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ASSESSING AN APICAL-RADIAL PULSE

Purpose
• To determine adequacy of peripheral circulation or presence of pulse deficit.

EXPECTED BEHAVIOR RATIONALE


EQUIPMENT:
• Watch with second hand
• Stethoscope
• Antiseptic wipes

PLANNING:
1. Gather equipments.
2. Wash your hands.
3. Identify patient and provide privacy.

INTERVENTION:
1. Explain the procedure to the patient Patients may be apprehensive if two nurses
especially if two nurses are taking the are at the bedside at the same time. So a
pulse. full explanation will help to allay fears.
2. Position the client appropriately.
• Assist the client to assume the
position described for taking the
apical pulse.
• If previous measurement were
taken, determine what position the
client assumed, and use the same
position.
3. Locate the apical and radial pulse
sites.
• In the two-nurse technique, one
nurse locates the apical impulse by
palpation or with the stethoscope while
the other nurse palpates the radial pulse
site.
• Count the apical and radial pulse
rates.

Two-Nurse Technique
• Place the watch where both nurses
can see it. The nurse who is taking
the radial pulse may hold the watch.
• Decide on a time to begin counting. A time when the second hand is on 12, 3, 6,
The nurse taking the radial pulse or 9 is usually selected.
says, “start” at the designated time.
• Each nurse counts the pulse rate for A full minute count is necessary to assess
60 seconds. Both nurses end the any discrepancies between the two pulse
count when the nurse taking the sites.
radial pulse says,”STOP”
• The nurses who assess the apical
rate also assess the apical pulse
rhythm and volume (ie, whether the
heartbeat is strong or weak). If the
pulse is irregular beats come at
random or at predictable times. The
latter situation creates a regular
irregularity.
• The nurse assessing the radial pulse
rate also assesses the radial pulse
rhythm and volume.

One-Nurse Technique
• Assess the apical pulse for 60
seconds.
• Assess the radial pulse for 60
seconds.

4. Document and report pertinent


assessment data.
• Promptly report to the nurse in
charge any notable changes from
previous measurements or any
discrepancy between the two
pulses.
• Document the apical and radial
(AR) pulse rates, rhythm, volume,
and any pulse deficit.
• Record any other pertinent
observations such as pallor,
cyanosis, or dyspnea.
• Check the physician’s order for any
directions related to a discrepancy
in the AR pulse rates.

EVALUATION FOCUS:

Equality of apical and radial pulse rates,


relationship to other vital signs, in
particular; skin color and temperature.