Your pulse is the vibration of blood as your heart pumps it through your arteries. You can feel your pulse by placing your fingers over a large artery that lies close to your skin.
The apical pulse is one of eight common arterial pulse sites. It can be found in the left center of your chest, just below the nipple. This position roughly corresponds to the lower (pointed) end of your heart. Check out a detailed diagram of the circulatory system.
Listening to the apical pulse is basically listening directly to the heart. It’s a very reliable and noninvasive way to evaluate cardiac function. It’s also the preferred method for measuring heart rate in children.
A stethoscope is used to measure the apical pulse. A clock or wristwatch with seconds is also needed.
The apical pulse is best assessed when you are either sitting or lying down.
Your doctor will use a series of “landmarks” on your body to identify what’s called the point of maximal impulse (PMI). These landmarks include:
- the bony point of your sternum (breastbone)
- the intercostal spaces (the spaces between your rib bones)
- the midclavicular line (an imaginary line moving down your body starting from the middle of your collarbone)
Starting from the bony point of your breastbone, your doctor will locate the second space between your ribs. They’ll then move their fingers down to the fifth space between your ribs and slide them over to the midclavicular line. The PMI should be found here.
Once the PMI has been located, your doctor will use the stethoscope to listen to your pulse for a full minute in order to obtain your apical pulse rate. Each “lub-dub” sound your heart makes counts as one beat.
An apical pulse rate is typically considered abnormal in an adult if it’s above 100 beats per minute (bpm) or below 60 bpm. Your ideal heart rate at rest and during physical activity are very different.
Children have a higher resting pulse rate than adults. The normal resting pulse ranges for children are as follows:
- newborn: 100–170 bpm
- 6 months to 1 year: 90–130 bpm
- 2 to 3 years: 80–120 bpm
- 4 to 5 years: 70–110 bpm
- 10 years and older: 60–100 bpm
When the apical pulse is higher than expected, your doctor will evaluate you for the following things:
Additionally, a heart rate that is consistently higher than normal could be a sign of heart disease, heart failure, or an overactive thyroid gland.
When the apical pulse is lower than expected, your doctor will check for medication that may be affecting your heart rate. Such medications include beta-blockers given for high blood pressure or anti-dysrhythmic medications given for irregular heartbeat.
Pulse deficit
If your doctor finds that your apical pulse is irregular, they’ll likely check for the presence of a pulse deficit. You doctor may also request that you have an electrocardiogram.
Two people are needed to assess pulse deficit. One person measures the apical pulse while the other person measures a peripheral pulse, such as the one in your wrist. These pulses will be counted at the same time for one full minute, with one person giving the signal to the other to start counting.
Once the pulse rates have been obtained, the peripheral pulse rate is subtracted from the apical pulse rate. The apical pulse rate will never be lower than the peripheral pulse rate. The resulting number is the pulse deficit. Normally, the two numbers would be the same, resulting in a difference of zero. However, when there’s a difference, it’s called a pulse deficit.
The presence of a pulse deficit indicates that there may be an issue with cardiac function or efficiency. When a pulse deficit is detected, it means that the volume of blood pumped from the heart may not be sufficient to meet the needs of your body’s tissues.
Listening to the apical pulse is listening directly to your heart. It’s the most efficient way to evaluate heart function.
If your pulse is outside of the normal range or you have an irregular heartbeat, your doctor will evaluate you further.
Chapter 2. Patient Assessment
Temperature, pulse, respiration, blood pressure (BP), and oxygen saturation, are measurements that indicate a person’s hemodynamic status. These are the five vital signs most frequently obtained by health care practitioners (Perry, Potter, & Ostendorf, 2014). Vital signs will potentially reveal sudden changes in a patient’s condition and will also measure changes that occur progressively over time. A difference between patients’ normal baseline vital signs and their present vital signs may indicate the need for intervention (Perry et al., 2014). Checklist 15 outlines the steps to take when checking vital signs.
| 1. Temperature:
|
Normal (oral) = 35.8ºC to 37.3ºC
Oral temperature: Place the thermometer in the mouth under the tongue and instruct patient to keep mouth closed. Leave the thermometer in place for as long as is indicated by the device manufacturer. Axillary temperature: Usually 1ºC lower than oral temperature. Place the thermometer in patient’s armpit and leave it in place for as long as is indicated by the device manufacturer. Tympanic membrane (ear) temperature: Usually 0.3°C to 0.6°C higher than an oral temperature. The tympanic membrane shares the same vascular artery that perfuses the hypothalamus. Do not force the thermometer into the ear and do not occlude the ear canal. Rectal temperature: Usually 1ºC higher than oral temperature. Use only when other routes are not available. |
| 2. Pulse:
Normal resting heart rate = 60 to 100 beats per minute |
Radial pulse: Use the pads of your first three fingers to gently palpate the radial pulse at the inner lateral wrist.
Apical pulse: Taken as part of a focused cardiovascular assessment and when the pulse rate is irregular. Apical heart rate should be used as the parameter indicated in certain cardiac medications (e.g., digoxin). Apical pulse rate should be taken for a full minute for accuracy, and is located at the fifth intercostal space in line with the middle of the clavicle in adults. Carotid pulse: May be taken when radial pulse is not present or is difficult to palpate. |
| 3. Respiration rate:
Normal resting respiratory rate = 10 to 20 breaths per minute |
Count respiratory rate unobtrusively while you are taking the pulse rate so that the patient is not aware that you are taking the respiration rate. Count for 30 seconds or for a full minute if irregular. |
| 4. Blood pressure (BP):
The average BP for an adult is 120/80 mmHg, but variations are normal for various reasons. |
The systolic pressure is the maximum pressure on the arteries during left ventricular contraction.
The diastolic pressure is the resting pressure on the arteries between each cardiac contraction. The patient may be sitting or lying down with the bare arm at heart level. Palpate the brachial artery just above the antecubital fossa medially. Wrap the BP cuff around the upper arm about 2.5 cm above the brachial artery. Palpate the radial or brachial artery, and inflate the BP cuff until the pulse rate is no longer felt. Then inflate 20 to 30 mmHg more. Place the bell of the stethoscope over the brachial artery, and deflate the cuff slowly and evenly, noting the points at which you hear the first appearance of sound (systolic BP), and the disappearance of sound (diastolic BP). |
| 5. Oxygen saturation (SpO2):
A healthy patient will have an SpO2 of ≥ 97%. |
A pulse oximeter sensor attached to the patient’s finger or earlobe measures light absorption of hemoglobin and represents arterial SpO2. |
| Data source: Jarvis et al., 2014; Stephen, Skillen, Day, & Jensen, 2012 |
- Which type of thermometer is the best example of a non-invasive, safe, and efficient tool for measuring temperature?
- A 40-year-old male patient has a blood pressure of 140/100 mmHg. Is this normal for this patient? What additional data would you need to collect before making a decision about care for this patient?