You check apical pulse by placing a stethoscope over the apex of the heart at the fifth intercostal space, midclavicular line, and counting the beats for one full minute.
Medical professionals, nursing students, and caregivers often need the most accurate heart rate measurement possible. Peripheral pulses, like the one on your wrist, offer a quick estimate. However, direct auscultation of the heart provides the gold standard for accuracy. This method allows you to hear the heart valves closing, distinct rhythms, and potential irregularities that a wrist check might miss.
Accuracy matters here. A discrepancy in this count can alter medication administration or signal a change in cardiac status. This guide breaks down the anatomical landmarks, the equipment needed, and the precise steps to obtain an accurate reading.
What Is The Apical Pulse?
The apical pulse is the heartbeat heard at the apex (the bottom tip) of the heart. When you listen here, you hear the mitral valve and tricuspid valve closing. This sound creates the “lub” part of the heartbeat cycle. Since you are listening directly over the source of the pumping action, this pulse site is the most reliable.
Doctors and nurses prefer this site when a patient has an irregular heart rhythm, takes cardiac medication, or is an infant. In these cases, the radial pulse (wrist) might not feel every beat the heart generates. The apical count catches those weak beats.
Tools You Need Before Starting
You cannot measure this pulse with your fingers alone. You need specific equipment to hear the internal sounds of the chest cavity.
- High-quality stethoscope — A device with a working diaphragm (flat side) and bell (cup side) helps, though the diaphragm is standard for adults.
- Watch with a second hand — Digital timers work, but a sweeping second hand often makes counting easier.
- Alcohol wipes — Hygiene protects both you and the patient.
- Pen and paper — Record the value immediately to prevent memory errors.
How Do You Check Apical Pulse?
Correct technique ensures the data you gather is valid. The process involves preparation, locating the site, and counting with focus.
1. Prepare The Equipment And Patient
Hygiene and comfort come first. The stethoscope touches the patient’s bare skin, so temperature and cleanliness matter.
- Clean the earpieces — Wipe them down with alcohol to prevent ear infections.
- Clean the diaphragm — Wipe the chest piece. If the room is cold, warm the diaphragm in your palm for ten seconds to avoid startling the patient.
- Position the patient — Have them sit upright or lie supine (flat on their back). Sitting up brings the heart closer to the chest wall.
- Expose the chest — Respect privacy. Only expose the left side of the chest where you will listen. Shift clothing rather than removing it entirely if possible.
2. Locate The Landmarks
You cannot just place the stethoscope anywhere on the left side. You must find the Point of Maximal Impulse (PMI). This is where the heart beats closest to the rib cage.
- Find the sternal notch — Feel for the U-shaped dip at the base of the neck.
- Move down to the Angle of Louis — Slide your fingers down about 2 inches until you feel a bony ridge.
- Slide right to the 2nd rib — Move your fingers to the patient’s left. This is the 2nd rib. The gap below it is the 2nd intercostal space.
- Count down the spaces — Move your fingers down the rib cage. Count the gaps: 3rd, 4th, and finally the 5th intercostal space.
- Find the midclavicular line — Imagine a vertical line dropping from the center of the collarbone (clavicle). The intersection of the 5th intercostal space and this imaginary line is your target.
3. Listen And Count
Once you find the spot, the actual measurement begins. This requires silence and concentration.
- Place the diaphragm — Hold the stethoscope chest piece firmly against the skin at the PMI.
- Identify the heartbeat — Listen for the “lub-dub” sound. One “lub-dub” equals one beat.
- Count for 60 seconds — Watch your clock. Count every distinct “lub-dub” cycle for one full minute. Do not multiply a 30-second count by two. Irregularities appear sporadically, and a full minute captures them.
- Note the rhythm — While counting, assess if the rhythm is regular (steady like a clock) or irregular (chaotic or skipped beats).
Locating The Apical Pulse Site On The Chest
Finding the exact spot challenges many students. Anatomy varies between individuals. For women, breast tissue can obscure the 5th intercostal space. In these scenarios, use the back of your hand to displace breast tissue upward gently, or ask the patient to do it if they are able. This exposes the chest wall for better sound transmission.
Body mass index also plays a role. In very thin patients, the pulse is visible to the eye. In patients with higher body fat, the sounds may be faint. If you struggle to hear sounds at the standard site, ask the patient to lean forward or roll slightly onto their left side. This maneuver brings the heart closer to the chest wall, amplifying the sound.
For children under age seven, the landmarks shift slightly. Their hearts sit higher in the chest. You will find their apical pulse at the 4th intercostal space rather than the 5th.
When Should You Perform This Check?
Nurses and doctors do not use the apical method for every routine vital sign check. It takes more time and effort than a radial pulse check. You use this method when specific clinical indicators exist.
Irregular Heart Rhythms
If you feel a radial pulse and it skips beats or feels chaotic, you must switch to an apical check. The radial artery only throbs when the heart pumps with enough force to send a wave to the wrist. Weak beats might not reach the wrist, but you will hear them at the apex.
Cardiac Medications
Certain drugs, known as cardiac glycosides (like Digoxin), slow the heart rate to improve pumping efficiency. Protocols typically require you to hold the medication if the heart rate drops below 60 beats per minute. A radial pulse is not accurate enough for this decision. You must confirm the true rate at the apex before administering the dose.
Infant Assessment
Peripheral pulses in babies are difficult to feel and count accurately due to their rapid rate and chubby limbs. The apical pulse is the standard method for assessing heart rate in infants and toddlers.
Radial vs. Apical Pulse: The Differences
Understanding the relationship between these two sites helps in identifying vascular issues. In a healthy person, the two rates should be identical. Every time the heart beats (apical), a wave of blood should reach the wrist (radial).
Pulse Deficit Explained
Sometimes, the numbers do not match. If the apical rate is 90 but the radial rate is 72, you have a pulse deficit of 18. This indicates that 18 beats were too weak to perfuse to the extremities. Conditions like atrial fibrillation or heart failure often cause this. To measure this, two nurses usually count simultaneously—one at the wrist, one at the chest—for the same minute.
Normal Ranges And Interpretation
Once you have the number, you must interpret it. Normal ranges vary by age and physical condition. A “normal” rate for a resting adult differs greatly from a normal rate for a crying infant.
| Age Group | Normal Heart Rate (BPM) |
|---|---|
| Newborns (0–1 month) | 70 – 190 |
| Infants (1–11 months) | 80 – 160 |
| Children (1–2 years) | 80 – 130 |
| Children (3–4 years) | 80 – 120 |
| Children (5–6 years) | 75 – 115 |
| Children (7–9 years) | 70 – 110 |
| Adults & Adolescents | 60 – 100 |
| Athletes (Resting) | 40 – 60 |
Analyzing The Sound (S1 and S2)
When asking how do you check apical pulse, you are also asking what you should hear. The heartbeat sounds like “lub-dub.”
- S1 (Lub) — This is the first sound. It is lower in pitch and longer. It signifies the closing of the mitral and tricuspid valves. It marks the start of systole (pumping).
- S2 (Dub) — This is the second sound. It is higher pitched and shorter. It signifies the closing of the aortic and pulmonic valves. It marks the start of diastole (filling).
Troubleshooting Common Difficulties
Even experienced clinicians struggle to hear heart sounds occasionally. Environmental noise or patient anatomy often interferes.
Reduce Ambient Noise
Stethoscopes amplify everything, including the rustle of clothes or a television in the background. Turn off the TV. Ask the patient to remain silent. Ensure the stethoscope tubing is not rubbing against your own clothing or the bed rails.
Adjust The Stethoscope Pressure
If you press too hard with the bell side, you stretch the skin tight, making it act like a diaphragm. This filters out low-frequency sounds. If using the diaphragm, press firmly to create a seal. If using the bell, rest it lightly on the skin.
Manage Respiratory Noise
Breath sounds can mask heart sounds. If the patient is breathing heavily, ask them to hold their breath for a few seconds. This silences the lungs, allowing the heart sounds to pop out. Be sure to tell them to breathe again promptly.
Recording The Data
Documentation completes the procedure. A number written on a scrap of paper is not part of the medical record until entered formally. When charting apical pulse, notation matters.
- Mark the site — Explicitly state “Apical” or “AP” so other providers know you did not use the radial site.
- Note the rate — Write the beats per minute (BPM).
- Describe the rhythm — Use terms like “regular,” “irregular,” or “regularly irregular.”
- Document interventions — If you withheld medication because the rate was low, document that specific action and the doctor notification.
Why The One Minute Rule Matters
Time is a constraint in healthcare, and taking a full minute feels long. Shortcutting this step reduces validity. Mathematical averaging (counting for 15 seconds and multiplying by 4) assumes the heart rate is perfectly constant. In patients needing an apical check, the rate is rarely constant.
Arrhythmias often follow patterns where the heart beats normally for ten seconds, then skips, then races. A 15-second count might catch only the normal section, giving a false sense of security. The full 60-second count smooths out these variances, providing a true average of the patient’s cardiac output.
Apical Pulse In Emergency Situations
In a cardiac arrest scenario, you generally check the carotid pulse (neck) or femoral pulse (groin). These central pulses are easier to find quickly without equipment. However, in a non-arrest emergency where a patient is deteriorating, checking the apical pulse helps assess if the heart is actually contracting effectively or if visible ECG rhythms on a monitor are not producing mechanical beats (PEA – Pulseless Electrical Activity).
Key Takeaways: How Do You Check Apical Pulse?
➤ Place the stethoscope at the 5th intercostal space, midclavicular line.
➤ Count the “lub-dub” sounds for exactly 60 seconds for accuracy.
➤ Use this method for infants, irregular rhythms, or prior to cardiac meds.
➤ Warm the stethoscope diaphragm to prevent patient discomfort and shivering.
➤ Compare radial and apical rates to identify any pulse deficit.
Frequently Asked Questions
Can you check your own apical pulse?
Yes, but it is difficult. You need a stethoscope and the ability to position it correctly on your chest while looking at a clock. Most people find the noise of holding the tubing interferes with the sound. Checking your radial (wrist) or carotid (neck) pulse is much easier for self-assessment.
Why is the apical pulse louder in some people?
The intensity of the sound depends on the distance between the heart and the stethoscope. Thin people have less tissue (muscle, fat) buffering the sound. Additionally, conditions like hypertension or fever can cause the heart to contract more forcefully, creating a louder “knock” against the chest wall.
What if I hear a third sound?
A third heart sound (S3) or fourth (S4) is abnormal in most adults. It sounds like a gallop (lub-dub-ta or ta-lub-dub). In older adults, this can indicate heart failure or fluid overload. If you hear this extra beat, document it immediately and notify a physician for further assessment.
Does anxiety affect the apical pulse reading?
Yes, stress and anxiety release adrenaline, which increases heart rate (tachycardia). If a patient seems anxious, their reading might be falsely high. Wait five minutes, talk to them calmly to help them relax, and measure again to get a true resting rate.
Why do we not use the thumb to feel a pulse?
This rule applies to palpating peripheral pulses, not the apical pulse (since you use a stethoscope). However, if you are cross-checking the radial pulse, never use your thumb. Your thumb has its own strong arterial pulse. You might end up counting your own heart rate instead of the patient’s.
Wrapping It Up – How Do You Check Apical Pulse?
Mastering the apical pulse assessment is a fundamental skill for any healthcare provider. It moves beyond the convenience of a wrist check and provides a direct line to the heart’s function. By finding the correct landmarks at the 5th intercostal space and listening for a full minute, you gather data that is reliable and actionable.
Remember that this technique is not just for cardiac patients. It is the standard for children, the safety check for medication administration, and the tie-breaker when peripheral pulses are weak. Take the time to practice locating the landmarks. Once your fingers know the path down the rib cage, the process becomes second nature.