Name ____________________________________
Date -------------- Score _____________
Procedure 31-5 Obtain Vital Signs: Obtain an Apical Pulse
CAAHEP COMPETENCIES: I.PI.1, I.AI.2, III.PIII.2, IV.PIV.2, IV.PIV.8
ABHES COMPETENCIES: 9.c
Task: To determine and record accurately a patient's apical heart rate .
Equipment and Supplies
• Watch with a second hand
• Patient gown as needed
• Stethoscope
• Alcohol wipes
• Patient's record
Standards: Complete the procedure and all critical steps in --------- - - - - minutes with a minimum score
of 85% in three attempts.
Scoring: Divide the points earned by the total possible points. Failure to perform a critical step, indicated by
an asterisk (*), results in an unsatisfactory overall score.
Time began _____________
Time ended _____________
Steps
1. Sanitize your hands and clean the stethoscope's
earpieces and diaphragm with alcohol swabs.
*2. Introduce yourself, identify your patient, and explain
the procedure.
Possible
Points
Attempt
Attempt
2
3
20
10
4. Assist the patient into the sitting or supine position.
10
5. Hold the stethoscope's diaphragm against the palm of
your hand for a few seconds.
10
6. Place the stethoscope just below the left nipple in the
intercostal space between the fifth and sixth ribs, over
the apex of the heart.
10
10
8. Help the patient sit up and dress.
5
9. Sanitize your hands.
5
*10. Record the pulse in the patient's chart (e.g., AP = 96), as
well as any arrhythmias.
Attempt
1
10
3. If necessary, help the patient disrobe from the waist up
and provide a gown that opens in the front.
*7. Listen carefully for the heartbeat. Count the pulse for
1 full minute. Note any irregularities in rhythm and
volume.
Total minutes: _____________
10
269
Copyright© 2011, 2007, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Procedure 31-5 Obtain VItal Signs
Documentation in the Medical Record:
A patient comes to the office today complaining that he has had pain in the left lower abdominal quadrant for
3 weeks. The patient also complains of nausea after eating. The patient denies any constipation or diarrhea.
Obtain an apical pulse and document the case using the SOAPE format.
5:
0:
Comments:
Points earned - - - - - - - -- - - - - + 100 possible points = Score _ _ _ _ _ % Score
Instructor's signature - - - - - -- - - -270
Procedure 31-5 Obtain VItal Signs
Copyright© 2011, 2007, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.