Measuring Weight and Height Accurately

Measuring Weight and Height

• Weight and height are measured upon admission and whenever ordered.
• Types of scales include balance beam, chair, lift, wheelchair, and digital scales.

Weighing Clients Accurately

• Clients should wear only a gown or pajamas when being weighed.
• Clients should void before being weighed.
• Weigh clients at the same time of day, wearing similar clothing.
• Morning is the best time to weigh a client before they have a meal.
• Use the same scale for daily, weekly, and monthly weights for consistency.
• Balance the scale at zero before weighing the client.
• Record weights in kilograms.

Measuring Height Accurately

• Heights are used to calculate certain treatments or medication doses.
• Clients must not wear shoes or hats when their height is measured.
• The client's hair must be flat for an accurate height measurement.
• Clients must stand straight with their feet touching the back.
• Clients must look straight ahead.
• Record height in centimeters.

Vital Signs

• Vital signs indicate how well the essential body processes are functioning:
  • Regulation of body temperature
  • Breathing
  • Heart function
• The five vital signs of body function include:
  • Temperature
  • Pulse
  • Respirations
  • Blood pressure
  • Oxygen saturation (SpO2)

Why Measure Vital Signs?

• Vital signs are measured to detect changes in normal body function.
• They provide information about responses to treatment.
• Vital signs are part of regular client assessment.
• They often signal life-threatening events.
• A person's vital signs vary within certain limits.

When to Measure Vital Signs

• During physical exams
• Upon admission to a facility
• As often as required by the client’s condition
• Before and after surgery, complex procedures, or diagnostic tests
• After some care measures
• After a fall or other injury
• When medications affect the respiratory or circulatory system
• After the client has been given medication to relieve a fever
• When there are complaints of pain, dizziness, light-headedness, feeling faint, shortness of breath, or rapid heart rate
• Anytime the client is not feeling well
• As stated on the care plan or doctor’s orders

Important Considerations for Vital Signs

• Accuracy is essential when measuring, recording, and reporting vital signs.
• Unless otherwise ordered, vital signs should be taken with the client lying or sitting.

Body Temperature

• Body temperature is the amount of heat in the body.
• Changes in temperature can indicate various illnesses such as:
  • Infection
  • Neurological changes

Normal Body Temperature Ranges

Body Temperature Sites

• Temperature sites include:
  • Mouth (oral)
  • Ear (tympanic membrane)
  • Armpit (axillary)
  • Rectum (PSW's do not do this)
• Each site has its own normal range.
• Report temperatures that are above or below the normal range.

Thermometers

• Types of thermometers:
  • Electronic thermometers: Some come with oral and rectal probes with disposable covers (most accurate).
  • Tympanic membrane thermometers: Very inaccurate if technique is not done properly.
  • Dot matrix thermometers
  • Temperature-sensitive tape

Pulse

• The pulse is the beat of the heart, felt at an artery as a wave of blood passes through it.
• Pulse Rate:
  • Number of heartbeats felt per minute.
  • Normal adult pulse rate is between 60 and 100 beats per minute.

Pulse Sites

• Pulse sites (two of each, one on each side of the body):
  • Temporal
  • Carotid
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior tibial
  • Pedal pulse

Pulse Abnormalities

• Report abnormal pulses to the nurse at once.
• Tachycardia = heart rate of more than 100 beats per minute.
• Bradycardia = heart rate of less than 60 beats per minute.

Pulse Rhythm and Force

• The rhythm of the pulse should be regular.
  • An irregular pulse occurs when the beats are not evenly spaced, or beats are skipped.
• Force relates to pulse strength.
  • A forceful pulse is described as strong, full, or bounding.
  • Hard-to-feel pulses are described as weak, thready, or feeble.
• While electronic blood pressure equipment can count pulses, rhythm and force are determined manually.

Pulse Oximeter

• Measures both the pulse rate and the oxygen level in the blood.
• Placed on the client’s index finger.
• Infrared light detects hemoglobin carrying oxygen.
  • If placed on fingers with poor circulation will not read properly due to cold or impaired circulation.
• Expressed as a % or SpO2 (peripheral capillary oxygen saturation).

Respirations

• Count respirations when the person is at rest.
• Position the person so you can see the chest rise and fall.
  • To count respirations, watch the chest rise and fall for 30 seconds and then multiply by 2.
  • If respirations are irregular, count for a full minute.
• The person should not know that you are counting respirations.
  • Count respirations right after taking a pulse.
  • Keep your fingers or stethoscope over the pulse site.
• Healthy adults have 12 to 20 respirations per minute.

Abnormal Respirations

• Report the following:
  • Respiratory rate
  • Uniformity and depth of respirations (shallow, normal, or deep)
  • Respiratory rhythm—regular or irregular
  • Pain or difficulty breathing
  • Any respiratory noises
  • Any abnormal respiratory patterns

Blood Pressure

• Blood pressure (BP) is the amount of force exerted against the walls of an artery by the blood.
• Blood pressure is controlled by:
  • The force of heart contractions
  • The amount of blood pumped with each heartbeat
  • How easily the blood flows through the blood vessels
  • The heart is pumping blood during systole
  • The heart is at rest during diastole

Systolic vs Diastolic Pressure

• Systolic pressure is the amount of force needed to pump blood out of the heart.
• Diastolic pressure is the pressure in the arteries when the heart is at rest.
• Blood pressure is measured in millimeters (mm) of mercury (Hg).
  • The systolic pressure is recorded over the diastolic pressure (e.g., 140/60).
• Blood pressure has normal ranges:
  • Systolic pressure—100 to 140 mm Hg
  • Diastolic pressure—60 to 90 mm Hg
• Hypertension is a consistent BP that is more than 140/90.
• Hypotension is a BP that is less than 90/60.

Blood Pressure Measurements

Report the following blood pressure measurements:

• Any systolic measurement at or above 140 mm Hg
• A diastolic pressure at or above 90 mm Hg
• A systolic pressure below 90 mm Hg
• A diastolic pressure below 60 mm Hg

Bring to Lab

• Bring watch with a second hand OR Digital watch that measures seconds
• "You cannot use your phone."