Measuring the pulse: radial, apical and the pulse deficit

What it is

Pulse technique is simple, but errors are common: pressing so hard that the pulse disappears, or counting an irregular pulse for too short a time. The radial pulse is the routine site in adolescents and adults. The apical pulse, heard over the apex of the heart, is the most accurate and is assessed before many cardiac medicines. If the apical rate is higher than the radial rate, the difference is the pulse deficit: beats that do not reach the periphery, as can happen in atrial fibrillation with a fast ventricular rate.

Reference values

• Adult at rest: 60 to 100 bpm; rates below 60 or above 100 need prompt follow-up.
• Newborn (0 to 1 month): 100 to 160 bpm; infant: 80 to 140; school age: 70 to 100.
• Amplitude: 0 absent, 1+ weak, 2+ normal, 3+ bounding.
• An irregular rhythm is recorded as regularly irregular or irregularly irregular; irregularly irregular suggests atrial fibrillation.

What you need

• Watch with a second hand or a stopwatch.
• A clean stethoscope for the apical pulse.
• Patient at rest, sitting or lying, with the forearm supported.
• For the pulse deficit: apical auscultation and radial palpation done at the same time.

How to measure it (and why)

1. Let the patient rest a few minutes with the arm supported — exertion and anxiety raise the rate.
2. Feel the radial pulse with the pads of the first three fingers on the thumb side of the wrist, pressing until you feel it — too much pressure blots it out.
3. Count a full minute, especially if the rhythm is irregular — in 15 or 30 seconds irregular beats are missed.
4. Also assess rhythm, amplitude and whether both sides match — the number alone does not show an arrhythmia or a weak pulse.
5. If the radial pulse is irregular or hard to feel, or before a cardiac medicine, listen at the apex for 60 seconds — it is the most accurate count.
6. For the pulse deficit, listen at the apex and feel the radial pulse at the same time, for a minute — so both counts cover the same beats.
7. Record rate, site or method, rhythm and amplitude; if there is a deficit, both rates — this allows comparison with later checks.

How to read it

• The apical pulse is assessed before many cardiac medicines.
• In newborns and children under 5 the radial pulse is hard to feel: use the brachial or apical pulse.
• If the patient is unresponsive, check the carotid pulse first: it is the last to disappear and guides whether CPR is needed.
• Irregular rhythms are more common after 65, but a new irregular rhythm is always reported.

Next step: when to call for help

• Call if the rate is outside the call-out parameters of the order or protocol, or has changed sharply from the trend.
• Call if a new irregular rhythm or a pulse deficit appears.
• Call at once for a fast or slow pulse with symptoms, chest pain or worsening breathlessness.
• No central pulse: activate the resuscitation code per protocol.

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Elsewhere in DurgiPedia

• Arterial pulse: rate, rhythm and amplitude

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Skills (Open RN), 1.3 Vital Signs (Open RN, Wisconsin Technical College System (LibreTexts), 2021); Nursing Skills (Open RN), 9.3 Cardiovascular Assessment (Open RN, Wisconsin Technical College System (LibreTexts), 2021); Hajar R. The Pulse from Ancient to Modern Medicine: Part 3. Heart Views 19(3):117-120 (Heart Views (PubMed Central, open access), 2018).

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