Steps

Rationale/Points of Emphasis

1 Review child’s medical record for baseline data on pulse rate; know range for age (see Appendix A ).

Provides database for comparison. Cardiac output is dependent on heart rate in infants; therefore, heart rate is normally much faster in infants than in older children.

2 Determine site:

• 
  

  In child younger than 2 years, apical auscultation is easier to obtain.

  
  
• 
  

  In older children, apical auscultation may be performed or a peripheral pulse may be palpated.

Yields most accurate values.

3 Calm child, if required. Obtain measurement when child is quiet whenever possible.

Factors such as agitation, crying, pain, and anxiety alter (usually increase) heart rate.

4 Perform hand hygiene.

Reduces transmission of microorganisms.

Steps

Rationale/Points of Emphasis

1 Cleanse stethoscope chest piece with antiseptic wipe before and after examination.

Reduces the spread of microorganisms.

2 Identify site. Palpate the chest wall to determine the point of maximal impulse (PMI):

• 
  

  In children younger than 7 years—just left of the midclavicular line and fourth intercostal space

  
  
• 
  

  In children older than 7 years—left midclavicular line and fifth intercostal space (Figure 120-1)

These positions approximate where heart sounds are best heard at these ages.

caREminder

Optimally, a quiet room and a quiet, cooperative, or sleeping child will contribute to more success when auscultating the heart. Noisy respirations, crying infants, and environmental noises detract from the ability to detect heart sounds and possible murmurs.

Figure 120-1 A: Location of point of maximal impulse in child younger than 7 years. B: Location of point of maximal impulse in child older than 7 years.

3a Place diaphragm of stethoscope over the PMI and count heart rate:

• 
  

  If child’s pulse is regular, count for 30 seconds and multiply by 2.

  
  
• 
  

  If pulse is irregular, count for 1 full minute.

Counting for a full minute gives you a more accurate rate, particularly when a sinus arrhythmia or other irregularity is present.

caREminder

Warm chest piece of the stethoscope by rubbing it in the palm of your hand. A cold stethoscope can cause discomfort or startle the child.

3b Note rhythm and quality of sound. If a murmur is heard, not where it is heard best and what it sounds like.

Murmurs are not uncommon in infants but must be evaluated for potential pathology.

3c Report murmur to the healthcare prescriber.

4 Return equipment to safe storage area. Perform hand hygiene.

Reduces transmission of microorganisms.

5 Record heart rate, site used to obtain, and child’s activity level (e.g., asleep, quiet, crying, fussing) in the medical record.

Makes findings available to other health team members; indicates child’s status and allows comparison of measurements.