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Nursing Skills Laboratory Procedure


Assessing the Apical Pulse

Achievement of SATISFACTORY in all categories is necessary

Student's Name: ____________________

Grade (circle one):

P = achieved 3 or above in all categories

F = achieved 2 or below in one or more categories

The following scale is utilized:

1 = Failing 2 = Unsatisfactory 3 = Satisfactory 4 = Good 5 = Superior

ACTION
S
G SA U
F
  • Gather the supplies
5 4 3 2 1
  • Explain the procedure to the patient
5 4 3 2 1
  • Wash and dry hands carefully
5 4 3 2 1
  • Draw the curtain around the bed for privacy
5 4 3 2 1
  • Go to and stand as close as possible to the right side of the bed
5 4 3 2 1
  • Lock the wheels of the bed
5 4 3 2 1
  • Clean the ear attachments and diaphragm of the stethoscope with alcohol swabs, if necessary
5 4 3 2 1
  • Warm the diaphragm of the stethoscope by holding it in the palm of your hands for a few moments
5 4 3 2 1
  • Raise the bed to waist level and elevate the head of the bed to 30 degrees
5 4 3 2 1
  • Lower the siderail nearest you
5 4 3 2 1
  • Fold the top linens down past the patient's hips
5 4 3 2 1
  • Assist the patient in removing his/her gown to expose his/her anterior chest
5 4 3 2 1
  • Insert the ear attachments of the stethoscope into your eas sot that they tilt slightly forward
5 4 3 2 1
  • Position the stethoscope so that the binaurals and tubing hang freely, and the binaurals, tubing, and diagphragm do not touch any clothing
5 4 3 2 1
  • Place the index finger of your right hand on the Angle of Louis of the patient's anterior chest
5 4 3 2 1
  • Move the index finger of your right hand away form the Angle of Louis of the patient's anterior chest to the left to locate the his/her 2nd intercostal space (ICS) just to the left of his/her sternum
5 4 3 2 1
  • Walk the index finger of your right hand doward from the patient's 2nd ICS to his/her 5th ICS
5 4 3 2 1
  • Compress the index finger of your right hand lightly on the 5th ICS in the left mid-clavicular line (LMCL) of the patient's anterior chest to palpate his/her apical pulse
5 4 3 2 1
  • Remove the index finger of your right hand from the 5th ICS in the LMCL of the patient's anterior chest and place the diaphragm of the stethoscope over the location where you palpated his/her apical pulse
5 4 3 2 1
  • Hold the diaphragm of the stethoscope in place over the location where you palpated the patient's apical pulse with the thumb and index finger of your right hand
5 4 3 2 1
  • Auscultate the patient's apical pulse
5 4 3 2 1
  • Count the rate of the apical pulse for 30 seconds and multiply by two
5 4 3 2 1
  • Count the rate of the apical pulse for one minute if it is irregular
5 4 3 2 1
  • Assess the rhythm of the apical pulse
5 4 3 2 1
  • Unfold the top linens over the patient
5 4 3 2 1
  • Lower the bed to the lowest level
5 4 3 2 1
  • Raise the siderail nearest you
5 4 3 2 1
  • Assure that the paitent's call light is readily available
5 4 3 2 1
  • Wash and dry hands carefully
5 4 3 2 1
  • Record the rate and rhythm of the apical pulse per agency policy
5 4 3 2 1
Comments:

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This page was last modified on 6/1/01