Apical Pulse Rate

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Do you use place your hand at the left 5th intercostal space midclavicular ( using the watch) or do you use the stethoscope and using the watch to take the apical pulse rate? I have seen some nurses use the sterthoscope and others their hand, which one is better? ( ex. giving digoxin)

Might be a very dumb question but I am curious :)

Ever seen PEA? Pulseless patients with a "normal" narrow complex sinus rhythm? Do not trust the monitor for a rate, ever. Electrical activity may have absolutely nothing to do with mechanical activity.

My instructor also told me to not trust the monitor for heart rate.

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My understanding is that we are talking about taking an AP on an alert patient. In that context I would trust the monitor.

You are right that we should use and trust monitors because that's why they are created but sometimes the monitors don't work properly, and if you have to give blood pressure meds it is best to take the apical pulse by using the stethoscope or hand method. I know this because I had different patients and I used the same monitor and it gave me the same rate and same blood pressure for everybody.

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Specializes in CICU, radiology, psych.
My understanding is that we are talking about taking an AP on an alert patient. In that context I would trust the monitor.

I've seen patient's with HR 100 on monitor, but having bigemny PVC's. When I palpated radial pulse I only got 50 because they were not perfusing the PVC's.

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Specializes in Critical Care.

A heart monitor should never be a substitute for an actual physical pulse rate for all of the reasons mentioned above.

Electrical activity does not necessarily equate to mechanical activity.

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Wow, apical by touch. Hmmm. When I worked registry as a CNA, I took so many vitals sometimes only BP's, apical. I was never taught at school both CNA or LVN by touch. To this day I don't use those wrist BP monitors. I want to hear the beat, I use stethoscope to hear it at the same time switch to lung sounds, and do bowel sounds, sometimes if I can't hear the apical I can always here the atrial between the 2nd and 3rd costal space on the right side. Can you identify a murmur with your finger?

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Specializes in NICU.

In my med/surg clinic (just finished), I had a heck of a time finding the apical pulse-usually due to obesity or they were just so crackly, but we're supposed to use our stethoscope.

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Specializes in Critical Care.
You are right that we should use and trust monitors because that's why they are created but sometimes the monitors don't work properly, and if you have to give blood pressure meds it is best to take the apical pulse by using the stethoscope or hand method. I know this because I had different patients and I used the same monitor and it gave me the same rate and same blood pressure for everybody.

Ok, bit confused here...you talk about using the same monitor for everybody in this post...are you talking about something like a dinamap? And, if you are giving a BP med..unless it's a beta blocker, why are you counting an apical pulse rate? And honestly, making the statement to "never trust the monitor" like it's gospel, is one of those generalizations I'd have to say you need to back up with some evidence.

GilaRN brings up PEA....and says not to ever trust the monitor for a heart rate. I couldn't disagree more...that is where experience, assessment and common sense come into play. I better not be giving BP meds to a pt in PEA....unless it's a med to RAISE bp! At that point, when I've got an unresponsive patient, I'm doing compressions and getting ready to do all kinds of fun things like trying to pace.

You know, stating an absolute like this can be dangerous...what makes patients interesting is that no two are alike. If you can show me data that states I MUST not trust the monitor when I'm doing assessments, then I might believe it. If you want to do this in your practice..that's fine. But doing it just because your instructor said to do it...uh, uh, no way.

I had a nursing instructor who didn't recommend we learn the symptoms of low sodium levels..she said we'd never see them because this country uses too much salt. REALLY??? I see it all the time in the ICU's...and we lost out on an excellent learning opportunity due to her incorrect information. That lecture took place, oh 14 years ago..and I still remember it. Taught me to back things up.

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Wow, apical by touch. Hmmm. When I worked registry as a CNA, I took so many vitals sometimes only BP's, apical. I was never taught at school both CNA or LVN by touch. To this day I don't use those wrist BP monitors. I want to hear the beat, I use stethoscope to hear it at the same time switch to lung sounds, and do bowel sounds, sometimes if I can't hear the apical I can always here the atrial between the 2nd and 3rd costal space on the right side. Can you identify a murmur with your finger?

I am shocked that no one here has felt or taken an apical pulse by touch. As I said previously, my professor used the stethoscope and had me take the apical pulse by touch at the same time and we both got the same rate. I am not saying it is the right way to take it that's why I posted here to see what nurses use the hand method or the stethoscope for apical pulse.

I guess people are teaching me wrong things :(

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

An apical pulse by palpation/touch is not standard nursing assessment. As many posters above have indicated, one cannot assess the quality of the heart tones by touch and this is an important part of our assessment.

This is the difference...if you just want a number, ask a nonprofessional to obtain that number by one of several methods including allowing a machine to get it for you...if you want an assessment of the apical pulse ask a nurse (professional)...h/she will listen, touch, and count, as well as consider the LOC of the patient.

The rub with using ONLY ONE METHOD of assessing heart rate is this...not all apical beats are actually perfused beats...this is a big deal (the other day my grand daughter had an apical pulse of 86, irregularly irregular with a brachial/radial pulse of 54 IR/IR) and must be reported to the physician. As well if you routinely listen to your patient's heart, while you feel their brachial or radial pulse you will be able to subjectively compare your findings with previous findings. This is how conscientious nurses pick up on subtle changes allowing timely intervention which may significantly improve outcomes. Things like murmurs, clicks, rubs, etc...good luck.

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Really you never used your hand to take the apical pulse?

:)

Nope, never used my hand to take an apical pulse and never heard of this before. You mention the "hand method" like it's a standard nursing assessment but it really isn't.

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Nope, never used my hand to take an apical pulse and never heard of this before. You mention the "hand method" like it's a standard nursing assessment but it really isn't.

I never said that the hand method is a standard nursing assessment, I asked if any of you use it to take an apical pulse.

I am sorry for the confusion.

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Specializes in multispecialty ICU, SICU including CV.

This thread just goes to show that what you learn in nursing school is not what is always appropriate for clinical practice. - the monitor/no monitor debate, assessment techniques, etc. I see a lot of NA/Rs and nursing students posting in this thread that are regurgitating what their instructors told them with no clinical practice to back it up. Nursing instructors aren't God and don't know everything -- in fact, some of them have been out of clinical practice for many years and don't know what's what in current nursing practice. I had one instructor my very first semester that gave us the run down of her resume, and although she had been licensed for many years, she spent only 5 years in clinical practice, and that was 20 years prior, and that was only part-time when her kids were small. The entire rest of her career was spent in education. She was very out of touch with reality - now that I am out in the workforce, and can look back at that part of my schooling. Of COURSE we learn the very basics and the nuts and bolts of physical assessment, A&P, nursing practice, pharmacology etc. from our instructors, but I am not convinced that many basic nursing instructors are clinical experts in anything.

I am not intending to bash nursing education. Obviously they play a very important role in society and there aren't enough of them to go around at this moment in time. Many are very gifted, talented, knowledgeable, intelligent, etc. But, even as an entry-to-practice level student, it pays to be skeptical. Most of your "real" clinical skills will not be obtained until you get your first job and are able to use, practice and hone them. What works and what doesn't work -- it is best to do your reading and find what is evidence-based and then go out there and do it -- find out for yourself.

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