![]() ![]() Ostendorf (Eds), Clinical nursing skills & techniques (8th ed., pp. McDaniel, MS, BSN, RN Referencesįetzer, S. 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.Īmanda R.Perform hand hygiene and clean the bell of your stethoscope with an alcohol swab.Replace the patient’s clothing and bed covers.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.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.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. Listen for the “lub-dub” of normal heart sounds.It is kind to warm the stethoscope in your hands before placing it on the patient to avoid an unexpected chill.This is generally just below the breast tissue. Place your stethoscope where the imaginary line and the fifth intercostal space intersect.The midclavicular line is an imaginary line drawn straight down from the middle of the clavicle (in this case, the left clavicle).Count down three more to reach the fifth intercostal space. Directly beside this is the second intercostal space. To find the correct location, first locate the sternal notch at the top of the sternum.This is the location of the apex of the heart. Place the bell of the stethoscope at the fifth intercostal space, at the left midclavicular line.Adjust the bed covers and/or the patient’s clothing so that the sternum and left side of the chest are exposed. The patient should be sitting or lying supine.Ensure patient privacy by closing the curtain or door.Introduce yourself to the patient, perform hand hygiene, and clean the bell of the stethoscope with an alcohol swab. ![]() Clock or watch with seconds displayed, or a second hand.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.). 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. She now works as a nurse on a NeuroTelemetry unit and continues to write and edit on a freelance basis. 15.6 Measuring and recording apical pulse. Choose from 186 different sets of apical pulse flashcards on Quizlet. She worked as a medical writer in the pharmaceutical industry for 11 years before pursuing a career in nursing. Learn apical pulse with free interactive flashcards. Thus this study clearly es- tablishes that left ventricular function does in fact affect the nature of the apical impulse in patients with coronary artery. McDaniel, MS, BSN, RNĪmanda is a BSN/RN with a MS in Physiology and a BA in English. ![]()
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