Assessing a client’s pulse is a fundamental skill that provides immediate insight into cardiovascular function. Nurses routinely check the radial pulse at the wrist, which offers a quick measure of the heart rate and rhythm. However, relying solely on this peripheral assessment can sometimes miss underlying cardiac issues. A more comprehensive evaluation is necessary, known as checking for a pulse rate deficit, which evaluates the efficiency of the heart’s pumping action. This assessment is specifically indicated when a client’s pulse rhythm is noticeably irregular or fast.
Understanding the Pulse Rate Deficit
A pulse rate deficit is the numerical difference between the apical heart rate and the radial pulse rate. The apical heart rate is the true rate of ventricular contraction, heard directly over the heart with a stethoscope. The radial pulse rate is the number of beats felt at a peripheral artery, such as the wrist. In a healthy cardiovascular system, the apical and radial rates are identical because every contraction is forceful enough to push a wave of blood to the periphery.
A deficit occurs when a ventricular contraction is too weak or too rapid to create a pressure wave palpable at the radial site. This means some heartbeats are ineffective in generating peripheral circulation. Conditions like atrial fibrillation, where electrical activity is disorganized, often cause this phenomenon. An irregular or rapid rhythm prevents the ventricles from filling properly, resulting in a low-volume contraction that fails to reach the wrist.
Preparing for the Assessment
The accurate assessment of a pulse deficit requires careful preparation. The client should be positioned comfortably, ideally lying supine or in a low semi-Fowler’s position, which provides easy access to the chest and wrist. The procedure requires a reliable stethoscope to auscultate heart sounds and a watch or clock with a second hand for precise timing.
The most accurate method necessitates two healthcare professionals, typically two nurses. One nurse performs the apical count while the other simultaneously counts the radial pulse. Both nurses must agree on the starting time to ensure the counts are synchronized over the same sixty-second interval. This collaborative approach eliminates the inaccuracies that occur if one person attempts both counts consecutively.
The Simultaneous Apical-Radial Assessment Technique
The assessment begins with locating the two distinct pulse sites. The apical pulse is found by placing the stethoscope diaphragm over the apex of the heart, usually at the fifth intercostal space medial to the midclavicular line. The second nurse simultaneously palpates the radial pulse on the thumb side of the client’s wrist, using the pads of the index and middle fingers.
Synchronization is achieved when the nurse palpating the radial pulse signals the start of the count. Both nurses begin counting the beats at the exact same moment, utilizing the same timepiece. Counting must be performed for a full sixty seconds to capture the true rate and any irregularities. This duration is important, especially when the rhythm is irregular, as shorter counts may not accurately reflect the overall rate.
One nurse focuses on the “lub-dub” sounds of the heart to determine the apical rate, while the other counts the palpable pulsations at the wrist for the radial rate. At the end of the minute, the counts are stopped simultaneously upon a predetermined signal. The pulse deficit is then calculated by subtracting the radial rate from the apical rate. For example, an apical rate of 90 beats per minute and a radial rate of 72 beats per minute yields a pulse deficit of 18 beats per minute.
Interpreting the Findings and Next Steps
Any difference greater than zero between the apical and radial rates constitutes a pulse deficit, reflecting ineffective cardiac contractions. A difference exceeding ten beats per minute is considered clinically significant, indicating potential cardiovascular impairment. The presence of a deficit suggests that the heart is contracting, but the stroke volume of some beats is insufficient to produce a palpable peripheral wave.
The most common cause linked to a pulse deficit is an arrhythmia, such as atrial fibrillation, but it can also be seen with premature ventricular contractions or severe heart failure. This finding signifies that the heart is not effectively pumping blood to the periphery, which compromises the delivery of oxygen and nutrients to tissues. The nurse must accurately document both the apical and radial rates, along with the calculated deficit.
This finding must be immediately reported to the healthcare provider as it warrants further investigation and possible intervention. The nurse should also assess the client for other signs of decreased cardiac output, such as shortness of breath, pallor, fatigue, or dizziness. A significant pulse deficit often leads to a request for diagnostic testing, such as an electrocardiogram (ECG), to identify the underlying electrical rhythm disturbance.