Pulse Palpation

Simultaneous measurement of the apex beat and radial pulse is usually done when a patient is in atrial fibrillation as it indicates the efficacy of drug therapy.

The apex is the tip or summit of an organ; the apex beat is the heart’s impact against the chest wall during systole. It is primarily due to recoil of the apex of the heart as blood is expelled during systole and correlates with left ventricular contraction (Scott and MacInnes, 2006). The normal location of the apex beat is the fifth or sixth intercostal space in the mid clavicular line, with the patient supine at 45ยบ (Scott and MacInnes, 2006).

Atrial Fibrillation

Atrial fibrillation is common (Jevon, 2009), affecting around 10% of people aged over 70 (Goodacre and Irons, 2008). Causes include valvular heart disease, ischaemic heart disease, dilated cardiomyopathy, aortic stenosis, hypertension, pericarditis, cardiac surgery, thyrotoxicosis, pulmonary disease, alcohol excess and alcohol withdrawal.
It is characterised by an irregular pulse (Jevon, 2009), with atria discharging at 350-600 impulses/min (Bennett, 2006). These impulses bombard the atrioventricular junction and are intermittently conducted to the ventricles, resulting in an irregular QRS rhythm (Jevon, 2009).
The ventricular rate depends on the degree of atrioventricular conduction.
In atrial fibrillation, the atria fibrillate rather than contract in a controlled manner, leading to a fall in stroke volume and cardiac output (Jevon, 2009). Classic electrocardiogram features include a wavy, irregular baseline of ‘f’ (fibrillation) waves and no normal ‘P’ waves, with an irregular and often rapid ventricular response (Goodacre and Irons, 2008).
Controlling the ventricular response in atrial fibrillation benefits patients in terms of symptoms, quality of life and prevention of conditions such as tachycardia induced cardiomyopathy (Jevon, 2009).
Digoxin, calcium channel blockers and beta-blockers can be used to control the ventricular rate. Digoxin is often prescribed for chronic atrial fibrillation (Singer and Webb, 2005); it helps to control the ventricular rate, especially with associated heart failure (Jowett and Thompson, 1995).

Apex and radial pulse

Checking the radial pulse alone is unreliable when assessing the ventricular rate in people with atrial fibrillation. When the ventricular rate is rapid, some contractions may not be strong enough to transmit an arterial pulse wave through the peripheral artery, resulting in an apex-radial pulse deficit (Lip, 1993).
Simultaneous monitoring of the apex beat and radial pulse is advisable in patients with atrial fibrillation as it helps determine the ventricular rate more reliably and ascertain whether an apex beat-radial pulse deficit is present (Jevon, 2007). However, routine apex beat-radial pulse monitoring is not usually undertaken if ECG monitoring is available.
It is helpful to monitor the apex beat and apex-radial pulse deficit when a patient is prescribed digoxin, to assess the drug’s effectiveness. The maintenance dose is usually determined by the ventricular rate at rest; this should not be allowed to fall below 60bpm except in special circumstances, such as when beta-blockers are being given.



stethoscope for apical pulse in 5th intercostal space at mid clavicular line or slightly left.
fingers for radial
if a difference in pulses,
apical minus radial = pulse deficit

Document findings in patient's record including
- site
- pulse rate
- rhythm and volume (full/bounding,weak/thready).

full/bounding = particularly strong, or increased volume.

weak or thready = particular difficult to palpate

Identify pulse patterns as:
Normal - 60 to 80 beats per minute.
Tachycardia - More than 100 beats per minute.
Bradycardia - Less than 60 beats per minute.
Irregular - Uneven time intervals between beats.



7 pulse points

  • Temporal. The side of the head, near the temples.
  • Carotid. Pulse located at the side of the neck.
  • Brachial. Arm.
  • Femoral. Pulse located in the middle of the groin.
  • Radial. What artery is used to take the pulse at the wrist?
  • Popliteal. Back of knee.
  • Pedal. The side of the foot, near ankle.


What Pulse Qualities are Assessed?

The pulse rhythm, rate, force, and equality are assessed when palpating pulses.

Pulse Rhythm

The normal pulse rhythm is regular, meaning that the frequency of the pulsation felt by your fingers follows an even tempo with equal intervals between pulsations. If you compare this to music, it involves a constant beat that does not speed up or slow down, but stays at the same tempo. Thus, the interval between pulsations is the same. However, sinus arrhythmia is a common condition in children, adolescents, and young adults. Sinus arrhythmia involves an irregular pulse rhythm in which the pulse rate varies with the respiratory cycle: the heart rate increases at inspiration and decreases back to normal upon expiration. The underlying physiology of sinus arrhythmia is that the heart rate increases to compensate for the decreased stroke volume from the heart’s left side upon inspiration.

Points to Consider

If a pulse has an irregular rhythm, it is important to determine whether it is regularly irregular (e.g., three regular beats and one missed and this is repeated) or if it is irregularly irregular (e.g., there is no rhythm to the irregularity). Irregularly irregular pulse rhythm is highly specific to atrial fibrillation. Atrial fibrillation is an arrhythmia whereby the atria quiver. This condition can have many consequences including decreased stroke volume and cardiac output, blood clots, stroke, and heart failure.

Pulse Rate

The pulse rate is counted by starting at one, which correlates with the first beat felt by your fingers. Count for thirty seconds if the rhythm is regular (even tempo) and multiply by two to report in beats per minute. Count for one minute if the rhythm is irregular.

Pulse Force

The pulse force is the strength of the pulsation felt when palpating the pulse. For example, when you feel a client’s pulse against your fingers, is it gentle? Can you barely feel it? Alternatively, is the pulsation very forceful and bounding into your fingertips? The force is important to assess because it reflects the volume of blood, the heart’s functioning and cardiac output, and the arteries’ elastic properties. Remember, stroke volume refers to the volume of blood pumped with each contraction of the heart (i.e., each heart beat). Thus, pulse force provides an idea of how hard the heart has to work to pump blood out of the heart and through the circulatory system.
Pulse force is recorded using a four-point scale:
  • 3+ Full, bounding
  • 2+ Normal/strong
  • 1+ Weak, diminished, thready
  • 0 Absent/non-palpable
Practice on many people to become skilled in measuring pulse force. While learning, it is helpful to assess pulse force along with an expert because there is a subjective element to the scale. A 1+ force (weak and thready) may reflect a decreased stroke volume and can be associated with conditions such as heart failure, heat exhaustion, or hemorrhagic shock, among other conditions. A 3+ force (full and bounding) may reflect an increased stroke volume and can be associated with exercise and stress, as well as abnormal health states including fluid overload and high blood pressure.

Pulse Equality

Pulse equality refers to whether the pulse force is comparable on both sides of the body. For example, palpate the radial pulse on the right and left wrist at the same time and compare whether the pulse force is equal. Pulse equality is assessed because it provides data about conditions such as arterial obstructions and aortic coarctation. However, the carotid pulses should never be palpated at the same time as this can decrease and/or compromise cerebral blood flow.