{"id":282,"date":"2021-08-28T02:36:14","date_gmt":"2021-08-28T06:36:14","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/auscultation-of-the-apical-pulse\/"},"modified":"2024-06-29T18:44:30","modified_gmt":"2024-06-29T22:44:30","slug":"auscultation-of-the-apical-pulse","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/auscultation-of-the-apical-pulse\/","title":{"raw":"Auscultation of the Apical Pulse","rendered":"Auscultation of the Apical Pulse"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Auscultation of the apical pulse<\/strong> involves assessing the <strong>rate<\/strong> and the <strong>rhythm<\/strong>. This is best done at the apex, which is landmarked at the 5<sup>th<\/sup> intercostal space (for adults) and the 4<sup>th<\/sup> intercostal space (for children) at the left midclavicular line. See <strong>Figure 7<\/strong>.<\/span><\/p>\r\n<p style=\"text-align: center\"><img src=\"http:\/\/pressbooks.library.ryerson.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2021\/11\/Apical-Pulse-1024x1024.png\" alt=\"Drawn image that identifies the locations of the midclavicular line, apical pulse of the infant\/young child and apical pulse of the adult\" class=\"alignnone wp-image-1012\" width=\"532\" height=\"601\" \/><\/p>\r\n<strong>Figure 7<\/strong>: Location of apical pulse\r\n\r\n<span style=\"color: #000000\">Illustration by Hillary Tang from the vital signs chapter<\/span> <span style=\"color: #000000\">(image was cropped and illustrated upon for the purposes of this chapter).<\/span>\r\n\r\n&nbsp;\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Auscultation of the apical pulse involves the following steps (see <strong>Video 9<\/strong>):<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">1. Keep the client in a supine position and continue to drape.<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li><span style=\"color: #000000\">This procedure can also be completed in a sitting position.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">2. Cleanse the stethoscope.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">3. <strong>Physically landmark<\/strong> the location of the apical pulse.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">4. Place the diaphragm of the stethoscope at the correct location with a complete seal.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">5. Count the <strong>rate<\/strong> for one minute and <strong>report beats per minute<\/strong>.<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li><span style=\"color: #000000\">One beat is considered one cardiac cycle (systole and diastole) and it sounds like \u201club dub.\u201d Lub correlates with the closure of the AV valves and is referred to as S1; it signals the beginning of ventricular contraction (systole). Dub correlates with the closure of the SL valves and is referred to as S2; it signals the beginning of ventricular relaxation (diastole).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Apical pulses are typically counted for a full minute to assess for any irregularities.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">6. Note the <strong>rhythm<\/strong> (e.g., regular or irregular rhythm).<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li><span style=\"color: #000000\">Normally, the rhythm is <strong>regular<\/strong> which means there is an even tempo with equal intervals between beats.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">If the rhythm is <strong>irregular<\/strong>, note whether it is a regularly irregular rhythm or an irregularly irregular rhythm.<\/span>\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Regularly irregular rhythm<\/strong>: a regularity to the irregular rhythm, for example three regular beats and one missed beat and then this pattern is continually repeated.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">OR<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Irregularly irregular rhythm<\/strong>: an irregularity to the irregular rhythm, for example there is no pattern to the irregular rhythm. For example, you might hear two beats in a row, 1 missed beat, three beats in a row, 1 missed beat, 1 beat etc... This irregular rhythm is more concerning. When it is irregularly irregular, it is an erratic rhythm in which the heart is not always fully contracting at systole and filling with blood at diastole. This type of rhythm is highly specific to atrial fibrillation, in which the atria quiver. This can result in blood clots and decreased stroke volume and cardiac output. As a result, it can also lead to the heart not optimally perfusing blood to the periphery.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If the rhythm is irregular, check for a <strong>pulse deficit<\/strong>. A pulse deficit is when the radial pulse is less than the apical pulse, meaning that you will feel less palpable pulses at the radial site compared to the number of beats heard when auscultating the apical pulse. Normally there is no pulse deficit when a heart is perfusing the periphery. Experts suggest that a pulse deficit of more than 10 should be investigated further particularly when associated with other symptoms. To assess for a pulse deficit, use the following steps:<\/span>\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">While auscultating the apical pulse, also palpate the radial pulse. You can usually do this at the same time and note whether they are equal.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If they are unequal, count the apical pulse for one minute, and then count the radial pulse for one minute. Next, subtract the radial pulse from the apical pulse to obtain the client\u2019s pulse deficit. For example, if the apical pulse is 90 beats per minute and the radial pulse is 72 beats per minute, you would calculate the pulse deficit as 18 beats per minute (90 \u2013 72 = 18), meaning that those 18 times that the heart contracts, the blood is not being perfused to the periphery.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<ol style=\"text-align: left\">\r\n \t<li style=\"list-style-type: none\"><\/li>\r\n<\/ol>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">7. Note the <strong>findings<\/strong><\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li><span style=\"color: #000000\">Normal findings might be documented as (example): \u201cApical pulse 82 beats per minute with a regular rhythm.\u201d<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Abnormal findings may be documented as (example): \u201cApical pulse 134 beats per minute with an irregularly irregular rhythm.\u201d<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">See <strong>Audio 1<\/strong> to listen to a normal apical pulse. Listen for the \u201club dub.\u201d And then listen again, and count the pulse and report the beats per minute. (Find the answer at the bottom of this page)<\/span><\/p>\r\n&nbsp;\r\n<p style=\"text-align: left\"><span>[h5p id=\"232\"]<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Audio 1<\/strong>: Normal apical pulse<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">(Attribution statement: taken from<\/span> <a href=\"https:\/\/wtcs.pressbooks.pub\/nursingskills\/chapter\/9-3-cardiovascular-assessment\/\" target=\"_blank\" rel=\"noopener\">https:\/\/wtcs.pressbooks.pub\/nursingskills\/chapter\/9-3-cardiovascular-assessment\/<\/a>)<\/p>\r\n&nbsp;\r\n\r\n&nbsp;\r\n\r\n[embed]https:\/\/youtu.be\/D_bsn97IBXo[\/embed]\r\n\r\n<strong>Video 9<\/strong>: Auscultation of apical pulse.\r\n\r\n<strong>ANSWER<\/strong>: The apical pulse rate in <strong>Audio 1<\/strong> is 64 beats per minute.\r\n\r\n&nbsp;\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 style=\"text-align: center\">Priorities of Care<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Notify the physician\/nurse practitioner if a client has an irregularly irregular rhythm and is showing signs of bradycardia or tachycardia. Additionally, a pulse deficit is of concern because it is suggesting that the heart is not perfusing the periphery. Thus, you should perform a full cardiac assessment. Unless the client is showing signs of clinical deterioration and requires prompt intervention, you should first complete a full cardiac assessment so that you can provide a full report of the relevant cues and share recommendations for actions.\u00a0<\/span><\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n&nbsp;\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\">Activity: Check Your Understanding<\/span><\/h2>\r\n<p style=\"text-align: left\"><span>[h5p id=\"226\"]<\/span><\/p>\r\n&nbsp;\r\n\r\n&nbsp;","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Auscultation of the apical pulse<\/strong> involves assessing the <strong>rate<\/strong> and the <strong>rhythm<\/strong>. This is best done at the apex, which is landmarked at the 5<sup>th<\/sup> intercostal space (for adults) and the 4<sup>th<\/sup> intercostal space (for children) at the left midclavicular line. See <strong>Figure 7<\/strong>.<\/span><\/p>\n<p style=\"text-align: center\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/pressbooks.library.ryerson.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2021\/11\/Apical-Pulse-1024x1024.png\" alt=\"Drawn image that identifies the locations of the midclavicular line, apical pulse of the infant\/young child and apical pulse of the adult\" class=\"alignnone wp-image-1012\" width=\"532\" height=\"601\" \/><\/p>\n<p><strong>Figure 7<\/strong>: Location of apical pulse<\/p>\n<p><span style=\"color: #000000\">Illustration by Hillary Tang from the vital signs chapter<\/span> <span style=\"color: #000000\">(image was cropped and illustrated upon for the purposes of this chapter).<\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Auscultation of the apical pulse involves the following steps (see <strong>Video 9<\/strong>):<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">1. Keep the client in a supine position and continue to drape.<\/span><\/p>\n<ul style=\"text-align: left\">\n<li><span style=\"color: #000000\">This procedure can also be completed in a sitting position.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">2. Cleanse the stethoscope.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">3. <strong>Physically landmark<\/strong> the location of the apical pulse.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">4. Place the diaphragm of the stethoscope at the correct location with a complete seal.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">5. Count the <strong>rate<\/strong> for one minute and <strong>report beats per minute<\/strong>.<\/span><\/p>\n<ul style=\"text-align: left\">\n<li><span style=\"color: #000000\">One beat is considered one cardiac cycle (systole and diastole) and it sounds like \u201club dub.\u201d Lub correlates with the closure of the AV valves and is referred to as S1; it signals the beginning of ventricular contraction (systole). Dub correlates with the closure of the SL valves and is referred to as S2; it signals the beginning of ventricular relaxation (diastole).<\/span><\/li>\n<li><span style=\"color: #000000\">Apical pulses are typically counted for a full minute to assess for any irregularities.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">6. Note the <strong>rhythm<\/strong> (e.g., regular or irregular rhythm).<\/span><\/p>\n<ul style=\"text-align: left\">\n<li><span style=\"color: #000000\">Normally, the rhythm is <strong>regular<\/strong> which means there is an even tempo with equal intervals between beats.<\/span><\/li>\n<li><span style=\"color: #000000\">If the rhythm is <strong>irregular<\/strong>, note whether it is a regularly irregular rhythm or an irregularly irregular rhythm.<\/span>\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Regularly irregular rhythm<\/strong>: a regularity to the irregular rhythm, for example three regular beats and one missed beat and then this pattern is continually repeated.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">OR<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Irregularly irregular rhythm<\/strong>: an irregularity to the irregular rhythm, for example there is no pattern to the irregular rhythm. For example, you might hear two beats in a row, 1 missed beat, three beats in a row, 1 missed beat, 1 beat etc&#8230; This irregular rhythm is more concerning. When it is irregularly irregular, it is an erratic rhythm in which the heart is not always fully contracting at systole and filling with blood at diastole. This type of rhythm is highly specific to atrial fibrillation, in which the atria quiver. This can result in blood clots and decreased stroke volume and cardiac output. As a result, it can also lead to the heart not optimally perfusing blood to the periphery.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If the rhythm is irregular, check for a <strong>pulse deficit<\/strong>. A pulse deficit is when the radial pulse is less than the apical pulse, meaning that you will feel less palpable pulses at the radial site compared to the number of beats heard when auscultating the apical pulse. Normally there is no pulse deficit when a heart is perfusing the periphery. Experts suggest that a pulse deficit of more than 10 should be investigated further particularly when associated with other symptoms. To assess for a pulse deficit, use the following steps:<\/span>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">While auscultating the apical pulse, also palpate the radial pulse. You can usually do this at the same time and note whether they are equal.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If they are unequal, count the apical pulse for one minute, and then count the radial pulse for one minute. Next, subtract the radial pulse from the apical pulse to obtain the client\u2019s pulse deficit. For example, if the apical pulse is 90 beats per minute and the radial pulse is 72 beats per minute, you would calculate the pulse deficit as 18 beats per minute (90 \u2013 72 = 18), meaning that those 18 times that the heart contracts, the blood is not being perfused to the periphery.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol style=\"text-align: left\">\n<li style=\"list-style-type: none\"><\/li>\n<\/ol>\n<p style=\"text-align: left\"><span style=\"color: #000000\">7. Note the <strong>findings<\/strong><\/span><\/p>\n<ul style=\"text-align: left\">\n<li><span style=\"color: #000000\">Normal findings might be documented as (example): \u201cApical pulse 82 beats per minute with a regular rhythm.\u201d<\/span><\/li>\n<li><span style=\"color: #000000\">Abnormal findings may be documented as (example): \u201cApical pulse 134 beats per minute with an irregularly irregular rhythm.\u201d<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">See <strong>Audio 1<\/strong> to listen to a normal apical pulse. Listen for the \u201club dub.\u201d And then listen again, and count the pulse and report the beats per minute. (Find the answer at the bottom of this page)<\/span><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: left\"><span><\/p>\n<div id=\"h5p-232\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-232\" class=\"h5p-iframe\" data-content-id=\"232\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Normal S1\/S2\"><\/iframe><\/div>\n<\/div>\n<p><\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Audio 1<\/strong>: Normal apical pulse<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">(Attribution statement: taken from<\/span> <a href=\"https:\/\/wtcs.pressbooks.pub\/nursingskills\/chapter\/9-3-cardiovascular-assessment\/\" target=\"_blank\" rel=\"noopener\">https:\/\/wtcs.pressbooks.pub\/nursingskills\/chapter\/9-3-cardiovascular-assessment\/<\/a>)<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Auscultation of Apical Pulse\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/D_bsn97IBXo?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><strong>Video 9<\/strong>: Auscultation of apical pulse.<\/p>\n<p><strong>ANSWER<\/strong>: The apical pulse rate in <strong>Audio 1<\/strong> is 64 beats per minute.<\/p>\n<p>&nbsp;<\/p>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 style=\"text-align: center\">Priorities of Care<\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p style=\"text-align: left\"><span style=\"color: #000000\">Notify the physician\/nurse practitioner if a client has an irregularly irregular rhythm and is showing signs of bradycardia or tachycardia. Additionally, a pulse deficit is of concern because it is suggesting that the heart is not perfusing the periphery. Thus, you should perform a full cardiac assessment. Unless the client is showing signs of clinical deterioration and requires prompt intervention, you should first complete a full cardiac assessment so that you can provide a full report of the relevant cues and share recommendations for actions.\u00a0<\/span><\/p>\n<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\">Activity: Check Your Understanding<\/span><\/h2>\n<p style=\"text-align: left\"><span><\/p>\n<div id=\"h5p-226\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-226\" class=\"h5p-iframe\" data-content-id=\"226\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Ch.4 - Auscultation of the Apical Pulse\"><\/iframe><\/div>\n<\/div>\n<p><\/span><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"author":34,"menu_order":12,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-nc"},"chapter-type":[],"contributor":[72],"license":[56],"class_list":["post-282","chapter","type-chapter","status-publish","hentry","contributor-december-2021","license-cc-by-nc"],"part":260,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/282","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":9,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/282\/revisions"}],"predecessor-version":[{"id":2890,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/282\/revisions\/2890"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/260"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/282\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=282"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=282"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=282"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=282"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}