A registered nurse (RN), licensed practical nurse (LPN), or unlicensed assistive personnel (UAP) may measure heart rate. When the heart rate is measured by the UAP, any variance from previous measurements is reported to the licensed caregiver.
Heart rate is measured to assess the general status of each child within the first hour of admission to an acute care setting.
Monitor heart rate every 4 to 8 hours during acute illness while child is a patient on a general care unit and every 1 to 2 hours in the intensive care unit.
Heart rate is reassessed to monitor response to treatment regimens and as indicated by nursing or medical judgment.
Watch or clock with a second hand or digital readout
Stethoscope
Antiseptic
Assess for associated factors that affect heart rate and quality, including hypoxia, hyperthermia, hypothermia, hypovolemia, hemorrhage, pain, anxiety, crying, and level of activity. Children may normally have a sinus arrhythmia in which heart rate increases with inspiration and decreases with expiration.
Review medical record for medical diagnosis, current medications, or past history of arrhythmias.
Explain to the child and the family what you are going to be doing and why. Use terms appropriate for developmental level. For example, instead of saying, “I am going to take your pulse,” say, “I am going to listen to your heart and count the beats.” If age appropriate, demonstrate on family member, self, or stuffed animal first. Offer the child a chance to manipulate the stethoscope if appropriate as this may decrease anxiety.

Preprocedural Care
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Measuring Heart Rate by Auscultation of Apical Pulse
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