12.9 : 心尖搏动评估

Assessing the apical pulse is indicated for children younger than two, cardiac patients, and prior to specific medication administration.

It is auscultated at the left midclavicular line at the fifth intercostal space.

Before the procedure, gather equipment, such as a stethoscope, watch, pen, documentation aids, and alcohol swabs.

Identify and approach the patient.

Explain the procedure and obtain verbal consent.

Perform hand hygiene and provide privacy.

Clean the stethoscope's diaphragm and earpieces with an alcohol swab to reduce the transmission of microorganisms.

Position the patient in a sitting or reclining posture, exposing the chest.

Ensure the stethoscope’s audibility.

Place the stethoscope at the apical site and check for cardiac valve closure sounds, the S1 lub, and the S2 dub sounds.

Check the pulse for one full minute.

Post-procedure, cover the patient and provide a comfortable position.

Replace the equipment, perform hand hygiene, and record the findings.