Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Skill Checklists for Taylor's Clinical Nursing Skills:

A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 1-5

Assessing the Apical Pulse by Auscultation

Goal:The patient’s pulse is assessed accurately without injury

and the patient experiences minimal discomfort. Comments

1. Check medical order or nursing care plan for frequency of
   pulse assessment. More frequent pulse measurement may
   be appropriate based on nursing judgment. Identify the
   need to obtain an apical pulse measurement.


2. Perform hand hygiene and put on PPE, if indicated.


3. Identify the patient.


4. Close curtains around bed and close the door to the room,
   if possible. Discuss procedure with patient and assess
   patient’s ability to assist with the procedure.


5. Put on gloves, as appropriate.


6. Use alcohol swab to clean the diaphragm of the stethoscope.
   Use another swab to clean the earpieces, if necessary.


7. Assist patient to a sitting or reclining position and expose
   chest area.


8. Move the patient’s clothing to expose only the apical site.


9. Hold the stethoscope diaphragm against the palm of your
   hand for a few seconds.
   10.Palpate the space between the fifth and sixth ribs (fifth
   intercostal space), and move to the left midclavicular line.
   Place the diaphragm over the apex of the heart.


10. Listen for heart sounds (“lub-dub”). Each “lub-dub” counts
    as one beat.


11. Using a watch with a second hand, count the heartbeat for
    1 minute.


12. When measurement is completed, remove gloves, if worn.
    Cover the patient and help him or her to a position of
    comfort.


13. Clean the diaphragm of the stethoscope with an alcohol
    swab.


14. Remove additional PPE, if used. Perform hand hygiene.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

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