the stethoscope by holding it in the palm of the hand for a moment. Insert the earpieces of the stethoscope into the ears. Place the diaphragm of the stethoscope over the apical impulse and listen for normal S1 and S2 heart sounds, which are heard as “lub dub”. Count the heartbeat for 30 seconds and multiply by 2 if the rhythm is irregular or if the apical impulse is being taken on an infant or child. Assess the rhythm and the atrength of the heartbeat. Assess the rhythm of the heartbeat by noting the pattern of intervals between the beats. As normal pulse has an equal time period between the beats. Assess the strength (volume) of the heartbeat. Document and report pertinent assessment data. Record the pulse site and rate, rhythm, and volume. Report to the nurse in charge any pertinent data such as pallor, cyanosis, dyspnea, tachycardia, bradycardia, irregular rhythms, and reduced strength of the heartbeat.
