Assessing Apical Pulse ...Bookshelf ID: NBK553078 PMID: 31971719. Evaluating a patient who presents with cardiac symptoms is a complex and multi-step process. In addition to obtaining a thorough history, a detailed cardiac examination is of paramount importance. In the era where medical technologies advance rapidly, one may think that savvy medical …Located the apical and radial pulse sites. Had the second health care provider palpate the radial pulse while they auscultated the apical pulse. 10. Counted ...The apical pulse is the heartbeat measured at the apex of the heart using a stethoscope. In contrast, a radial pulse is a heartbeat measured at the radial artery in the wrist using the fingertips. The apical pulse is more accurate for detecting irregular heartbeats and measuring heart rate, while the radial pulse is easier and quicker to …Apical Pulse. Apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In infants and young children, the apical pulse is …The apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum and farthest down on the chest wall, usually caused by the LV ...Technique. The brachial pulse can be located by feeling the bicep tendon in the area of the antecubital fossa. Move the pads of your three fingers medial (about 2 cm) from the tendon and about 2–3 cm above the antecubital fossa to locate the pulse. See Figure 3.4 for correct placement of fingers along the brachial artery.In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular line. The location of the Apical pulse. Apical pulse rate is indicated during some assessments, such as when conducting a cardiovascular assessment and when a client is taking certain cardiac medications (e.g., digoxin) (OER #1). At each of the four locations on the chest, a different valve can be heard. (Credit: OpenStax Anatomy and Physiology, CC-BY license) ... Figure 19.17 Apical Pulse Location. The …Cardiac apex (posterior view) Although palpation has largely replaced percussion in patient exams, it is nevertheless still useful. This is especially true when the point of maximal impulse (PMI), also known as the apical impulse, cannot be felt where the apex of the heart is located. The PMI will best be located with the patient in a supine …Aug 3, 2023 · Location, amplitude, and duration of the impulse should be noted at this point. When the apical impulse cannot be palpated, percussion can be a useful option. Under these circumstances, cardiac dullness can occupy a large area, especially if there is a large pericardial effusion making the impulse undetectable. 2.6.5 Carotid Pulse. The carotid pulse (CP) is a pressure signal acquired over the carotid artery as it passes near the surface of the body at the neck. It delivers a pulse signal signifying the variations in arterial blood pressure and volume with each heartbeat. Because of the proximity of the recording site to the heart, the CP signal ...Point of maximal impulse - An excellent place to auscultate heart sounds and apical pulse and is located in the left ... Photo by MedicTests.com on February 23, ...Jan 1, 2022 · Areas where you can take a pulse Apical Pulse. The wrist (which is also called radial pulse): This can be considered the most common location for a doctor to check a pulse. In order to find it, let’s place your fingers on the patient’s wrist, or just under the patient’s thumb. Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.Peripheral Vascular Disease Assessment (Screencast) By Barbara Lawson. Learners use peripheral vascular assessment data to examine characteristics of these four conditions: peripheral arterial disease, deep vein thrombosis, chronic venous insufficiency, and acute arterial occlusion. A matching exercise completes the learning object. Watch Now. Learn how to assess the rate and rhythm of the apical pulse, a landmarked location at the 5th or 4th intercostal space at the left midclavicular line. Find out the steps, tips, and …The apical pulse should always be closer to the midline than the mid-clavicular line. If lateral to the MCL, this suggests cardiac enlargement. In patients with ...Aug 3, 2023 · Location, amplitude, and duration of the impulse should be noted at this point. When the apical impulse cannot be palpated, percussion can be a useful option. Under these circumstances, cardiac dullness can occupy a large area, especially if there is a large pericardial effusion making the impulse undetectable. Print Apical Pulse | Definition, Location & Rate Worksheet 1. Cardiac function is the ability of the heart to pump _____. blood to the lungs. air to the lungs. water to the body.When you assess a pulse point you will be assessing: Rate: count the pulse rate for 30 seconds and multiply by 2 if the pulse rate is regular, OR 1 full minute if the pulse rate is irregular. Always count the apical pulse for 1 full minute. A normal pulse rate in an adult is 60-100 bpm. Strength: grade the strength of the pulse and check the ...Your apical pulse is a pulse point on your chest at the bottom tip of your heart. It lets your provider listen to your heart as it contracts and pumps blood. It can show your heart …A 79-year-old client whose radial pulse is 120 beats/minute. To assess the apical pulse, the nurse should place the stethoscope at which location on the left side of the client's chest? Between the fifth and sixth ribs. A nurse is measuring the apical pulse of a client. The axillary lymph nodes are a collection of 5 groups of lymph nodes found in the axillary region of the upper limb. The axillary region is commonly referred to as the ‘armpit’, although it is a three-dimensional, pyramidal space which changes shape based upon whether the arm is adducted or abducted. The axillary lymph nodes have a ...Jun 16, 2022 · The apical pulse is one of the nine common pulse sites on your body, near your heart. It can be used to assess cardiac function and diagnose certain conditions such as heart disease or an overactive thyroid. Learn how to find your apical pulse, what is the typical range, and what does an unusual rate or deficit mean. Apical pulse is taken at the fifth intercostal space at the left midclavicular line. Your pulse, or heart rate, is an important indicator of health and is the vibration of blood …Palpation the Precordial Cardiac Exam. When palpating for the PMI, your finger pads are more sensitive than finger tips. Along with palpating for near the apex, you should also palpate both lower parasternal, pulmonary, aortic, suprasternal and epigastric regions for a complete exam. Somtimes, it will be difficult to palpate the PMI in certain ... Exposing the chest area at the apical site. Holding the stethoscope's diaphragm against the palm of the hand for a few seconds. Assisting the client to a sitting or reclining position. Holding the stethoscope's diaphragm against the palm of the hand for a few seconds. Prior to administering a heart medication, the nurse takes an apical pulse.Discover how you can use CSS Animation Pulse to add a pop of visual interest to your website. Trusted by business builders worldwide, the HubSpot Blogs are your number-one source f...Feb 2, 2010. Off the top of my head, age will have something to do with the location- newborn babes have the apical impulse at about the 4th ICS rather than the 5th in older children and adults. An abnormal situation like cardiac enlargement will displace the impulse down and left, and the impulse will be palpable at more than one interspace.It is the difference in the apical pulse and the radial pulse. These should be taken at the same time, which will require that 2 people take the pulse. One with a stethoscope and one at the wrist ...The difference between apical and radial pulse is called pulse deficit. If your physician finds any irregularity in apical pulse, they will check for pulse deficit, which requires both apical and radial pulse measurements taken simultaneously. They should be measured for one full minute, with one person signaling the other to start counting. Learn what apical pulse is and how to measure it at the left center of the chest below the nipple. Find out the normal range of apical pulse for different ages and …Learn how to locate and auscultate the apical pulse in different age groups and situations, such as infants, children, adults, and obese people. Find out the technique, tips, and factors to consider when taking …Technique. The brachial pulse can be located by feeling the bicep tendon in the area of the antecubital fossa. Move the pads of your three fingers medial (about 2 cm) from the tendon and about 2–3 cm above the antecubital fossa to locate the pulse. See Figure 3.4 for correct placement of fingers along the brachial artery.Vital Signs – Apical Pulse · Concepts Integration Labs · Lab Descriptions · Resources · Faculty and Staff · Practice Labs Sign-up.A person's pulse can be heard and felt at different locations in the body. The apical pulse refers to the pulse that can be felt or heard when feeling or ...Part of a Nursing assessment, is the assessment of the APICAL PULSE. This video describes how to assess an apical pulse, where to locate / find it using land...Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds. Measure the radial pulse for 1 minute, wait 5 minutes, and then ...Apical constriction is a cell shape change that promotes tissue remodeling in a variety of homeostatic and developmental contexts, including gastrulation in many organisms and neural tube formation in vertebrates. In recent years, progress has been made towards understanding how the distinct cell biological processes that together …Sep 29, 2022 · The temporal pulse point is located in front of the ear toward the temple. This pulse is an ideal place to check in the elderly for vision loss or headaches assessment. The head-to-toe exam of the client should also include the temporal pulse. 6. Apical Pulse. The apical pulse point is a very reliable indicator of true cardiac status. Located the apical and radial pulse sites. Had the second health care provider palpate the radial pulse while they auscultated the apical pulse. 10. Counted ...Dec 5, 2021 · 6. Use your fingers to find the pulse. Put your point and middle finger on the infant's inner bend of the upper arm at the back of the elbow. Press your fingers firmly but gently against the baby's skin to try to feel the pulse. Count the pulse rate of the infant for one full minute for accurate results. Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered …Auscultation of the Apical Pulse. Auscultation of the Cardiac Valves. Health Promotion and Disease Prevention: Considerations and Interventions. Clinical Judgment – Case Study. Key Takeaways. Chapter 5 - Gastrointestinal System. ... At each location, listen as long as you need to complete the assessment, but for at least two to three full cardiac cycles …In the root apical meristem, the cells are produced in two directions. In the shoot apical meristem, cells are only created in one direction. The shoot apical meristem may exist at the tips of plants, as in many dicots, or may start slightly below the soil and generate leaves which grow upward, like most monocots.However, in both groups the …Dec 30, 2023 · Start by asking the patient to take off their shirt. To take the apical pulse, you will need to access the bare chest. 2. Feel the first rib by finding the clavicle. Feel for the clavicle. The clavicle is also called the collarbone. It can be felt at the top of the rib cage. ASSESSING APICAL PULSE DEFINITION A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The middle three fingertips are used for palpating pulse sites except the apex of the heart. A stethoscope is used for assessing apical pulses. (Berman, 2011) PURPOSES: ...The Apical Pulse is taken during a cardiac assessment at the Mitral valve point in the 5th intercostal space at the midclavicular line. Anycardiac arrhyhmia medications will be used as interventions. Apical pulse can determine several different cardiac issues that ma lead to potential increases for thrommosiss ischemias hemorrhages aneur r s or ... 30 Jan 2024 ... Apical pulse, also known as point of maximal impulse (PMI), is the location on the chest where the heart's sounds are loudest and clearest.Palpation the Precordial Cardiac Exam. When palpating for the PMI, your finger pads are more sensitive than finger tips. Along with palpating for near the apex, you should also palpate both lower parasternal, pulmonary, aortic, suprasternal and epigastric regions for a complete exam. Somtimes, it will be difficult to palpate the PMI in certain ... ➢ The apical pulse is taken with a stethoscope. • A stethoscope is an instrument used to listen to the sounds produced by the heart, lungs, and other body ...The normal pulse is the pulse for a healthy adult and was used for comparison with other pulses . A typical pulse wave is shown in Figure 3(a) . In Figure 3 , ① is the shock of left ventricular contraction, ② is the reflected wave, ③ is the incisura by the sudden closing of aortic valve, and ④ was created by the closure of aortic valve ...Determine why assessment of the apical pulse is indicated. Conditions that require assessment of the apical pulse include digitalis therapy, blood loss, cardiac or respiratory disease, or other conditions that affect oxygenation status. Assess factors that may alter the pulse, such as activity and medications. If the client has been recently active, wait 10 to …6. Use your fingers to find the pulse. Put your point and middle finger on the infant's inner bend of the upper arm at the back of the elbow. Press your fingers firmly but gently against the baby's skin to try to feel the pulse. Count the pulse rate of the infant for one full minute for accurate results.Apical location often can be best estimated by observation or palpation of the apex with the patient sitting up, leaning forward, and exhaling. Turning the patient into the left lateral decubitus position improves appreciation of the contour of the apical pulsation, but prolongs the thrust and displaces it laterally.Apical pulse assessment and location demonstration for nurses: Where is the location of the apical pulse? It is found on the left side of the chest in the 5t...The normal apical pulse rate of an adult is 60 to 100 beats. Another common place to take your pulse is the carotid artery, found on the neck between the wind pipe and neck muscle. ... The apical pulse provides information on count, rhythm, strength and quality of the heart. how r u hllo payal Hĺó friends Advertisement Advertisement …S1 and S2 make up sounds heard at the apical pulse which is located at the fifth intercostal space at the left midclavicular line. The apical impulse is the ...Dec 5, 2021 · 6. Use your fingers to find the pulse. Put your point and middle finger on the infant's inner bend of the upper arm at the back of the elbow. Press your fingers firmly but gently against the baby's skin to try to feel the pulse. Count the pulse rate of the infant for one full minute for accurate results. Mar 13, 2019 · This video demonstrates the proper way to take an Apical pulse.Apical pulse is done on the patient's chest with a stethoscope. Without proper placement, the ... Point-of-Care Ultrasonography (POCUS) Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination includes the following: Vital sign measurement. Pulse palpation and auscultation.The apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum and farthest down on the chest wall, usually caused by the LV ...The Apical Pulse is taken during a cardiac assessment at the Mitral valve point in the 5th intercostal space at the midclavicular line. Anycardiac arrhyhmia medications will be used as interventions. Apical pulse can determine several different cardiac issues that ma lead to potential increases for thrommosiss ischemias hemorrhages aneur r s or ... May 24, 2020 - Explore Amy Bowles's board "Apical pulse", followed by 277 people on Pinterest. See more ideas about apical pulse, nurse, pulses. Sep 27, 2017 · The apical pulse is one of the eight common arterial pulse sites. It can be found in the left center of your chest, just below the nipple. It's a reliable and noninvasive way to evaluate cardiac function and measure heart rate in children. Learn how to find it, what are the target rates, and what are the signs of abnormal or irregular heartbeats. The arterial pulse is the abrupt expansion of an artery resulting from the sudden ejection of blood into the aorta and its transmission throughout the arterial system. The impulse that results from left ventricular ejection can be transmitted down the aorta at a velocity 20 times greater than the velocity of the ejected blood bolus. The peak of this arterial pulse is the …More answers. An apical pulse is a pulse taken in the 4th or 5th left intercostal space directly over the apex of the heart. The apical pulse can be auscultated or (in most patients) palpated. In ...The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications. Auscultation of the Apical Pulse. Auscultation of the Cardiac Valves. Health Promotion and Disease Prevention: Considerations and Interventions. Clinical Judgment – Case Study. Key Takeaways. Chapter 5 - Gastrointestinal System. ... At each location, listen as long as you need to complete the assessment, but for at least two to three full cardiac cycles …In this video I demonstrate how to locate the 9 main pulse points on the body. This video will help you easily identify where to palpate for these 9 main pul...For practice, we have made this clip 30 seconds so you will need to multiply it by two to report it as beats per minute (but remember, the most accurate measurement is to count the apical pulse for one minute ). The reported apical rate in Audio clip 3.1 is: 60 bpm (30 x 2) with a regular rhythm. Audio clip 3.1: Counting apical pulse rate. Your apical pulse is a pulse point on your chest at the bottom tip of your heart. It lets your provider listen to your heart as it contracts and pumps blood. It can show your heart rate, rhythm and strength. Learn where to find it, why it's measured, how to take it and what it means for your health. Locations of your pulse There are various pulses that can be felt in different parts of the body: On the wrist of the hand, below the thumb is the radial pulse. In the neck, on both the sides of trachea is the carotid …Implementation of Apical Pulse. Expose left chest. Warm the diaphragm of the stehoscope in the palm of your hand for a inute or two. Locate the apex of the heart by palpating for the fifth intercoastal space at the midclavicular line. List to the heart sounds with the diaphragm of the stehoscope. Count the number of beats for one minute. Answer and Explanation: 1. Become a Study.com member to unlock this answer! Create your account. View this answer. A person's pulse can be heard and felt at different locations in the body. The apical pulse refers to the pulse that can be felt or heard when feeling... See full answer below.Areas where you can take a pulse Apical Pulse. The wrist (which is also called radial pulse): This can be considered the most common location for a doctor to check a pulse. In order to find it, let’s place your fingers on the patient’s wrist, or just under the patient’s thumb.The apical pulse is found at the top of the heart, as often heard through a stethoscope with the patient lying on their left side. The heartbeat consists of two different sounds, often called a “lab-dub,” and each club-dub counts as one beat. Another commonplace to take a pulse is the carotid artery, which is located in the neck, between the wind tube and the neck muscle.Apical Pulse. Apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line. In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular ... The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications. Study with Quizlet and memorize flashcards containing terms like To assess the apical pulse, the nurse should place the stethoscope at which location on the left side of the client's chest?, A group of students are reviewing information about taking an apical-radial pulse. Which information is accurate?, What is the best way for the nurse to promote …An infant is ordered a scheduled dose of Digoxin. The patient’s apical pulse rate is 78 bpm. The nurse would: A. Administer the dose as ordered B. Hold the dose and reassess the apical pulse rate in 1 hour C. Skip this dose but administer the next scheduled dose D. Hold the dose and notify the physician. NCLEX Questions Source ...Looking at the anterior chest, observe for any abnormal pulsations and locate the apical pulse, which should be present at the 5th ICS at the midclavicular line. The apical pulse is the point of maximal impulse. ... Note that the locations for auscultation do not represent where the valves themselves are located. Rather, the locations represent ...Looking at the anterior chest, observe for any abnormal pulsations and locate the apical pulse, which should be present at the 5th ICS at the midclavicular line. The apical pulse is the point of maximal impulse. ... Note that the locations for auscultation do not represent where the valves themselves are located. Rather, the locations represent ...Cardiac Auscultation. Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Hearing-impaired health care practitioners can use amplified stethoscopes. High-pitched sounds are best heard with the diaphragm of the stethoscope. Low-pitched sounds are best heard with the bell.Apical pulse is usually used for infants and children up to 3 years of age. Apical pulse assessment is indicated for clients whose peripheral pulse is irregular and for client with cardiovascular, pulmonary and renal disease. For the pulse location, how to locate the pulse?, and reasons for the using the site, see the table below. A pulse felt or heard over the part of the chest wall that lies over the apex of the heart. In healthy people this is roughly located at the left mid-clavicular ...Apical Pulse. Apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In infants and young children, the apical pulse is …Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.The nine pulse points on the body are important to learn as a nurse or healthcare professional. You'll be using many of these common pulse points during your...Apical Pulse. By Maribeth Blankenheim. In this animated activity, learners practice listening and counting the apical pulse of adults, children, and infants. Watch Now. 208.
Mar 13, 2019 · This video demonstrates the proper way to take an Apical pulse.Apical pulse is done on the patient's chest with a stethoscope. Without proper placement, the ... . Tire air pressure near me
The Apical Pulse is taken during a cardiac assessment at the Mitral valve point in the 5th intercostal space at the midclavicular line. Anycardiac arrhyhmia medications will be used as interventions. Apical pulse can determine several different cardiac issues that ma lead to potential increases for thrommosiss ischemias hemorrhages aneur r s or ... The apical pulse is the heartbeat measured at the apex of the heart using a stethoscope. In contrast, a radial pulse is a heartbeat measured at the radial artery in the wrist using the fingertips. The apical pulse is more accurate for detecting irregular heartbeats and measuring heart rate, while the radial pulse is easier and quicker to …Figure 19.17 Apical Pulse Location. The location where the heart’s mitral valve is best heard when using auscultation with a stethoscope. (Credit: Health Assessment Guide for Nurses by Feng, Bertiz, Agostini. Creative Commons license CC-BY-4.0) 2. Calculate how many seconds it takes from the start of one heart beat to the next. Record: _____ 3. Pulse refers to a pressure wave that expands and recoils the artery when the heart contracts/beats. It is palpated at many points throughout the body. The most common locations to accurately assess pulse as part of vital sign measurement include radial , brachial , carotid, and apical pulse as shown in Figure 9.7.1 The techniques vary …Apical Pulse. Apical pulse is auscultated with a stethoscope over the chest where the heart’s mitral valve is best heard. In infants and young children, the apical pulse is …If the apical pulse is not found at the fifth intercostal space at the left midclavicular line, document the location of the point of maximal impulse. Report ...Determine why assessment of the apical pulse is indicated. Conditions that require assessment of the apical pulse include digitalis therapy, blood loss, cardiac or respiratory disease, or other conditions that affect oxygenation status. Assess factors that may alter the pulse, such as activity and medications. If the client has been recently active, wait 10 to …At each of the four locations on the chest, a different valve can be heard. (Credit: OpenStax Anatomy and Physiology, CC-BY license) ... Figure 19.17 Apical Pulse Location. The location where the heart’s mitral valve is best heard when using auscultation with a stethoscope. (Credit: Health Assessment Guide for Nurses by Feng, Bertiz, Agostini.The palpable left ventricular apical impulse (as shown by the presence of retraction of the chest wall medial to it) is generally analyzed in terms of its location, area, am- plitude, duration, and whether or not it is associated with a definite presystolic hump or distention (atrial kick). While a large area and large amplitude apical impulseAt which location is apical pulse taken? Apex of the heart. advanced principles client status. View this set. At which location is apical pulse taken? Apex of the heart. Client Status Test. View this set. At which location is apical pulse taken? apex of the heart. Midterm review. View this set. At which location is apical pulse taken? Apex of the …Cardiac apex (posterior view) Although palpation has largely replaced percussion in patient exams, it is nevertheless still useful. This is especially true when the point of maximal impulse (PMI), also known as the apical impulse, cannot be felt where the apex of the heart is located. The PMI will best be located with the patient in a supine …Place stethoscope on the site and listen for the lub-dub sound of the heart. ... Accurately pulse in patient chart or electronic medical record with the ...Exposing the chest area at the apical site. Holding the stethoscope's diaphragm against the palm of the hand for a few seconds. Assisting the client to a sitting or reclining position. Holding the stethoscope's diaphragm against the palm of the hand for a few seconds. Prior to administering a heart medication, the nurse takes an apical pulse.Sep 27, 2017 · The apical pulse is one of the eight common arterial pulse sites. It can be found in the left center of your chest, just below the nipple. It's a reliable and noninvasive way to evaluate cardiac function and measure heart rate in children. Learn how to find it, what are the target rates, and what are the signs of abnormal or irregular heartbeats. The apical pulse , in contrast, is a central pulse; that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI) ...Respiration Technique. Leave your fingers in place when you are done counting the pulse, and then begin assessing respiration. Observe the rise and fall of the chest or abdomen. Count for 30 seconds if the rhythm is regular or for a full minute if it is irregular. Report respiration as breaths per minute, as well as whether breathing is relaxed ...Pulse description is a recurrent theme in the vascular examination. There are several common methods including a scale of 0-4 and a scale of 0-2. I prefer the 0-2 scale*: 0 – No pulse can be palpated. 1 – A weaker than normal pulse is palpated. 2 – A normal pulse is palpated. * – If a pulse can be palpated stronger than normal, an ...It’s possible you could see the apical pulse, which would be at the 5th intercostal space, left midclavicular line. Then palpate this same spot for the point of maximum impulse, or PMI - this is the point at which the pulse is the strongest. ... You should hear an S1 and an S2 sound at each location. A-Aortic, 2nd intercostal space, right ...Apical. At the apex of the heart. In an Adult, this located on the left side of the chest just about 3 inches to the left of the sternum and at the 4th, 5th or ....