Assessing Apical Pulse Flashcards
The apical pulse
is the most reliable noninvasive way to assess cardiac function. The apical pulse rate is the assessment of the number and quality of apical sounds in 1 minute
S1 and S2
S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systole begins. S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.
The stethoscope
is a closed cylinder that amplifies sound waves as they reach the surface of the body.
The five major parts of the stethoscope are
the earpieces, binaurals, tubing, bell, and diaphragm.
Binaurals should be
angled and strong enough so the earpieces stay firmly in place without causing discomfort.
The earpieces follow
the contour of the ear canal, pointing toward the face when the stethoscope is in place.
longer tubing
decreases sound transmission. Stethoscopes can have one or two tubes
The diaphragm
the larger, circular, flat-surfaced portion of the chest piece. It transmits high-pitched sounds created by high-velocity movement of air and blood.
The bell
is the cone-shaped portion of the chest piece, usually surrounded by a rubber ring to avoid chilling the patient during placement. It transmits low-pitched sounds created by the low-velocity movement of blood. Hold the bell lightly against the skin for sound amplification.
risk factors for alterations in the apical pulse
heart disease, cardiac dysrhythmias, sudden onset of chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of a large volume of intravenous (IV) fluid, internal or external hemorrhage, and administration of medications that alter heart function
signs and symptoms of altered cardiac function
dyspnea or shortness of breath, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin.
factors that affect the apical pulse rate and rhythm
age, exercise or activity, athletic conditioning, position changes, medication, temperature, sleep, and sympathetic stimulation.
Do not delegate this skill to nursing assistive personnel (NAP) when…
a pulse abnormality is suspected or when the patient’s condition warrants a more accurate assessment.
Before delegating routine performance of this skill, be sure to inform NAP of the following:
The frequency of measurement and factors related to the patient’s history, such as the risk for an abnormally slow, rapid, or irregular pulse.
The patient’s usual pulse values and the need to report to you any abnormalities in rate or rhythm.
When assessing the apical pulse for the first time…
establish the apical pulse as the baseline. Compare the apical heart rate to the acceptable range for the patient age. Notify the practitioner if it is not within an acceptable range.
The PMI of an infant is usually located
at the third to fourth ICS near the left sternal border.
In infants and children younger than 2 years, an apical pulse provides the most reliable HR assessment and is counted for 1 full minute because of possible irregularities in rhythm.
Breath holding in an infant or child affects apical pulse rate.
The PMI is often difficult to palpate in some older adults because
the anterior-posterior diameter of the chest increases with age and the heart becomes repositioned because of left ventricular enlargement.
When assessing older adult women with sagging breast tissue…
gently lift the breast tissue and place the stethoscope at the fifth ICS or the lower edge of the breast.
Heart sounds are sometimes muffled or difficult to hear in older adults because
of an increase in air space in the lungs.
The older adult has a decreased HR at rest.1
