Nursing care
Apical vs radial pulse: when to use each and how to measure a pulse deficit
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
The radial pulse is palpated at the wrist and suits routine checks in adults with a regular rhythm. The apical pulse is auscultated at the fifth intercostal space, midclavicular line, for a full minute and is the most accurate rate. A pulse deficit is the apical rate minus the radial rate, counted at the same time.
Know what each pulse actually measures
The apical pulse is the heartbeat heard directly over the apex of the heart, so it counts every ventricular contraction that produces a sound. The radial pulse is the pressure wave felt at the wrist, so it counts only beats strong enough to reach the periphery. That single difference explains why the apical rate can exceed a simultaneous radial count, while a radial rate higher than the apical rate usually signals a counting error.
Locate the apical pulse at the fifth intercostal space on the left midclavicular line, using the stethoscope diaphragm. The radial pulse is palpated with the pads of two fingers on the thumb side of the inner wrist. In infants and young children, the radial pulse is hard to feel, so apical or brachial sites are preferred.
Choose the site that fits the situation
A radial pulse is appropriate for routine vital signs in a stable adult with a regular rhythm. Best practice is counting for a full minute, especially if any irregularity is felt, and describing the rhythm as regularly irregular or irregularly irregular. The radial site also gives information about strength and equality, which matters during circulation checks.
An apical pulse is indicated when the rhythm is irregular, when the radial pulse is weak or difficult to find, in young children, and before giving many cardiac medicines. Atrial fibrillation is the classic exam example, because rapid irregular beats vary in stroke volume. Count the apical rate for 60 seconds and document the site so trends can be compared accurately.
Measure a pulse deficit correctly
A pulse deficit is present when the apical rate exceeds the radial rate. It means some contractions do not produce enough stroke volume to create a palpable wave at the wrist, which commonly occurs in atrial fibrillation. Subtract the radial count from the apical count to find the deficit, then record both numbers and the difference.
The method usually taught uses two nurses counting simultaneously for one full minute, starting on a shared signal: one listens at the apex while the other palpates the radial artery. One nurse counting the sites one after the other introduces timing error. A new or widening deficit should be reported because it may signal poorly controlled rate or worsening cardiac output.
Check the apical rate before cardiac medicines
Medicines that slow heart rate or conduction, such as digoxin and some rate-control drugs, are commonly preceded by an apical pulse check. The radial count can underestimate the true ventricular rate when the rhythm is irregular, which could lead to giving or withholding a dose on the wrong number. Follow the prescribed parameters and facility policy.
If the apical rate falls below the prescribed threshold, or a previously regular rhythm becomes irregular, hold the dose as directed and notify the prescriber. A deficit alone does not determine whether to give a medicine. Assess for dizziness, low blood pressure, nausea or vision changes, which may suggest toxicity in a patient taking digoxin.
Reason through an original practice item
Imagine a hypothetical patient with atrial fibrillation who is due for a rate-control medicine. The radial pulse is 72 and irregular. Options include giving the dose based on the radial count, taking an apical pulse for a full minute first, or checking the pedal pulse. Taking the apical pulse first is correct because the irregular rhythm makes the radial count unreliable.
Suppose the apical count is 96 while a colleague simultaneously counts 72 at the wrist. The pulse deficit is 24. The distractor of checking the pedal pulse adds a further peripheral site with the same limitation. The nurse documents both rates and the deficit, compares them with the prescribed parameters and reports the finding.
Sources and further reading
Open RN Nursing Skills: Vital signs. Pulse sites, full 60-second counts for irregular rhythms, paediatric sites and apical pulse before cardiac medicines.
Open RN Nursing Skills: Cardiovascular assessment. Apical location at the fifth intercostal space midclavicular line and counting over 60 seconds.
Merck Manual Professional: Atrial fibrillation. Pulse deficit definition and mechanism, irregularly irregular pulse and digoxin for rate control.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our fundamentals practice questions are the closest set to what this page covers.
Common questions
Where is the apical pulse located in adults?
At the fifth intercostal space on the left midclavicular line. Listen with the stethoscope diaphragm and count for a full minute.
What does a pulse deficit of 20 mean?
The heart is contracting 20 more times per minute than the wrist pulse shows, so some beats are too weak to reach the periphery. Report it with both rates.
Can one nurse measure a pulse deficit?
One nurse counting each site in turn is less accurate because the rate can change between counts. Two nurses counting at the same time is preferred.
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