Measuring Weight, Height and Vital Signs

Measuring Weight and Height

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

Guidelines for Weighing Clients Accurately

• The client 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 best before a meal.
• Use the same scale for daily, weekly, and monthly weights.
• Balance the scale at zero (0) before weighing.
• Record weight in kilograms.

Guidelines for Measuring Height Accurately

• The client should not wear shoes or a hat.
• Hair must be flat.
• The client must stand straight with feet touching the back.
• The client must look straight ahead.
• Record height in centimeters.
• Heights get used to calculate certain treatments or medication doses

Vital Signs

• Vital signs show how well the fundamental body processes function.
• Essential body processes include regulation of body temperature, breathing, and heart function.
• The five vital signs of body function are temperature, pulse, respirations, blood pressure, and oxygen saturation (SpO2).

Why Measure Vital Signs

• Vital signs get measured to detect changes in normal body function, to learn about responses to treatments, as part of regular client assessment, and they can signal life-threatening events.
• A person's vital signs vary within certain limits.

When Vital Signs Get Measured

• Vital signs get measured during physical exams, upon admission to a facility, as often as required by the client's condition, before and after surgery, complex procedures/diagnostic tests, after some care measures, and after a fall or other injury.
• They are also measured when medications affect the respiratory or circulatory system, after medication is given to relieve a fever, when complaints of pain, dizziness, light-headedness, feeling faint, shortness of breath, or a rapid heart rate occur or any time the client is not feeling well.
• As stated on the care plan or doctor's orders.
• It's essential to be accurate when measuring, recording, and reporting vital signs.
• Unless ordered otherwise, take vital signs with the client lying or sitting.

Body Temperature

• Body temperature indicates the amount of heat in the body.
• Changes in temperature can indicate illnesses like infection and neurological changes.

Normal Body Temperature Ranges

• Mouth (oral temperature): Average is 37.0°C (98.6°F), with a normal range of 36°C-37.5°C (96.8°F-99.5°F)
• Ear (tympanic temperature): Average is 37.4°C (99.3°F), with a normal range of 35.8°C-38.0°C (96.4°F-100.4°F)
• Underarm (axillary temperature): Average is 36.5°C (97.7°F), with a normal range of 34.7°C-37.3°C (94.5°F-99.1°F)
• Rectum (rectal temperature): Average is 37.5°C (99.5°F), with a normal range of 35.5°C-38°C (95.9°F-100.4°F)
• Different sites for taking temperature: mouth, rectum, armpit (axilla) and tympanic membrane.
• Each site has its own normal range.
• Temperatures above or below the normal range always merit a report.

Types of Thermometers

• Electronic thermometers
  • Some have oral and rectal probes with disposable covers (most accurate)
• Tympanic membrane thermometers
  • Inaccurate if technique isn't correct
• Dot matrix thermometers
• Temperature-sensitive tape

Pulse

• The pulse is the heart's beat felt at an artery as a wave of blood passes through it.
• Normal adult pulse rate: 60-100 beats per minute.
• Report abnormal pulses at once.
• Tachycardia: heart rate of more than 100 beats per minute.
• Bradycardia: heart rate of less than 60 beats per minute.
• Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and pedal pulse are pulse sites on the body

Pulse Rhythm and Force

• The rhythm of the pulse should be regular
• Irregular pulse: Beats are not evenly spaced/skipped
• Force relates to pulse strength.
• A forceful pulse is strong, full, or bounding.
• Hard-to-feel pulses are weak, thready, or feeble.
• Electronic blood pressure equipment can count pulses.
• Assessing pulse rhythm/force needs to be done manually as such information is not given electronically.

Pulse Oximeter

• Oxygen saturation is an % or SpO2 (peripheral capillary oxygen saturation)
• A pulse oximeter measures both the pulse rate and oxygen level in the blood.
• Placed on client's index finger
• Infrared light detects hemoglobin carrying oxygen.
  • It won't read properly with poor circulation or if cold/ impaired.

Respirations

• Count respirations when the person is at rest.
• Check respirations by observing the chest rise and fall.
• To count respirations, watch the chest rise and fall for 30 seconds and multiply the number 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 you are taking the pulse.
  • Keep your fingers or stethoscope over the pulse site.
• Healthy adults have 12-20 respirations per minute.

Abnormal Respirations require you to report:

• Respiratory rate
• Uniformity and depth of respirations (shallow, normal, or deep)
• Respiratory rhythm—regular or irregular
  • Pain or difficulty breathing

Blood Pressure

• Blood pressure (BP) indicates the force exerted against artery walls by blood.
• Blood pressure is controlled by the force of heart contractions, the amount of blood pumped with each heartbeat and how easily the blood flows through the blood vessels.
• Systole refers to the heart pumping blood.
• Diastole refers to the heart at rest.
• Systolic pressure is the 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).
• Systolic pressure is recorded over diastolic pressure.
  • EG: 140/60
• Normal blood pressure ranges:
  • Systolic pressure: 100-140 mm Hg
  • Diastolic pressure: 60-90 mm Hg
• Hypertension: consistent BP more than 140/90.
• Hypotension: BP less than 90/60.
• Report these 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

Lab Reminder

• Bring a watch with a second hand or a digital watch to measure seconds.
• Phones are not allowed.