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    Saint Paul University Philippines: School of Nursing and Allied Health Sciences

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    This document provides a student procedure checklist for assessing apical pulse. It outlines the necessary equipment, steps to take, and rationale for each step. The key steps are to introduce yourself to the patient, explain the procedure, locate the apical impulse over the heart, use a stethoscope to listen for heart sounds and count the heartbeat for 60 seconds, ensure patient safety, and document findings. Following these steps helps nurses accurately measure the pulse and assess the patient's condition in a safe, organized manner.

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    Saint Paul University Philippines: School of Nursing and Allied Health Sciences

    Uploaded by

    RaRe TV
    125 views3 pages
    This document provides a student procedure checklist for assessing apical pulse. It outlines the necessary equipment, steps to take, and rationale for each step. The key steps are to introduce yourself to the patient, explain the procedure, locate the apical impulse over the heart, use a stethoscope to listen for heart sounds and count the heartbeat for 60 seconds, ensure patient safety, and document findings. Following these steps helps nurses accurately measure the pulse and assess the patient's condition in a safe, organized manner.

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    Assesing Apical Pulse Students' Copy (1)

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    This document provides a student procedure checklist for assessing apical pulse. It outlines the necessary equipment, steps to take, and rationale for each step. The key steps are to introduce yourself to the patient, explain the procedure, locate the apical impulse over the heart, use a stethoscope to listen for heart sounds and count the heartbeat for 60 seconds, ensure patient safety, and document findings. Following these steps helps nurses accurately measure the pulse and assess the patient's condition in a safe, organized manner.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    125 views3 pages

    Saint Paul University Philippines: School of Nursing and Allied Health Sciences

    Uploaded by

    RaRe TV
    This document provides a student procedure checklist for assessing apical pulse. It outlines the necessary equipment, steps to take, and rationale for each step. The key steps are to introduce yourself to the patient, explain the procedure, locate the apical impulse over the heart, use a stethoscope to listen for heart sounds and count the heartbeat for 60 seconds, ensure patient safety, and document findings. Following these steps helps nurses accurately measure the pulse and assess the patient's condition in a safe, organized manner.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Saint Paul University Philippines

    Tuguegarao City, Cagayan 3500

    School of Nursing and Allied Health Sciences

    College of Nursing

    NCM103 – FOUNDATIONS OF NURSING PRACTICE

    STUDENT PROCEDURE CHECKLIST – VITAL SIGNS

    B. ASSESING APICAL PULSE

    A. LEARNING OBJECTIVES
    At the end of the laboratory session the students will be able to:
    • Perform medical asepsis.
    • Accurately measure patient’s apical pulse.
    • Document and record the pulse in an appropriate format.

    B. EQUIPMENT
    Clock or watch with sweep second hand or digital seconds indicator
    Stethoscope
    Antiseptic wipes

    C. PROCEDURE

    EVIDENCED TO BE PRODUCED RATIONALE


    RESPIRATION
    Review medical record (patient’s chart) for This establishes parameters for the patient’s
    baseline data and factors that influence normal measurements, provides direction in
    respiration device selection, and site to use for
    measurement.
    Introduce self This establishes rapport and good nurse-patient
    communication.
    Identifies client using 2 identifiers Proper identification ensures patient safety
    as the correct patient receives the correct
    procedure or therapy.
    Explains the procedure and purpose to the Explanation encourages patient participation
    client and coperation, allays fears and ensures
    • Inform the client of the site(s) at which accurate measurements.
    you will measure pulse.
    Gather necessary equipment This facilitates an organized assessment and
    makes effective use of the nurse’s time.
    Performs medical asepsis (hand wash) don Hands are washed before and after patient
    gloves if necessary/if situation requires contact to decrease the transmision of
    microorganisms.

    Gloves are worn as necessary to avoid


    contact with bodily secretions or fluids such
    as sweat.
    Provides privacy for the client Provision of privacy respects the patient’s
    dignty and avoids embarrassment.
    Assist the client to a comfortable resting Positioning promotes patient comfort and
    position facilittates proper site access for the procedure.
    Expose the area of the chest over the apex of Allows access to client’s chest for proper
    the heart. placement of the stethoscope.
    Use antiseptic wipes to clean the earpieces and
    diaphragm of the stethoscope. The diaphragm needs to be cleaned and
    disinfected if soiled with body substances.
    Both earpieces and diaphragms have been
    shown to harbor pathogenic bacteria (Muniz,
    Sethi, Zaghi, Ziniel, & Sandora, 2012).
    Locate the apical impulse This is the point over the apex of the heart
    where the apical pulse can be most clearly
    Palpate the angle of Louis (the angle between heard.
    the manu-brium, the top of the sternum, and
    the body of the ster-num). It is palpated just Ensures correct placemanet
    below the suprasternal notch and is felt as a
    prominence

    Slide index finger just to the left of the


    sternum, and palpate the second intercostal
    space

    Place your middle or next finger in the third


    intercostal space and continue palpating
    downward until you locate the fifth intercostal
    space.

    Move your index finger laterally along the fifth


    intercostal space toward the MCL Normally,
    the apical impulse is palpable at or just medial
    to the MCL

    Warm the diaphragm of the stethoscope by The metal of the diaphragm is usually cold and
    holding it in the palm of the hand for a can startle the client when placed immediately
    moment. on the chest

    Insert the earpieces of the stethoscope into This position facilitates hearing.
    your ears in the direction of the ear canals, or
    slightly

    Check the function of the stethoscope This is to be sure it is the active side of the
    head. If necessary, rotate the head to select the
    diaphragm side
    Place the diaphragm of the stethoscope The heartbeat is normally loudest over
    over the apical impulse and listen for the apex of the heart. Each lub-dub is
    the normal S1 and S2 heart sounds, counted as one heartbeat.
    which are heard as “lub-dub.”

    If the rhythm is regular, count the heartbeats A 60-second count provides a more
    for 30 seconds and multiply by 2. If the rhythm accurate assessment of an irregular pulse
    is irregular or for giving certain medications than a 30-second count.
    such as digoxin, count the beats for 60 second
    Rhythm is determined as regular or irregular;
    Observe the rhythm and the strength of the volume describes as normal, weak strong or
    heartbeat. bounding.

    Ensure that the patient is safe and comfortable. This prevents undue risks for and possible falls
    or injury, and promotes patient comfort.
    Remove gloves and discard in appropriate Proper disposal of soiled equipment prevents
    receptacle. transmission of microorganisms.
    Perform medical asepsis (hand wash). Medical asepsis post-procedure prevents the
    spread of microorganisms.
    Document findings in TPR sheet. This ensures proper recording and serves as
    means to communicate patient status to
    other health care team members.
    Inform the doctor for abnormal findings. This ensures continuity of care and
    collaborative planning for patient outcomes.

    References:

    • Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of
    nursing. Ninth edition. St. Louis, Mo.: Mosby Elsevier.

    • Weber, J. et al. (2014). Health Assessment in Nursing. (5th Ed.). Philadelphia, Lippincott

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