Apical Pulse
The most accurate heart rate, auscultated at the cardiac apex
Definition
The apical pulse is the heart rate measured by auscultating directly over the apex of the heart, the point of maximal impulse (PMI). Located at the fifth intercostal space, left midclavicular line in adults.
When to Assess
- Before administering digoxin, beta-blockers, or calcium channel blockers (hold for rate less than 60 bpm)
- In infants and children, where peripheral pulses may be difficult
- When an irregular or very slow/fast pulse is suspected
- Assessing pulse deficit in atrial fibrillation (apical-radial comparison)
Technique
Listen for a full minute using the stethoscope's diaphragm. Count 'lub-dub' as one beat, such as document rate, rhythm, and any additional heart sounds.
Nursing Considerations
Always count the apical pulse for one full minute in pediatrics and before cardiac medications. Report bradycardia, tachycardia, or new irregular rhythms to the provider. Compare apical and radial rates simultaneously to detect pulse deficits in atrial fibrillation.
NCLEX Relevance
Classic rule: Hold digoxin for adult apical pulse less than 60 bpm (less than 90 to 110 in infants). Also used for pulse deficit assessment.