Vital Signs – Apical Pulse

Equipment:

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• Wristwatch with second hand
• Stethoscope
• Pen and vital sign flow sheet in chart or electronic health record (EHR)
• Alcohol swab

Steps:

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1. WIIAPA:

1. 1. Wash hands
   2. Introduce self
   3. Identify patient (use 2 identifiers)
   4. Allergies – don’t forget food allergies
   5. Plan of care
   6. Assess patient

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2. Determine patient’s previous baseline apical rate.
3. If necessary, draw curtain around bed and/or close door.
4. Help patient to a supine or sitting position. Move aside bed linen and gown to expose sternum and left side of chest.
5. Locate anatomical landmarks to identify point of maximal impulse (PMI), also called apical impulse. (Fifth intercostal space at left midclavicular line)
6. Place diaphragm of stethoscope in palm of hand for 5 to 10 seconds to warm cold metal or plastic.
7. Place diaphragm of stethoscope over PMI at fifth ICS, at left MCL, and auscultate for normal S1 and S2 heart sounds (heard as “lub-dub”).
8. When you hear S1 and S2 with regularity, use second hand of watch and begin to count rate when sweep hand hits number on dial.
9. If apical rate is regular, count for 30 seconds and multiply by 2.
10. If HR is irregular or patient is receiving cardiovascular medication, count for a full 1 minute.
11. Note regularity of any dysrhythmia.
12. Replace patient’s gown and bed linen and return to comfortable position.
13. Discuss findings with patient. Return call bell and lower bed and raise side rails as needed.
14. Clean earpieces and diaphragm of stethoscope with alcohol swab routinely after each use. Hand hygiene.
15. Document.