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Understanding the Apical Pulse: Location and Significance

Learn where to find the apical pulse and understand its significance in patient assessment. Essential guide for RNs, LPNs, and nurse practitioners.

Content reviewed by Megan Andrews, MSN, APRN, ANP-C 

 

What is the apical pulse? 

The apical pulse, also known as the point of maximal impulse (PMI), provides critical information about the heart's function. It is the pulse over the apex of the heart, and it reflects the rhythmic contraction and relaxation of the left ventricle. This pulse is typically assessed in clinical settings to evaluate cardiac health, particularly in patients with cardiovascular conditions. 

 

Finding the apical pulse location

The apical pulse is located at the apex of the heart. Anatomically, the apex of the heart is found at the left fifth intercostal space at the midclavicular line. 

 

How to assess & take the apical pulse: 

Assessing the apical pulse is a fundamental skill for nurses and other healthcare professionals. Here's a step-by-step guide to perform an accurate assessment: 

  1. Gather equipment: You will need a stethoscope and a watch with a second hand or a digital timer. 
  2. Prepare the patient:  Inform the patient about the procedure to alleviate any anxiety. 
  3. Position the patient: The patient should be in a supine position or sitting upright. If the patient is supine, ask them to roll slightly to their left side, which brings the heart closer to the chest wall and makes the pulse easier to palpate. 
  4. Identify the landmarks: Start by locating the sternal notch, then move down to the angle of Louis (the joint between the manubrium and the body of the sternum). From the angle of Louis, move your fingers down the left sternal border until you reach the fifth intercostal space. 
  5. Locate the midclavicular line: This imaginary line runs vertically down from the midpoint of the clavicle. The intersection of the fifth intercostal space and the midclavicular line is the approximate location of the apex of the heart. 
  6. Palpate the apical pulse: Use your fingers to gently palpate this area for the pulsation. You may need to have the patient’s help repositioning breast tissue to properly assess. In some cases, especially in patients with a larger chest or those with conditions like emphysema, it may be challenging to feel the apical pulse. In such instances, auscultation with a stethoscope is recommended. 
  7. Auscultate the pulse: Place the diaphragm of the stethoscope over the apical impulse area. Listen for the "lub-dub" sounds, which correspond to the closing of the heart valves. The "lub" (S1) signifies the closure of the mitral and tricuspid valves, while the "dub" (S2) indicates the closure of the aortic and pulmonic valves. 
  8. Count the beats: Count the number of heartbeats for a full minute. This provides the apical heart rate. 

 

Clinical significance of the apical pulse 

Assessing the apical pulse is vital for several reasons: 

  • Accuracy: The apical pulse provides a more accurate measure of the heart rate compared to peripheral pulses, especially in cases of arrhythmias. This is because it reflects the actual cardiac contractions. 
  • Diagnosing cardiac conditions: Abnormalities in the apical pulse can indicate underlying cardiac conditions. For example, irregular rates can indicate  arrhythmias such as fibrillation. Lateral/inferior displacement of the apical pulse can be present in heart failure. 
  • Monitoring treatment effects: For patients on cardiac medications, especially those affecting heart rate and rhythm (e.g., beta-blockers or digoxin), monitoring the apical pulse helps assess the efficacy and safety of the treatment. 
  • Pediatric and geriatric assessments: In infants, young children, and elderly patients, the apical pulse is often the preferred site for pulse assessment due to the difficulty in palpating peripheral pulses. 

 

Common issues and troubleshooting 

While assessing the apical pulse, healthcare professionals may encounter some challenges: 

  • Obesity or large breasts: In such cases, repositioning the patient to a left lateral position may help. Additionally, having the patient sit upright and lean forward can also make the pulse easier to palpate and auscultate. Patients may help reposition breast tissues to better assess the apical pulse. 
  • Tachycardia or bradycardia: These conditions can make counting the pulse difficult. It’s important to count the pulse for a full minute to ensure accurate measurement.  
  • Noise interference: In a noisy environment, it may be challenging to hear the apical pulse clearly. Using a high-quality stethoscope and utilizing a quiet setting can mitigate this issue. 

Understanding and accurately assessing the apical pulse is essential for registered nurses, LPNs, and nurse practitioners. By mastering the technique of locating and assessing the apical pulse, healthcare professionals can enhance their clinical skills and improve patient outcomes.