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Difference between apical pulse and pulse monitored on display

Cardiac   (12,218 Views 15 Comments)
by redeyelpn redeyelpn (New Member) New Member

redeyelpn has 8 years experience and specializes in LTC.

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Auscultated irregular apical pulse 37, displaying 66 on monitor, implanted pacer. No observable s/s. What is up with that?

Interested in learning more about the world of cardiology and pacers. Read about this situation from a fb post. Wanted to learn more. Any info appreciated.

(Fairly new LPN)

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dianah has 43 years experience as a ADN and specializes in Cath Lab/Radiology.

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What was the rhythm on the monitor?

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Beverage specializes in Cardiac/Telemetry.

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Our bedside Tele monitors have settings for paced rhythms which must be activated otherwise my pt can show as half the apical rate of 35 instead of 70 or double the apical rate of 140 instead of 70. When in doubt check the pulse manually instead of relying on the monitor to calculate it.

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MunoRN has 10 years experience.

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Keep in mind that "pulse" and "heart rate" are actually two different things. On a cardiac monitor, heart rate refers to the ventricular rate based on the number of conduction impulses per minute (the number of QRS complexes per minute). "Pulse" refers to the number of those QRS complexes that produce a detectable pulsation, this can vary depending on where and how you are measuring it. PVC's, for instance, may not produce a palpable pulsation at the radial artery, so a patient's radial pulse by palpation would be their heart rate minus the number of PVC's per minute. But the PVC's might produce a detectable pulsation by doppler at the radial artery, giving them two different radial pulses, they might have a radial pulse of 40 by palp but a radial pulse of 60 by doppler.

The apical pulse is usually going to be the closest to the actual heart rate since you can typically auscultate every ventricular contraction, although they may not all sound the same. I'm guessing this might be why someone would get an apical pulse that varies significantly from the monitored heart rate, they may only be counting the contractions that produce the same exact sound.

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3 Articles; 30,196 Visitors; 2,815 Posts

When auscultating apical pulse, you are hearing mechanical activity. The monitor shows electrical conduction. The two do not always coincide. But, as pointed out in the posts above, more information is needed to adequately answer your question.

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icuRNmaggie has 24 years experience and specializes in MICU, SICU, CICU.

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It might help to look at the pleth (Sp02 waveform) which measures the pulse in the finger.

Also the arterial line waveform is the actual pulse in the radial or femoral artery.

These numbers should be very close to or the same as the cardiac rhythm.

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Been there,done that has 33 years experience.

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If you are seeing 66 QRS waves on the monitor, but only auscultating 37.. I would assume you are not hearing half of the audible pulse. If the rhythm is atrial fibrillation, this could be expected.. as 20 % of the cardiac output is lost without the atrial kick.

Was the pacer kicking in?

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CardiacKittyRN has 1 years experience and specializes in Cardiac.

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This is great info everyone! I knew that the reading on our tele screen often does not correlate with the pulse ox's reading in people in Afib or having frequent PVCs, but did not know the reason why. Always love learning something new! :)

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redeyelpn has 8 years experience and specializes in LTC.

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This is in Long term care no monitors. No telemetry. Ended up being a pacemaker gone bad.

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redeyelpn has 8 years experience and specializes in LTC.

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I should have clarified "monitor" being the dynamap

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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I should have clarified "monitor" being the dynamap

Dynamaps are notorious to have huge variations in HR vs radial or apical pulse especially with a patient with an arrhythmias, a-fib, murmur, or PVC/PAC. These same patients will not have an accurate BP reading due to machine limitations.

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canned_bread has 11 years experience and specializes in Cath lab, acute, community.

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Monitors can be fooled by you shaking one of the heart leads!

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