Goal: The patient’s pulse is assessed accurately without injury and the patient experiences minimal discomfort.
1. Check medical order or nursing care plan for frequency of pulse assessment. More frequent pulse measurement may be appropriate based on nursing judgment. Identify the need to obtain an apical pulse measurement.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to the room, if possible. Discuss procedure with patient and assess patient’s ability to assist with the procedure.
5. Put on gloves, as appropriate.
6. Use alcohol swab to clean the diaphragm of the stethoscope. Use another swab to clean the earpieces, if necessary.
7. Assist patient to a sitting or reclining position and expose chest area.
8. Move the patient’s clothing to expose only the apical site.
9. Hold the stethoscope diaphragm against the palm of your hand for a few seconds.
10. Palpate the space between the fifth and sixth ribs (fifth intercostal space), and move to the left midclavicular line. Place the diaphragm over the apex of the heart.
11. Listen for heart sounds (“lub-dub”). Each “lub-dub” counts as one beat.
12. Using a watch with a second hand, count the heartbeat for 1 minute.
13. When measurement is completed, remove gloves, if worn. Cover the patient and help him or her to a position of comfort.
14. Clean the diaphragm of the stethoscope with an alcohol swab.
15. Remove additional PPE, if used. Perform hand hygiene.
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