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This document provides information on assessing the apex beat, including defining the apex beat, listing normal heart rates by age, and describing the purpose and location for assessment. It details the factors that can affect heart rate and the nursing process for assessment. This involves locating the apex pulse in the 5th intercostal space, counting heartbeats for one minute, documenting, and reporting any abnormalities to the primary provider. The goals are to obtain baseline data, monitor for issues, and ensure the heart rate is normal.
This document provides information on assessing the apex beat, including defining the apex beat, listing normal heart rates by age, and describing the purpose and location for assessment. It details the factors that can affect heart rate and the nursing process for assessment. This involves locating the apex pulse in the 5th intercostal space, counting heartbeats for one minute, documenting, and reporting any abnormalities to the primary provider. The goals are to obtain baseline data, monitor for issues, and ensure the heart rate is normal.
This document provides information on assessing the apex beat, including defining the apex beat, listing normal heart rates by age, and describing the purpose and location for assessment. It details the factors that can affect heart rate and the nursing process for assessment. This involves locating the apex pulse in the 5th intercostal space, counting heartbeats for one minute, documenting, and reporting any abnormalities to the primary provider. The goals are to obtain baseline data, monitor for issues, and ensure the heart rate is normal.
ASSESSMENT OF APEX BEAT LEARNING OUTCOME At the end one hour lecture, the students must be able to: 1. Define apex beat. 2. List the variation of heart beat by age. 3. State the purpose of assessment of apex beat. 4. State the location of assessment of apex beat. 5. State the factor affecting for heart beat.
3 Ayu Sulaini_Apex Beat LEARNING OUTCOME 5. Explains the nursing management in assessment of apex beat. 6. Demonstrate the technique of assessment of apex beat 7. Appreciate the knowledge of assessment of apex beat.
4 Ayu Sulaini_Apex Beat DEFINITION Ayu Sulaini_Apex Beat 5 VARIATIONS OF HEART BEAT BY AGE Ayu Sulaini_Apex Beat 6 AGE HEAR T RATE AVERAGE (BPM) Newborn 130 (80-180) 1 year 120 (80-140) 5-8 years 100 (75-120) 10 years 70 (50-90) Teen 75 (50-90) Adult 80 (60-100) Older adult 70 (60-100) PURPOSE To obtain the heart rate of newborns, infants, and children 2 to 3 years old or of an adult with an irregular peripheral pulse To establish baseline data for subsequent evaluation To determine whether the cardiac rate is within normal range and the rhythm is regular To monitor clients with cardiac, pulmonary, or renal disease and those receiving medication to improve heart action. 7 Ayu Sulaini_Apex Beat Ayu Sulaini_Apex Beat 8 FACTOR AFFECTING HEART BEAT AGE GENDER EXERCISE FEVER MEDICATION HYPOVOLEMIA STRESS POSITION CHANGES PATHOLOGY Ayu Sulaini_Apex Beat 9 FACTOR AFFECTING HEART BEAT AGE AGE LOCATION Ayu Sulaini_Apex Beat 10 RIGHT LEFT INTERCOSTAL SPACE MID-CLAVICULAR LINE 5 TH intercostal space 1 cm medial to the mid-clavicular line Ayu Sulaini_Apex Beat 11 PURPOSE To obtain the heart rate of newborns, infants, and children 2 to 3 years old or of an adult with an irregular peripheral pulse To establish baseline data for subsequent evaluation To determine whether the cardiac rate is within normal range and the rhythm is regular To monitor clients with cardiac, pulmonary, or renal disease and those receiving medication to improve heart action. 12 Ayu Sulaini_Apex Beat Ayu Sulaini_Apex Beat 13 ASSESSMENT Ayu Sulaini_Apex Beat 14 ACTION RATIONALE 1. Patient condition
To know the reason for any abnormalities 2. Clinical sign of cardiovascular alterations (dyspnea, pallor, cyanosis) 3. Factors that may alter heart rate (medication) 4. Know the previous heart rate before the actual procedure As a data baseline 5. Environment Provide adequate work space PLANNING Ayu Sulaini_Apex Beat 15 Watch with a second hand or indicator Stethoscope Antiseptic wipe IMPLEMENTATION Ayu Sulaini_Apex Beat 16 ACTION RATIONALE 1. Greet client and introduce self. Explain to the client regarding the procedure. Get the client cooperate and to reduce patient anxiety. 2. Perform hand hygiene. To minimize the organism transmission. 3. Provide for client privacy. Maintain the client self-image 4. Use antiseptic wipes to clean the earpieces and diaphragm. The diaphragm needs to be cleaned and disinfected, to minimize the organism transmission. 5. Standing on the side of the client Avoid expose other part in order to maintain the privacy of the client. IMPLEMENTATION Ayu Sulaini_Apex Beat 17 ACTION RATIONALE 6. Locate the apical pulse by: Slide your index finger just to the left of the sternum, and palpate the second intercostal space. Place your middle or next finger in the third intercostal space. Continue palpating downward until you locate the fifth intercostal space. Move your index finger laterally along the fifth intercostal space toward the mid-clavicle line (MCL).
To obtain the accurate result 7. Place the diaphragm of the stethoscope over the apical impulse and listen for the normal heart sounds To listen to heart sounds IMPLEMENTATION Ayu Sulaini_Apex Beat 18 ACTION RATIONALE 8. Count the heartbeats for 1 minute Provide a more accurate assessment 9. Comfort the client Ensure comfort 10. Inform the client result 11. Document in the client record As a documentation EVALUATION Ayu Sulaini_Apex Beat 19 ACTION RATIONALE 1. Relate the result to baseline data and health status Detect early abnormalities 2. Report to the primary provider any abnormal findings. Early treatment, to prevent further complication. DEMONSTRATION Ayu Sulaini_Apex Beat 20 CONCLUSION 1. Define apex beat. 2. List the variation of heart beat by age. 3. State the purpose of assessment of apex beat. 4. State the location of assessment of apex beat. 5. State the factor affecting for heart beat. 5. Explains the nursing management in assessment of apex beat. 6. Demonstrate the technique of assessment of apex beat 7. Appreciate the knowledge of assessment of apex beat.
Ayu Sulaini_Apex Beat 21 REFERENCES Berman, A., Snyder, S. J., Kozier, B., & Erb, G. (2008). Kozier & Erbs Fundamental of nursing: Concepts, process and practice (8 th ed.). New Jersey: Prentice Hall.
Rasnah Abd. Rahman & Salizar Mohamed Ludin (2005). Prosedur kejururawatan menggunakan proses kejururawatan. Selangor,Malaysia:Prentice Hall