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Measurements, Vital Signs, & Pain Assessment
MEASUREMENTS
Measurements
Height Weight Head Circumference
– Children only
Body Mass Index Waist to Hip Ratio
Why Height & Weight?
Height & weight reflects a person’s general level of health – In older adults, height & weight coupled with a
nutritional assessment determine the cause of and treatment for chronic disease or helps to identify those who have difficulty feeding or other dietary issues
– In children, data is used to assess both growth and development Weight also necessary for dosing of medication
Increased or Decreased Height
Increased – Gigantism
Decreased – Malnutrition – Dwarfism
Hypopituitary Achrondroplastic
Height
Height (>2 y/o-adulthood)
– Remove shoes – Place back to scale
or wall – Look straight ahead – Document in
centimeters or inches to nearest 1/8 in.
Length (< 2y/o) – Hold head midline,
push down knees until legs are flat.
2
Increased or Decreased Weight
Increased – Excess Nutrition – Cushing’s syndrome – Fluid retention
Decreased – Malnutrition – Acute or Chronic illness
Consider cancer
– Eating Disorder – Mental Illness
Weight
Weight (2 y/o-adult) – Remove shoes and
heavy outer clothing – Record in pounds or
kilograms (often kg for children)
– Record to nearest ¼ lb Weight (< 2y/o)
– Check calibration, remove all clothing, stay very close to infant so does not fall.
– Record to nearest ½ oz in infants and ¼ lb or 0.1kg for toddlers
Why Head Circumference?
Assess for brain growth and abnormalities – Microcephaly – Macrocephaly
Hydrocephalus
Head Circumference
Measured at birth and each well child visit and then yearly until age 6 years.
– (Well child visits: 1 wk, & months 1, 2, 4, 6, 9, 12, 15, 18, 24)
Circle tape at widest point and record in centimeters
– Above pinna or ears and around occipital prominence
– May need to repeat a few times.
Body Mass Index (BMI)
More accurate estimate of body fat than weight alone.
Weight (kg)/Height (m²) or Weight (lbs)/height (in.²) x 703
Underweight <18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Obesity I 30.0-34.9 Obesity II 35.0-39.9 Obesity III >40
BMI: Body Mass Index
More than than half of U.S. adults are overweight (>25)
More than one quarter of U.S. adults are obese (>30)
These are risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis, sleep apnea, and some forms of cancer
3
Waist to Hip Ratio
Assesses body fat distribution as an indicator of health risk
– Android obesity with increased risk for obesity related disease and early mortality.
Waist Circumference/Hip Circumference – Waist- smallest circumference (in inches) below rib cage
and above iliac crest at end of gentle expiration. – Hip- largest circumference of the buttocks
Android obesity: Men >1.0, Women >0.8
VITAL SIGNS
Vital Signs
Temperature (T) Pulse (P) Respiratory Rate (R) Blood Pressure (BP) Pain (5th vital sign)
Often included – Pulse ox
Use of Vital Sign Measurements
Establish patient’s baseline – On admission to health care facility – Before surgical or invasive diagnostic procedure, transfusion of
blood products, administration of medications that affect cardiovascular, respiratory or temperature control functions
Monitor current condition & identify problems – According to routine schedule ordered by provider – During transfusion of blood products, administration of
medications that affect cardiovascular, respiratory or temperature control functions
– -When pt’s general physical condition changes – When pt reports nonspecific symptoms of physical distress
Use of Vital Sign Measurements
Evaluating Response to Intervention – After administration of medications or
interventions to address: Temperature Pulse Blood pressure Respiration Pain
Guidelines for Nursing Practice
The nurse caring for the patient is responsible for analyzing vital signs &making decisions about interventions
Make sure equipment is functioning and appropriate for the size, age, and condition of the patient
Know each patient’s: – Medical history – Prescribed medications and therapies – Baseline vital signs
4
Guidelines for Nursing Practice
Know the minimum required frequency for obtaining vital sign measurements.
– Appropriately judge whether more frequent assessments are necessary.
Use vital sign measurements to determine indications for medication administration
Document vital signs and communicate significant changes to healthcare provider
Develop teaching plan to instruct pt/caregiver in vital sign assessment and significance of findings.
Vital Signs: Temperature
Temperature Conversions
Convert Fahrenheit to Celsius – C = (F -32°) x 5/9
Convert Celsius to Fahrenheit – F = (9/5 x C) + 32°
How to Measure
Surface Sites – Oral – Axillae – Skin
Core Sites – Rectum – Tympanic Membrane – Temporal Artery – Esophagus – Pulmonary Artery – Urinary Bladder
Oral
Oral sublingual site with rich blood supply from carotid arteries
How to use: – Slide probe cover over BLUE tip probe & place in the posterior
sublingual pocket with mouth completely closed. After beeps eject probe cover.
– Ideally wait 20-30 minutes after patient smoked or ingests hot liquids/foods.
Advantages: Accurate & convenient Disadvantages: Cannot be used if the patient is
unconscious, confused, seizure prone, shaking chills, less than 5 years old, disease/surgery of the mouth, mouth breather, or tachypnic
Axillary
Axillary temperature is 0.9°F lower than oral temp Typically used with newborns and unconscious patients
– Not recommended for fever in infants or young children
How to use: – Slide probe cover over BLUE tip probe and place tip into center
of unclothed axilla. Lower arm and place across patient’s chest. If child- hold child’s arm next to body
Advantages: Safe & accessible for infants & children when environment controlled
Disadvantages: Long measurement time. Lags behind core temp during rapid temperature change. Easily affected by the environment.
5
Skin
Tempa-Dot – Chemically impregnated dots that change color at
different temperatures – Typically single use
Good for children and patients on isolation
Temperature sensitive patch/tape – Applied to forehead
or abdomen
Skin
Advantages: – Inexpensive, provides continuous reading, safe
and noninvasive, and used for neonates Disadvantages:
– Measurements lag behind other sites during temp change, especially hyperthermia. Adhesion impaired by diaphoresis or sweat. Readings affected by environmental temperature. Cannot be used in those with allergies to adhesive
Rectal Temperature
Higher than oral temps by 0.9 °F (average 99.3-99.6°F ) – Infants/Children-Rectal temp higher than adult (100 °F)
Measures temperature from blood vessels in rectal wall How to use:
– Apply gloves, place in Sims position, separate buttocks, & dip probe cover into lubricant. Attach probe with RED tip. Insert lubricated probe cover 1-1.5 inch into rectum. Eject probe cover and wipe probe with alcohol.
– Infants/Children-Insert NO further than 1 inch to avoid perforating rectum May use supine, Sims, or prone over adult’s lap
Rectal Temperature
Advantages: Not influenced by eating, drinking, smoking, or ability of patient to hold probe
Disadvantages: Patient discomfort & time consuming. Lags behind core temp during rapid temperature changes. Contraindicated in pre-term infants, immunosuppressed, and patients with diarrhea or rectal/GI surgery.
Tympanic
Higher (1°F ) than oral temperature. Senses infrared emissions of the tympanic
membrane How to use:
– Apply speculum cover. Pull ear up and back for >3y/o & down and back for <3y/o. Place covered probe tip snugly into ear canal, point speculum towards nose and press button and hold until beeps. Remove and eject cover.
– Make sure patient has been indoors for at least 10 minutes – Use other ear or route if: drainage from ear, ear surgery,
large amount of cerumen, pain from perforation or infection
Tympanic
Advantages – Fast, convenient, safe, reduced risk of injury and
infection, and non-invasive. Provides accurate core reading because eardrum close to hypothalamus; sensitive to core changes. Not affected by food/drink or smoking.
Disadvantages – Requires removal of hearing aids. Only one size.
Inaccuracies reported due to incorrect positioning. Affected by ambient temp devices (incubators, radiant warmers, facial fans). Otitis media and cerumen may distort reading. Contraindicated in ear/TM surgery.
6
Temporal Artery (TAT)
Enfrared sensor tip detects temperature of cutaneous blood flow through superficial temporal artery.
– Often used for infants, newborns, and children How to Use:
– Ensure forehead is dry. Place probe flush on skin. Push button and hold as move across
forehead from center of hairline and ending
with a touch behind earlobe. Release button and clean probe with alcohol.
Temporal Artery (TAT)
Advantages: – Fast, convenient, and comfortable. No risk to
patient or nurse. Reflects rapid change in core temp. Sensor cover not required.
Disadvantages: – Inaccurate with head covering or hair on
forehead. Affected by diaphoresis and sweating.
What do the Values Mean?
Normal Range – 96.8 – 100.4 °F (36 °- 38 °C)
Fever/Hyperthermia – > 100.4 °F
Hypothermia – < 96.8 °F – Severe:
< 86.0
What do the Values Mean?
Increased: Fever/Hyperthermia – Infection or inflammation – Trauma or disease to hypothalamus – Spinal cord injury – Prolonged exposure to sun/ high temperatures – Fluid volume deficit – On medications that decrease body’s ability to
lose heat – Have congenital absence of sweat glands or
serious skin disease that impairs sweating
Fever (Pyrexia)
Mild temp elevation up to 102.2F (39C) enhances immune system
– White blood cell production stimulated – Body decreased iron concentration in blood plasma , suppressing
growth of bacteria – Stimulates interferons, bodies natural virus-fighting substance
Prolonged fever weakens patient by exhausting energy stores, increasing oxygen demands and decreasing fluid volume
– Risk of Febrile seizures & dehydration in children
Hyperthermia- Additional S & S
Sweating/Diaphoresis Skin warm to touch Inactivity Confusion Excessive thirst Nausea Muscle cramps Visual disturbances Incontinence
Increased heart rate Decreased BP
If progresses Unconscious Nonreactive pupils Permanent
neurological damage
7
What do the Values Mean?
Decreased: Hypothermia – Trauma or disease to hypothalamus – Spinal cord injury – Prolonged exposure to cold temperatures – Unintentional exposure to cold (falling through ice
at lake) – Intentional- surgical to reduce metabolic demands
and oxygen requirements
Hypothermia- Additional S & S
Skin cool to touch Voluntary muscle
contraction Shivering Memory loss Poor judgement Decreased heart rate Decreased respiratory
rate
Decreased blood pressure
Skin cyanotic
If progresses – Cardiac dysrhythmias – Loss of consciousness – Unresponsive to
painful stimuli
1. You have delegated vital signs to assistive personnel. The assistant informs you that the client has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to:
A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the client to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature.
32 - 39
Vital Signs: Pulse
Pulse Basics
Pulse is the palpable bounding of blood flow created by ejection of blood into the aorta.
Peripheral pulses felt by palpating arteries lightly against underlying bone or muscles
Provides clinical data regarding the heart’s pumping action (cardiac output) – Cardiac output = heart rate x stroke volume – Abnormally slow, rapid, or irregular pulse alters CO
Pulse Basics
Changes in pulse rate caused by: – Heart disease/dysrhythmias (decreased CO) – Age – Exercise – Positions changes – Fluid balance (ie hemorrhage) – Medications – Temperature – Sympathetic stimulation
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Radial & Carotid Pulse Site
Radial – Place patient’s forearm straight alongside body or
across lower chest or abdomen. If sitting bend elbow at 90°and support
– Place pads of first 2-3 fingers in groove along thumb side (radius)
Carotid Place pads of first 2-3 fingers along medial edge
of sternocleidomastoid muscle in neck
Radial & Carotid Pulse Sites
Rate (beats/minute) – If pulse is regular then count for 30 seconds and
multiply by 2. If pulse irregular or weak count for 1 minute at apical site
– Normal Range Adult60-100 bpm
– Infants/Children: See Box 32-3 – Abnormal
> 100 bpm = Tachycardia < 60 bpm = Bradycardia
Radial & Carotid Pulse Sites
Rhythm – Normal
Regular Sinus Arrhythmia in children
– Irregular/Dysrhythmia Regularly irregular Irregularly irregular
Radial & Carotid Pulse Sites
Strength (Amplitude) – Normal
Strong (2+)
– Abnormal Weak or thready (1+) Bounding (3+)
Equality – Radial: Assess on both sides to determine if equal – Carotid: Never palpate simultaneously. Only one
at a time.
Apical Pulse Site
Auscultation of heart sounds Often used when:
– Heart rate is irregular – Peripheral pulse is weak – Patient taking medication that affects pulse
rate – Patient is < 2 y/o
Apical Pulse Site
Locate angle of Louis and slip finger into second intercostal space
Count to 5th intercostal space and move to midclavicular line
Auscultate with stethoscope & assess rate & rhythm
9
2. You notice that a teenager has an irregular pulse. The best action you should take includes:
A. Read the history and physical. B. Assess the apical pulse rate for one full minute. C. Auscultate for strength and depth of pulse. D. Ask if the client feels any palpations or faintness of breath.
32 - 49
Vital Signs: Respiratory Rate
Respiratory Rate
Assess breathing pattern. Observe chest wall expansion and bilateral
symmetrical movement of thorax. Assess the rate, depth, and rhythm of each
breath. Count for 30 seconds & multiply by 2 if regular
pattern In infants watch abdomen and count full minute
Respiratory Rate
Rate: – Adults: 12-20/min
Infants/children: Table 32-5 – Bradypnea–>12/min – Tachypnea: >20/min – Apnea
Rhythm: – Regular
Depth: – Hypoventilation–shallow respirations – Hyperventilation–deep, rapid respirations
3. A postoperative client is breathing rapidly. You should immediately:
A. Call the physician. B. Count the respirations. C. Assess the oxygen saturation. D. Ask the client if they feel uncomfortable.
32 - 53
Vital Signs: Blood Pressure
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Blood Pressure
Systolic: force of pressure in the walls of the arteries when the (L) ventricle contracts
Diastolic: force of pressure on walls of arteries when the heart is filling
Physiological factors controlling BP: – Cardiac output – Peripheral vascular resistance – Volume of circulating blood – Viscosity – Elasticity of vessel walls
Blood Pressure
Blood Pressure
Allow patient to sit for 5 minutes with feet flat on floor and legs uncrossed. Allow 30 minutes if just smoked or consumed caffeine.
Select appropriate cuff size – Width of the bladder should cover 40% of the upper arm – Length of the bladder should be about 80% of upper arm
circumference (almost long enough to encircle the arm) Cuff too small, the BP will be falsely elevated Cuff too large, the BP will be falsely lowered
Palpate brachial artery and apply cuff to bare arm 1 inch above antecubital space with arrow over brachial artery
Blood Pressure
Place arm at heart level Palpate the radial pulse & inflate cuff until
unable to palpate the radial pulse. Read this pressure on the manometer
& add 30 mmHg to it. Deflate the cuff & wait 15-30 seconds
Blood Pressure
Place the bell or diaphragm lightly over the brachial artery Inflate the cuff rapidly to the level just determined, and then
deflate it slowly at a rate of about 2-3 mm Hg per second. – If you deflate too slowly, you can cause congestion that falsely
increases the blood pressure. – Too fast falsely decreased reading
Note the level at which you hear the sounds of at least two consecutive beats. This is the systolic pressure
Continue to lower the pressure until the sounds disappear. This is the diastolic.
Read both the systolic and diastolic levels to the nearest 2 mm Hg.
11
Recording Blood Pressure
Systolic/Diastolic Record what arm the BP was taken on Blood pressures can normally vary 5-10 mm
Hg in different arms. Subsequent BP’s should be checked in the arm that has the higher value. – >10-15mmHg suggests arterial compression or
obstruction on side with lower pressure
Blood Pressure Classification
Normal <120/<80 Pre-hypertension 120-139/80-89 Hypertension stage 1 140-159/90-99 Hypertension stage 2 >160/>100
Hypotensive <90 systolic depending on
baseline BP
Blood Pressure
Thigh – Use if dressings, casts, double mastectomy,
intravenous catheters, arteriovenous fistulas/shunts surgery, trauma or burn makes upper extremities inaccessible for blood pressure measurement
– With patient in prone position put cuff 1 inch above popliteal artery
– Systolic BP 10-40mmHg higher than UE – Diastolic same as UE
Blood Pressure
Palpation – Used for patients whose arterial pulsations are too
weak to create Korotkoff sounds Ie Blood loss or decreased heart contractility
– Assess systolic pressure by palpation, but not diastolic
– Record as 90/-, palpated
Orthostatics
Primarily used to assess for dehydration as cause for feeling light headed or faint
– Abnormally low BP can be caused form the inability of vessels to compensate for change of position. BP medications, anticholinergics, hypovolemia, and baroreceptor insensitivity are all causes of orthostatic hypotension.
BP measures supine, sitting, standing Have pt supine for 2-3 minutes then take initial BP/
pulse then record after sitting and standing Orthostatic hypotension is a drop in systolic pressure
of >20 mm Hg (or in diastolic blood pressure of >10 mm Hg) and/or increase in pulse of 20bpm
MAP: Mean Arterial Pressure
Approximation of the average pressure in the systemic circulation throughout the cardiac cycle; reflects the components of the cardiac cycle
Will be read on automatic BP cuff and on arterial lines.
12
4. When assessing the blood pressure of a school-age child, using a normal-size adult cuff will affect the reading and produce a value that is:
A. Accurate B. Indistinct C. Falsely low D. Falsely high
32 - 67
Vital Signs: Pulse Oximetry
Pulse Oximetry (SpO2)
Indication of oxygen saturation Normal range typically 95-100% @ sea level.
– >92% in Colorado
May place clip on: – Finger – Toe – Nose – Earlobe
Include the use of any type of oxygen equipment, including route and flow rate
, Inc.
Vital Signs: Pain Assessment
Pain
The assessment of pain is based primarily on subjective data gathered from the patient
Use your OLDCART/OPQRST in gathering information
Pain intensity / rating scale is a good tool to use in assessing pain
What is the patient’s acceptable level of pain Find out if the pain is new Find out what helps or relieves the pain
– Pharmacologic – Non - pharmacologic
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Acute Pain Behaviors
Guarding Grimacing Rubbing/splinting of body parts Stillness Restlessness/reduced attention span Avoidance of social contact or conversation Refusing to eat Vocalization (i.e. moaning, crying) Agitation/striking out Diaphoresis Change in vital signs
Sample Charting
Sample Charting