Normal Apical Pulse



Normal apical pulse

  • Assuming the underlying heart rhythm is normal, a heart rate between 60 and 100 bpm would be considered normal at rest. Would go above 100 temporaril.
  • If you measure your heart rate (take your pulse) before, during and after physical activity, you’ll notice it will increase over the course of the exercise. The greater the intensity of the exercise, the more your heart rate will increase. When you stop exercising, your heart rate does not immediately return to your normal (resting) heart rate.

Part II: Assessment Techniques

Apical pulse: located in the 5th left intercostal space, 1.25 cm lateral to the mid-clavicular line. In contrast with other pulse sites, the apical pulse site is unilateral, and measured not under an artery, but below the heart itself (more specifically, the apex of the heart). See also apex beat. The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males.

Inspection

As you prepare to begin the actual assessment, you already have obtained and recorded the patient history and you arm yourself with pertinent data such as their chief complaint and allergic history.

Also keep in mind to allow a certain amount of time in order to complete a thorough exam. Many nurses do not have large blocks of time for completion of the assessment but you must be as thorough as possible. If this is an admission assessment, you must allow enough time to be complete. If this is an on-going assessment, not as much time will be required.

Begin Exam

  • Patient undresses, but allow for privacy.
  • Have the patient sit upright and inspect the thorax from the front.
  • Now inspect from the back of the patient.

You will inspect for posture and symmetry of the thorax, color of the skin, gross deformities of the skin or bone structure, the neck, face, eyes, and any abnormal contours. Breathing patters will also be noted. Be especially aware of the presence of cyanosis. Central cyanosis is a condition which will cause the lips, mouth, and conjunctiva to become blue. Peripheral cyanosis will cause blue discoloration mainly on the lips, ear lobes, and nail beds. Peripheral cyanosis might indicate a peripheral problem of vasoconstriction, and would generally be less severe than central cyanosis, which could indicate heart disease and poor oxygenation.

Apical Pulse Vs Radial Pulse

Thorax

Inspect for symmetry of thorax, point of maximum intensity (PMI). PMI is easier to find if the patient will lay on the left side. PMI may also be palpated. Check skin color of thorax.

Eyes

Pulse

Arcus Senilis is a light gray ring surrounding the iris, common in older patients; in younger patients it might indicate a type of lipid metabolism disorder, which is a precursor to coronary artery disease.

Xanthelasma is yellowish raised plaques on the skin surrounding the eyes. Can also appear on the elbows. This is a possible indication, or sign of hypercholesterolemia, often a precursor to coronary artery disease (atherosclerosis).

Palpation

Palpation, or touching, is the next part of the exam. In the stop above, if we noted any abnormalities, we will now palpate and evaluate them further.

Skin: temperature, texture, moisture, lumps, bumps, tenderness.

Examination of extremities for edema might also indicate a cardiovascular problem. Examine the feet, ankles, sacrum, abdomen, trunk, and face for edema. If you notice puffiness of frank edema, then palpate the area for pitting edema. Most facilities recognize the following scale:

+1 Pitting Edema

=

0 to ¼ inch indentation

+2 Pitting Edema

=

¼ to ½ inch indentation

+3 Pitting Edema

=

½ to 1 inch indentation

+4 Pitting Edema

=

More than 1 inch indentation

Breathing: lay hands the chest at different locations and feel the respiratory patterns, feel the ribs elevate and separate during normal breathing.

Pre-Cordial Areas you can feel the pounding of the heartbeat, normal and abnormal pulsations o the chest wall; PMI, as mentioned above.

Arteries: Assess all pulses

Rhythm

You undoubtedly assessed the apical pulse earlier when you took the patient’s vital signs, if not, now is the time. Assess the following pulses:

  • Apical heart rate – monitor for a full minute, note rhythm, rate, regularity.
  • Radial pulse – monitor for a full minute. Note the rhythm, rate, and the regularity. Note any differences from right to left radial, a large difference might indicate arterial blockage or even enlarged ventricles. If pulse is regular but volume diminishes from beat to beat, this might indicate left-sided heart failure and is called pulses alternans. If the volume of the pulse diminishes on inspiration, might indicate constrictive pericardial disease, the condition is called pulsus paradoxus.
  • Carotid, brachial, femoral, popliteal, posterior tibialis, and dorsalis pedis pulses – when checking these pulses do it the same way as the others mentioned in this section; right then left side. When you check the carotid, press gently and do not rub.

Do not palpate carotid on persons with known carotid disease or bruits; listen with stethoscope instead; and do not palpate both carotid pulses at the same time.

Carotid Artery:

Normal Apical Pulse Infant

  • Plateau pulse – slow rise and slow collapse pulse; may be caused by aortic stenosis, slow ejection of blood through a narrowed aortic valve.
  • Decreases amplitude (grade point pulse) – due to hemorrhagic shock, pulse is weak due to decreased blood volume.

Bounding Pulse - (Grade IV) can be due to hypertension, thyrotoxicosis, others; associated with high pulse pressure, the upstroke and downstroke of the pulse waves are very sharp.

It is common to use +1, +2, etc. when recording pulses:

  • 0 = absent
  • +1 = diminished or decreased
  • +2 = normal pulses
  • +3 = full pulse or slight increase in pulse volume
  • +4 = bounding pulse or increased volume

Veins – neck, arms, legs, etc.

Next: Part II: Assessment Techniques, Con't.

Normal Apical Pulse Rhythm

Details

'Term' is description of assessment findings, while 'Definition' is the notation which would be entered in the patient record.
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Additional Nursing Flashcards

Cards Return to Set Details

Term
Bowel sounds heard in all 4 quadrants vary in frequency, pitch, and intensity and occur irregularly from 20 times per minute
Definition
Bowel sounds present in all 4 quadrants
Term
Bowel sounds heard in all 4 quadrants vary in frequency, pitch, and intensity and occur less than 5 per minute
Definition
Bowel sounds hypoactive in all 4 quadrants
Term
Bowel sounds heard in all 4 quadrants, loud and greater than 60 per minute
Definition
Bowel sounds hyperactive in all 4 quadrants
Term
When palpating abdomen you observe that it is pliable with no significant resistance, it is not distended and the patient tells you that there is not pain with palpation or on rebound
Definition
Abdomen soft, non-tender, and flat.
Term
You inquire regarding the patients last bowel movement and the patient says, I had one this morning. You ask if they had any trouble and what the color and consistency was. The patient tells you it was formed, they had no difficulty, and it was brown.
Definition
Last BM [today's date]. Pt. reports formed, brown stool, and no straining on defecation.
Term
Pupils contract when light shined in eye, shape of pupils are round and both pupils are of equal size, pupils converge toward bridge of nose when following object which is moving toward nose from approximately 12 inches away.
Definition
PERRLA
Term
While the patient's eyes are closed the patient is able to identify light touch in all extremities.
Definition
Sensation to light touch present in all extremities.
Term
Patient grasps your first two fingers of both hands at the same time. The patients grip is strong and no difference in strength between the right and left is noted.
Definition
Hand grasp strength strong and equal bilaterally.
Term
The patient pushes and pulls with arms against resistance. You note that both arms are strong and the force in both the right and left arms is the same.
Definition
Upper extremity strength strong and equal bilaterally.
Term
The patient pushes and pulls with legs against resistance. You note that both legs are strong and the force in both the right and left arms is the same.
Definition
Lower extremity strength strong and equal bilaterally.
Term
Patient is able to push with the balls of his/her feet against the palms of your hands and to lift distal feet against palms of your hands placed on top of the patient feet strongly and equally with both feet.
Definition
Plantar flexion and extension strength strong and equal bilaterally.
Term
The patient tells you that she ate breakfast this morning. You place your hands on her neck and lightly palpate the larynx while asking her to swallow. The larynx moves upward and then back to its original position. The patient does not appear to strain or have difficulty swallowing. You note that the patient is not drooling or coughing.
Definition
Swallow intact. No drooling or coughing noted.
Term
You ask the patient to provide her name, the day of the week, and her location. She provides all the correct information. You note that she responds quickly and appropriately, her eyes are open and she is observing you as you move about the room. She is able to follow simple commands when you are asking her to participate in the assessment.
Definition
A & O x 3. Pt. able to follow simple commands.
Term
The patient is able to walk from the bed to the door without difficulty and no assistance. The patient walks in a straight line.
Definition
Gait steady.
Term
You ask the patient to close her eyes while holding her arms to her sides and you gently push your patient at the shoulder from the side front and back allowing her to adjust after each push. The patient stands upright with no loss of balance.
Definition
Balance intact.
Term
Pedal and radial pulses easily palpable, regular, and of the same strength between the right and left.
Definition
Radial and pedal pulses 2+ and equal bilaterally.
Term
When auscultation the apical pulse for 1 minute you note the rate of 78, and are able to hear the pulse well. The pulse is regular.
Definition
AP 78 strong and regular.
Term
While assessing the apical pulse, you palpate the left radial artery. The pulses and rhythms are equal.
Definition
Apical and radial pulses equal rhythm and rate.
Term
You press on a finger nail on each hand and a toenail on each foot. You observe the nail bed blanches when pressed and turns pink within less than 2 seconds once released.
Definition
Nail bed capillary refill < 2 seconds in upper and lower extremities bilaterally.
Term
While assessing the patient's feet and ankles you press momentarily behind the left and right distal tibia and the top of both feet. When you release the pressure the skin rebounds quickly and no swelling is noted.
Definition
No edema noted in bilateral lower extremities.
Term
Using your stethoscope you auscultate lung sounds on both the anterior and posterior chest in the 6 areas. Air movement is heard in all lobes with no crackles, pops, wheezes, bubbling, rubbing, or clicking sounds heard.
Definition
Lung sounds clear to auscultation and equal bilaterally.
Term
The chest is inspected and palpated anteriorly and posteriorly after auscultation. You note no lumps, the patient does not complain of pain, and you notice that the chest moves equally. The patient breaths will minimal effort and does not appear to be short of breath.
Definition
Eupnea; chest excursion equal bilaterally. No complaints of pain and no masses noted on palpation of anterior and posterior chest.
Term
During your assessment of the patient, you noted no wounds, rashes, bruises, discolorations, lesions or other problems with the skin. You also note that the skin is warm and dry when you touch the patient. The skin color has a pink hue, and after pinching up the skin on the clavicle and letting go the skin retracts back quickly.
Definition
Skin intact, color pink, warm and dry to touch, and turgor elastic.
Term
The patient states that she urinated before you came into the room and that it was left in the toilet as requested by the prior nurse. You inspect the toilet and observe straw colored clear liquid in the toilet. The patient states that she had no pain or difficulty voiding.
Definition
Pt. reports voiding this AM, toilet contains straw colored clear urine. Pt. denies difficulty urinating.