PROCEDURE. Apical pulse should be the first vital sign assessed

Apical pulse should be the first vital sign assessed. Other assessment procedures may be upsetting, leading to increased heart rate and crying, which makes hearing apical pulse difficult. An apical pulse should be taken on neonates, infants,and young children (under 2 years of age) and on all childrenwith cardiac problems or receiving digitalis preparations.

Radial pulse is unreliable in neonates and infants due to their small size and normally rapid heart rate. Radial pulse is unreliable in children with cardiac problems or receiving digitalis preparations due to possibly irregular heart rhythm.

1. Cleanse earpieces and diaphragm of stethoscope with an alcohol wipe. Reduces transmission of microorganisms from practitioner to practitioner and from client to client.

2. Warm stethoscope in hand for 5–10 seconds. Prevents client from being startled by cold bell; promotes client comfort.

3. Raise client’s gown to expose sternum and left chest. Allows for proper placement of stethoscope.

4. Place stethoscope over point of maximal impulse (PMI). Enhances ability to clearly hear heart sounds.

a. For infant, PMI is at 3rd to 4th inter-costal space near the sternum. (Figure 6)

FIGURE 6 Place stethoscope over point of

maximum impulse to count heart rate.

b. For older child, PMI is at 5th left inter-costal space in the midclavicular line.

5. Count pulse for one full minute. Each “lub-dub” sound is one beat. Assess apical pulse for rate, rhythm, and any abnormal heart sounds. If an irregular rhythm, determine if there is a regular pattern to the irregularity.

Counting for less than one minute may lead to inaccurate heart rate, especially in neonates, infants, and young children where arrhythmia is normal or in children with cardiac problems or receiving digitalis preparations.

6. If appropriate, evaluate for pulse deficit between the apical pulse and peripheral pulse by simultaneously taking the apical and radial pulse. For the inexperienced nurse this may be more accurately accomplished by using two nurses, one to count the apical pulse and one to count the radial pulse. Both nurses should use the same watch when performing this procedure.

7. Wash hands. It reduces transmission of microorganisms.

Ex.3 Change the following sentences into the structures of the subjunctive mood using the clichés given in italics: it is advisable that…; it is necessary that…; it is recommended that…; it is desirable that…; it is important that… it is essential that…:

e.g. Place index and middle fingers along the child’s radial artery.– It is advisable that one (should) use index and middle fingers along the child’s radial pulse.