Simple Guide On Which Is The Best Way To Take An Apical Pulse

The apical pulse is a critical vital sign used to assess heart function, particularly in infants, children, and patients with cardiac conditions. Unlike peripheral pulses taken at the wrist or neck, the apical pulse is measured directly over the apex of the heart using a stethoscope. It provides a more accurate reflection of heart rate and rhythm, especially when circulation is compromised or irregularities are suspected. Despite its importance, many healthcare providers—especially students and new clinicians—struggle with proper technique. This guide breaks down the most effective method for taking an apical pulse, outlines common errors, and offers practical tips for consistent accuracy.

Understanding the Apical Pulse

The apical pulse corresponds to the heartbeat heard through the chest wall at the point of maximal impulse (PMI), typically located in the fifth intercostal space at the midclavicular line on the left side of the chest. Because it reflects actual ventricular contractions, it’s considered the gold standard for heart rate assessment in clinical settings where precision matters—such as pediatric care, cardiac monitoring, and medication administration (e.g., before giving digoxin).

Peripheral pulses can sometimes undercount beats due to weak stroke volume or arrhythmias like atrial fibrillation. In contrast, the apical pulse captures every contraction, making it essential when assessing pulse deficit—the difference between apical and radial pulse rates.

“Accurate apical pulse measurement isn’t just about counting beats—it’s about understanding cardiac output and detecting early signs of deterioration.” — Dr. Linda Chen, Cardiac Nurse Educator

Step-by-Step Guide to Taking an Apical Pulse

Performing this assessment correctly requires attention to positioning, equipment, and timing. Follow these steps to ensure reliability:

1. Prepare the patient: Explain the procedure, ensure privacy, and assist the patient into a supine or sitting position. For optimal access, expose the left anterior chest while maintaining dignity with draping.
2. Gather supplies: Use a high-quality acoustic stethoscope with a diaphragm. Ensure the earpieces are clean and angled forward for comfort.
3. Locate the anatomical landmarks: Find the fifth intercostal space by counting down from the clavicle. The landmark is the angle of Louis (sternal angle) at the second rib. Move laterally to the midclavicular line—the imaginary vertical line running down from the midpoint of the clavicle.
4. Position the stethoscope: Place the diaphragm firmly but gently over the PMI. Avoid placing it directly on bony structures or breast tissue, which can interfere with sound transmission.
5. Listen and count: Auscultate for at least one full minute. Count each \"lub-dub\" as one beat. Note the rhythm (regular vs. irregular) and any abnormal sounds such as murmurs or gallops.
6. Document findings: Record the rate, rhythm, and quality. If comparing with radial pulse, perform both simultaneously if possible to detect pulse deficit.

Tip: In infants and young children, the apical impulse may be higher—often at the third or fourth intercostal space. Adjust your landmark accordingly.

Common Mistakes and How to Avoid Them

Even experienced clinicians can make errors that compromise accuracy. Awareness of frequent pitfalls improves consistency across assessments.

• Incorrect placement: Misidentifying the fifth intercostal space leads to inaccurate readings. Always use the angle of Louis as a starting point.
• Counting too quickly: A 30-second count multiplied by two may miss irregular rhythms. Always count for a full 60 seconds, especially in patients with known or suspected arrhythmias.
• Using the bell instead of the diaphragm: The diaphragm is better suited for high-frequency heart sounds. Reserve the bell for low-pitched murmurs.
• Pressing too hard: Excessive pressure can distort sounds or cause discomfort. Maintain gentle, even contact.
• Ignoring environmental noise: Perform the assessment in a quiet environment. Close doors, reduce background chatter, and ask the patient to breathe quietly.

Do’s and Don’ts: Quick Reference Table

Do’s	Don’ts
Use the diaphragm of the stethoscope	Use the bell for routine apical pulse assessment
Count for a full 60 seconds	Multiply a 15- or 30-second count in irregular rhythms
Palpate the PMI first if auscultation is difficult	Rely solely on palpation without auscultation
Ensure patient is relaxed and lying still	Attempt measurement during movement or agitation
Compare with radial pulse when indicated	Assume radial pulse equals apical rate in cardiac patients

Real-World Example: Detecting a Pulse Deficit

Nurse Maria was conducting a routine assessment on Mr. Thompson, a 72-year-old admitted with newly diagnosed atrial fibrillation. She routinely takes apical pulses in cardiac patients. As she placed her stethoscope at the fifth intercostal space, she noted an irregularly irregular rhythm. She counted 110 beats per minute over 60 seconds. Before documenting, she also took his radial pulse and counted only 92 beats in the same time frame.

Recognizing a pulse deficit of 18 beats, she immediately notified the physician. Further evaluation revealed inadequate ventricular filling leading to reduced stroke volume. The medical team adjusted his rate-control medication, preventing potential complications. This case highlights why relying solely on peripheral pulses can miss clinically significant issues—and why mastering apical pulse technique saves lives.

Frequently Asked Questions

When should I take an apical pulse instead of a radial pulse?

The apical pulse is preferred in infants and children under 5 years old, patients with cardiac conditions, those on certain medications (like beta-blockers or digoxin), and whenever an irregular rhythm is suspected. It’s also essential when assessing for pulse deficit.

Can I use an electronic stethoscope or Doppler device?

Yes, especially in obese patients or those with low cardiac output where traditional auscultation is challenging. Electronic amplification enhances sound clarity. However, always confirm proficiency with standard equipment first.

What if I can’t find the apical pulse?

Recheck your anatomical landmarks. Ask the patient to lean forward slightly or roll to the left side, which brings the heart closer to the chest wall. In some cases, especially post-chest surgery or with cardiomegaly, the PMI may be displaced laterally. Palpate for the strongest impulse and auscultate there.

Essential Checklist for Accurate Apical Pulse Measurement

Checklist:

• ☐ Patient positioned comfortably (supine or semi-Fowler’s)
• ☐ Stethoscope diaphragm warmed and clean
• ☐ Fifth intercostal space confirmed using sternal angle
• ☐ Midclavicular line identified
• ☐ Diaphragm placed firmly over PMI
• ☐ Heart sounds listened to for full 60 seconds
• ☐ Rate, rhythm, and any abnormalities documented
• ☐ Radial pulse compared if pulse deficit is suspected

Final Thoughts and Call to Action

Taking an apical pulse may seem straightforward, but precision matters. Whether you're a nursing student learning foundational skills or a seasoned provider refining your practice, consistent technique ensures reliable data that informs patient care. Mastery comes not from occasional use, but from deliberate, correct repetition.

Next time you assess a patient with a history of heart disease, dysrhythmia, or medication affecting cardiac function, skip the shortcut. Take the apical pulse properly—every time. Share this guide with colleagues, practice the landmarks, and advocate for accuracy in vital sign assessment. Your attention to detail could be the difference between missing a subtle decline and catching it early.

💬 Have a tip or experience with apical pulse assessment? Share your insights in the comments to help others improve their clinical skills.