Assessing an Apical-Radial Pulse

Apical and radial pulse rate are normally identical. Our radial pulse reflects the heartbeat or apical pulse; that is pulse rate is the same as the rate of the ventricular contractions of the heart. In case of arrhythmia or clients with certain cardiovascular disorders specifically Atrial fibrillation, Apical-Radial Pulse assessment may need to be assessed to determine the discrepancy between the two pulse rates or know as Pulse Deficit. This certain assessment can be taken by one or two nurse. The Two-nurse technique is recommended because it is more accurate.


ASSESSING AN APICAL-RADIAL PULSE
Purpose:
To determine adequacy of peripheral circulation or presence of pulse deficit.
ASSESSMENT
Assess
Clinical sing of hypovolemic shock (hypotension, pallor, cyanosis, and cold, clammy skin)
PLANNING
Assemble equipment and supplies
- Watch with second hand or indicator.
- Stethoscope
- Antiseptic wipes
IMPLEMENTATION
For two-nurse technique, make it sure that the other nurse is available at this time

Procedure

1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate.

2. Wash hand and observe other appropriate infection control procedures.

3. Provide client privacy.

4. Place the client in appropriate position. Position the client appropriately in a comfortable supine position or to a sitting position. Expose the area of the chest over the apex of the heart.

5. Locate the apical and radial pulse sites. For pulse sites you may visit Sites in Assessing a Pulse. In the two-nurse technique, one nurse locates the apical impulse by palpation or with the stethoscope while the other nurse palpates the radial pulse site. See Procedure of Radial Pulse Assessment.

6. Count the apical and radial pulse.

ONE-NURSE TECHNIQUE

1. Assess the apical pulse for 60 seconds.
2. Assess the radial pulse for 60 seconds.

TWO-NURSE TECHNIQUE

1. Place the watch where both nurses can see it. The nurse who is taking the radial pulse may hold the watch.

2. Decide on a time to begin counting. The nurse taking the radial pulse says “start” at the same time.

3. Each nurse counts the pulse rate for 60 seconds. Both nurses end the count when the nurse taking the radial pulse says “stop”.

4. The nurse who assesses the apical pulse also assesses the apical pulse rhythm and volume. If the pulse is irregular, note whether the irregular beats come at random or at predictable times.

5. The nurse assessing the radial pulse rate also assesses the radial pulse rhythm and volume.
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7. Document the apical and radial pulse rates, rhythm, volume, and any pulse deficit in the client record. Also record related data such as variation in pulse rate compared to normal for the client and other pertinent observations, such as pallor, cyanosis, or dyspnea.



Rationale

1. To lessen anxiety and to promote cooperation.


2. To reduce transmission of microorganism.




4. This ensures an accurate comparative measurement.























2. This ensures the simultaneous counts are taken.


3. A full 60-seconds count is necessary for accurate assessment of any discrepancies between the two pulse sites.
EVALUATION
1. Relate pulse rate and rhythm to other vital signs, to baseline data, and to general health status.

2. Report to the physician any changes from previous measurements or any discrepancy between the two pulses.

3. Conduct appropriate follow-up such as administering medication or other actions to be taken for a discrepancy in Apical and Radial pulse rate.




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