Best area for auscultating the apical pulse

In order to continue enjoying our site, we ask that you confirm your identity as a human. Thank you very much for your cooperation.

Apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line. In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular line (OER #1). See Figure 3.5 below.

Figure 3.5: Apical Pulse (Illustration credit: Hilary Tang)

Apical pulse rate is indicated during some assessments, such as when conducting a cardiovascular assessment and when a client is taking certain cardiac medications (e.g., digoxin) (OER #1). Sometime the apical pulse is auscultated pre and post medication administration. It is also a best practice to assess apical pulse in infants and children up to five years of age because radial pulses are difficult to palpate and count in this population. It is typical to assess apical pulses in children younger than eighteen, particularly in hospital environments. Apical pulses may also be taken in obese people, because their peripheral pulses are sometimes difficult to palpate.

Position the client in a supine (lying flat) or in a seated position. Physically palpate the intercostal spaces to locate the landmark of the apical pulse. Ask the female client to re-position her own breast tissue to auscultate the apical pulse. For example, the client gently shifts the breast laterally so that the apical pulse landmark is exposed. See Figure 3.6 below. Alternatively, the healthcare provider can use the ulnar side of the hand to re-position the breast tissue and auscultate the apical pulse. Ensure draping to protect the client’s privacy.

Either the bell or diaphragm are used to auscultate the client’s heart rate and rhythm. There is a pediatric-size stethoscope for infants. Typically, apical pulse rate is taken for a full minute to ensure accuracy; this is particularly important in infants and children due to the possible presence of sinus arrhythmia. Upon auscultating the apical pulse, you will hear the sounds “lub dup” – this counts as one beat. Count the apical pulse for one minute. Note the rate and rhythm.

Figure 3.6: Female client re-positioning her breast in order to auscultate the apical pulse

Listen to Audio clip 3.1 and count the apical pulse. For practice, we have made this clip 30 seconds so you will need to multiply it by two to report it as beats per minute (but remember, the most accurate measurement is to count the apical pulse for one minute). The reported apical rate in Audio clip 3.1 is: 60 bpm (30 x 2) with a regular rhythm

An interactive or media element has been excluded from this version of the text. You can view it online here: pb.libretexts.org/vitalsign/?p=112

Audio clip 3.1: Counting apical pulse rate

Alternatively, if viewing textbook as a pdf, use this link: https://www.youtube.com/embed/yL4E_6PaPgg?rel=0

Although pulses are best measured at rest, sometimes this is not possible. It is important to document other factors such as when a person is in pain or an infant/child is crying.

_________________________________________________________________________

Part of this content was adapted from OER #1 (as noted in brackets above):

© 2015 British Columbia Institute of Technology (BCIT). Clinical Procedures for Safer Patient Care by Glynda Rees Doyle and Jodie Anita McCutcheon, British Columbia Institute of Technology. Licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. Download this book for free at http://open.bccampus.ca

Your apical pulse is a pulse point on your chest that gives the most accurate reading of your heart rate. It’s also called the point of maximal impulse (PMI) and the apex beat.

Your other pulse points are located along your arteries. There are eight common arterial pulse points. These include your radial pulse (on your wrist) and your carotid pulse (along your neck). Usually, it’s easy to feel your pulse at one of those places using your fingers. When you press your fingers to your wrist, you’re feeling the pressure waves that your heart creates each time it contracts.

Your apical pulse is different. It’s not an arterial pulse point. You’re not feeling pressure waves. Instead, you’re feeling your left ventricle (lower left heart chamber) contract. Each time it contracts, it pushes blood out of your heart through your aorta and out to the rest of your body.

It’s impressive to think that you can actually feel your heart moving. However, it may be hard to feel your apical pulse with your fingers. Your care team may also check your apical pulse if you’re in the hospital.

Where is the apical pulse located?

Your apical pulse is located above the apex of your heart. Your apex is the tip of your left ventricle that points downward in the left side of your chest. If you have dextrocardia, meaning your heart is flipped from left to right, then your heart’s apex is on your right side.

So, where exactly is the apex of your heart? In adults, it’s located in an area of your chest in between the fifth and sixth ribs if you start counting from the top.

In children under age 7, the location is different. Their apex is located in their fourth intercostal space (so, between their fourth rib and their fifth rib).

Why is the apical pulse measured?

Your provider can gain valuable information by measuring your apical pulse. Automatic devices that quickly measure your pulse are helpful for showing your heart rate. But they can’t show your heart rhythm or the strength of your pulse. Your apical pulse can provide all that information relatively quickly and using only a stethoscope.

Your provider may measure your apical pulse to:

• Check your general health and wellbeing.
• Check your heart health.
• See how you’re doing after a test, procedure or surgery.
• Gather baseline information that can be compared with other pulse checks going forward.

How do you take an apical pulse?

Your provider uses a stethoscope to take your apical pulse. They need to apply the stethoscope directly to your bare skin. So, they’ll make sure you’re comfortable and covered with a sheet or blanket, if needed, for privacy.

Generally, your provider will follow these steps:

1. Ask you to lie down on your back or turned slightly to your left.
2. Use their fingers to locate your apical pulse.
3. Apply the end of the stethoscope (either the bell or the diaphragm) to your chest.
4. Listen for up to 60 seconds. Don’t be alarmed if they don’t say anything, or if this part feels like it takes a while. That’s normal. Your provider needs to listen carefully.
5. Remove the stethoscope from your chest.

Your provider may also check your pulse in other locations. For example, they may want to measure your apical-radial pulse.

Apical-radial pulse

Your provider may want to check both your apical pulse and your radial pulse (at your wrist) at the same time. This can show how well blood is traveling from your heart to the rest of your body. Your provider may ask another provider to assist. One person measures your apical pulse, while during the same 60 seconds, the other person checks your radial pulse.

Ideally, your apical pulse and your radial pulse are the same. But if your heart is weak or you have vascular disease, your radial pulse may be lower than your apical pulse. The difference between these two numbers is called a “pulse deficit.” Your pulse deficit can help your provider diagnose and check various conditions that affect your heart and blood vessels.

What is the normal apical pulse range?

The normal apical pulse range for most adults is 60 to 100 beats per minute (bpm). This is the ideal range for when you’re resting. Your pulse will go up if you:

• Exercise.
• Drink caffeine.
• Feel stressed or anxious.

As you get older, your pulse may naturally be lower. Other factors can impact your pulse, including certain medications and medical conditions. Talk with your provider to learn the pulse range that’s healthy for you.

It’s normal for children to have a higher pulse. The normal range varies based on their age. It’s highest when they’re under three months old (123 to 164 bpm) and gradually lowers as they approach adulthood. Talk with your child’s provider to learn more about their ideal pulse ranges at different stages of childhood.

What can the apical pulse show?

Your apical pulse can reveal signs of many different medical conditions. That’s because it allows your provider to hear more than just how fast your heart is beating. They can also hear:

• The strength of each heartbeat.
• How long each heartbeat lasts.
• The overall rhythm of your heart.

Your apical pulse may help your provider diagnose:

Sometimes, your provider may not be able to detect your apical pulse. This may be the case if you have:

• Obesity.
• Chronic lung disease.
• Pericardial effusion.
• Left pleural effusion.

If that happens, your provider will check your pulse at other locations and run other heart tests as needed.

A note from Cleveland Clinic

Modern technology offers us many tools, but manual pulse checks are still a valuable part of medical practice. Your apical pulse is a vital sign that can help your provider identify problems with your heart. Your provider may check your apical pulse during regular checkups. If you’re hospitalized, your care team may check your apical pulse often during your stay. Talk with your provider about your apical pulse and what it reveals about your heart health.