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Nursing Skills Laboratory Procedure


Assessing the Apical - Radial 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
  • Both nurses wash and dry hands carefully
5 4 3 2 1
  • Both nurses draw the curtain around the bed for privacy
5 4 3 2 1
  • The nurse taking the apical pulse goes to and stands as close as possible to the right side of the bed
5 4 3 2 1
  • The nurse taking the radial pulse goes to and stands as close as possible to the left side of the bed
5 4 3 2 1
  • One nurse locks the wheels of the bed
5 4 3 2 1
  • The nurse taking the apical pulse cleans the ear attachments and diaphragm of the stethoscope with alcohol swabs, if necessary
5 4 3 2 1
  • The nurse taking the apical pulse warms the diaphragm of the stethoscope by holding it in the palm of your hands for a few moments
5 4 3 2 1
  • One nurse raises the bed to waist level and elevates the head of the bed to 30 degrees
5 4 3 2 1
  • The nurse taking the apical pulse lowers the siderail nearest him/her
5 4 3 2 1
  • The nurse taking the radial pulse lowers the siderail nearest him/her
5 4 3 2 1
  • The nurse taking the apical pulse folds the top linens down past the patient's hips
5 4 3 2 1
  • The nurse taking the apical pulse assists the patient in removing his/her gown to expose his/her anterior chest
5 4 3 2 1
  • The nurse taking the radial pulse assist in positioning the patient's arm alongside his/her body with his/her wrist extended and the palm of his/her hand facing down to provide easy access to his/her radial pulse
5 4 3 2 1
  • One nurse places a watch where both nurses can see it
5 4 3 2 1
  • The nurse taking the apical pulse locates and palpates the apical pulse by: 1) placing the index finger of his/her right hand on the Angle of Louis of the patient's anterior chest, 2) moving the index finger of his/her right hand away from the Angle of Louis of the patient's anterior chest to the left to locate the patient's 2nd intercostal space (ICS) just to the left of his/her sternum, 3) walking the index finger of his/her right hand downward from the patient's 2nd ICS to his/her 5th ICS, 4) moving the index finger of his/her right hand laterally 5 - 7 centimeters ( 2 - 3 inches) in the 5th ICS to the patient's left midclavicular line (LMCL) of his/her anterior chest, 5) pressing the index finger of his/her right hand lightly in the 5th ICS in the LMCL of the patient's anterior chest to palpate his/her apical pulse, 6) removing the index finger of his/her right hand from the 5th ICS in the LMCL of the patient's anterior chest and placing the diaphragm of the stethoscope over the location where he/she palpated the patient's apical pulse
5 4 3 2 1
  • The nurse taking the radial pulse locates and palpates the radial pulse by: 1) placing the pads of his/her index and middle fingers on the flexor surface of one of the patient's wrists laterally, and 2) pressing the pads of his/her index and middle fingers lightly on the flexor surface of one of the patient's wrists laterally to palpate his/her radial pulse
5 4 3 2 1
  • The nurse taking the radial pulse decides on a time when to begin counting the apical and radial pulses
5 4 3 2 1
  • The nurse taking the radial pulse says "start" at the designated time
5 4 3 2 1
  • The nurse taking the radial pulse counts the patient's radial pulse for 60 seconds
5 4 3 2 1
  • The nurse taking the apical pulse counts the patient's apical pulse for 60 seconds
5 4 3 2 1
  • The nurse taking the radial pulse says "stop" 60 seconds after the designated start time
5 4 3 2 1
  • The nurse taking the radial pulse assesses the rate, rhythm, elasticity of the vessel wall, and force (amplitude) of the radial pulse
5 4 3 2 1
  • The nurse taking the apical pulse assesses the rate and rhythm of the apical pulse
5 4 3 2 1
  • The nurse taking the apical pulse unfolds the top linens over the patient
5 4 3 2 1
  • One nurse lowers the bed to the lowest level
5 4 3 2 1
  • The nurse taking the apical pulse raises the siderail nearest him/her
5 4 3 2 1
  • The nurse taking the radial pulse raises the siderail nearest him/her
5 4 3 2 1
  • One nurse assures that the patient's call light is readily available
5 4 3 2 1
  • Both nurses wash and dry hands carefully
5 4 3 2 1
  • One nurse records the following per agency policy: 1) the rate, rhythm, elasticity of the vessel wall, and force (amplitude) of the radial pulse), 2) the rate and rhythm of the apical pulse, and 3) any discrepancies between the two pulses or changes from previous measurements
5 4 3 2 1
Comments:

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This page was last modified on 6/1/01