Skills

PROCEDURE PLANNING

MEASURING APICAL-RADIAL PULSE

* After NI, pt’s cardiovascular activity will demonstrate
normal and same apical-radial pulse reading
DEFINITION
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Apical-radial pulse measurement is an assessment of
the pulses both in the apex and radial artery by the 2
nusres that is commonly used for pulse deficit EVALUATION

PURPOSE *After NI, pt’s cardiovascular activity demonstrated

normal and same apical-radial pulse reading

 For pulse evaluation to determine the integrity of

cardiovascular system

MATERIALS/EQUIPMENT COMPLICATION
*
*Stethoscope and watch
*Cardiac arrest and death

ASSESSMENT

* Assess the characteristics of apex and radial pulse (throbbing, bounding, pulseless, and weak, the rate and rhythm
* Assess for altered cardiac function (such as dec. CRT, pallor/cyanosis, clammy skin, Dyspnea, Fatigue, Chest pain,
Orthopnea, Syncope, Palpitations, Dependent edema

INTERVENTION AND RATIONALE

1. Perform hand hygiene.
2. Verify the correct patient using two identifiers.
3. Help the patient assume a supine or sitting position.
4. Using the same watch, one nurse counts the patient's apical pulse for 1 minute while the other nurse counts the radial pulse for
1 minute. One nurse gives the signal to start counting, and both start at the same time.

FOR RADIAL:
1. Palpate the radius using lightly compression and get 1 full minute assessment of radial pulse together w/ one nurse assessing
the apical pulse (Rationale: Pulse assessment is more accurate when using moderate pressure. Too much pressure occludes the
pulse, impairs blood flow, and may result in the nurse counting his or her own pulse rate. )
2. Determine the strength of the pulse (e.g., 0, 1+, 2+, 3+, 4+) (Rationale: To evaluate the characteristics of pulse)

FOR APICAL:
1. Warm the stethoscope by rubbing the bell on the palm. (Rationale: A cold stethoscope may surprise the patient and alter the
pulse rate.
2. Place the stethoscope at the apex (5th ICS LMCL) while other nurse palpates radial pulse. (Rationale: The point of maximal
impulse can be heard best at the apex.)

After 1 full minute assessment of apical-radial pulse:

*Compare the radial pulse and apical pulse. Normally, these two readings should be the same. If there is a difference, it is
called as pulse deficit.
*Help the patient to a comfortable position.
*Perform hand hygiene and Document the procedure and findings in t he patient’s record.