Measurements, Vital Signs, & Pain Assessment

MEASUREMENTS

Measurements

Why Height & Weight?  

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Height Weight Head Circumference – 

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Height & weight reflects a person’s general level of health – 

Children only

Body Mass Index Waist to Hip Ratio

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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  

Increased or Decreased Height  

Increased – 

 

Height  

Gigantism

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–  – 

Malnutrition Dwarfism    

Hypopituitary Achrondroplastic

Height (>2 y/oadulthood) – 

Decreased – 

Weight also necessary for dosing of medication

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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.

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Increased or Decreased Weight  

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Increased – 

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Eating Disorder Mental Illness

Why Head Circumference?  

Assess for brain growth and abnormalities –  – 

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Consider cancer

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Measured at birth and each well child visit and then yearly until age 6 years.

Hydrocephalus

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 Normal Overweight Obesity I Obesity II Obesity III

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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

Head Circumference

Microcephaly Macrocephaly  

Remove shoes and heavy outer clothing Record in pounds or kilograms (often kg for children) Record to nearest ¼ lb

Weight (< 2y/o) – 

Malnutrition Acute or Chronic illness  

Weight (2 y/o-adult) – 

Excess Nutrition Cushing’s syndrome Fluid retention

Decreased – 

Weight

(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

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May need to repeat a few times.

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

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Waist to Hip Ratio  

Assesses body fat distribution as an indicator of health risk – 

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Waist Circumference/Hip Circumference –  – 

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Android obesity with increased risk for obesity related disease and early mortality. 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)

Use of Vital Sign Measurements  

Establish patient’s baseline –  – 

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Monitor current condition & identify problems – 

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Often included – 

Pulse ox –  – 

Use of Vital Sign Measurements  

Evaluating Response to Intervention – 

Temperature Pulse   Blood pressure   Respiration   Pain

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

Guidelines for Nursing Practice  

After administration of medications or interventions to address:  

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

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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

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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.

Temperature Conversions  

Convert Fahrenheit to Celsius – 

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Vital Signs: Temperature

How to Measure  

C = (F -32°) x 5/9

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Convert Celsius to Fahrenheit – 

Surface Sites – 

F = (9/5 x C) + 32°

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Oral Axillae Skin

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Core Sites –  –  –  –  –  – 

Oral    

Axillary temperature is 0.9°F lower than oral temp Typically used with newborns and unconscious patients

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.

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How to use:

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

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Axillary  

Oral sublingual site with rich blood supply from carotid arteries How to use: – 

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Rectum Tympanic Membrane Temporal Artery Esophagus Pulmonary Artery Urinary Bladder

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Not recommended for fever in infants or young children 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.

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Skin  

Tempa-Dot –  – 

Chemically impregnated dots that change color at different temperatures Typically single use  

 

Skin

Good for children and patients on isolation

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Higher than oral temps by 0.9 °F (average 99.3-99.6°F )

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

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Tympanic    

Higher (1°F ) than oral temperature. Senses infrared emissions of the tympanic membrane How to use: – 

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Apply speculum cover. Pull ear up and back for >3y/o & down and back for 100.4 °F

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Hypothermia

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< 96.8 °F Severe:

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< 86.0 – 

Fever (Pyrexia)  

Mild temp elevation up to 102.2F (39C) enhances immune system –  –  – 

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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

Inaccurate with head covering or hair on forehead. Affected by diaphoresis and sweating.

What do the Values Mean?

Fever/Hyperthermia – 

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96.8 – 100.4 °F

Fast, convenient, and comfortable. No risk to patient or nurse. Reflects rapid change in core temp. Sensor cover not required.

Disadvantages: – 

forehead from center of hairline and ending with a touch behind earlobe. Release button and clean probe with alcohol.

What do the Values Mean?

Advantages:

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

Hyperthermia- Additional S & S                  

Sweating/Diaphoresis Skin warm to touch Inactivity Confusion Excessive thirst Nausea Muscle cramps Visual disturbances Incontinence

 Increased

heart rate BP

 Decreased

If progresses  Unconscious  Nonreactive pupils  Permanent neurological damage

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What do the Values Mean?  

Hypothermia- Additional S & S

Decreased: Hypothermia –  –  –  –  – 

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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

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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.

Skin cool to touch   Decreased blood pressure Voluntary muscle contraction   Skin cyanotic Shivering Memory loss If progresses Poor judgement –  Cardiac dysrhythmias –  Loss of consciousness Decreased heart rate –  Unresponsive to Decreased respiratory painful stimuli rate

Vital Signs: Pulse

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Pulse Basics

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)

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Cardiac output = heart rate x stroke volume Abnormally slow, rapid, or irregular pulse alters CO

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 – 

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Radial & Carotid Pulse Sites  

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)

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If pulse is regular then count for 30 seconds and multiply by 2.

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Normal Range

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Infants/Children: See Box 32-3 Abnormal

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Carotid  

Rate (beats/minute)

Place pads of first 2-3 fingers along medial edge of sternocleidomastoid muscle in neck

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If pulse irregular or weak count for 1 minute at apical site Adult60-100 bpm

> 100 bpm = Tachycardia < 60 bpm = Bradycardia

Radial & Carotid Pulse Sites

Radial & Carotid Pulse Sites

  Rhythm

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–  Normal

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Normal

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Abnormal

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 Regular  Sinus

Strength (Amplitude)

Arrhythmia in children

–  Irregular/Dysrhythmia  Regularly

irregular  Irregularly irregular

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Strong (2+) 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

Apical Pulse Site

  Auscultation

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  Often

of heart sounds used when:

Heart rate is irregular Peripheral pulse is weak –  Patient taking medication that affects pulse rate –  Patient is < 2 y/o – 

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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

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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.

Vital Signs: Respiratory Rate

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Respiratory Rate          

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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

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.

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Rate: – 

Adults: 12-20/min

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Bradypnea–>12/min Tachypnea: >20/min Apnea

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Infants/children: Table 32-5

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Rhythm:

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Depth:

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Regular Hypoventilation–shallow respirations Hyperventilation–deep, rapid respirations

Vital Signs: Blood Pressure

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Blood Pressure

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:  

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Cardiac output Peripheral vascular resistance Volume of circulating blood Viscosity Elasticity of vessel walls

Blood Pressure  

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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)    

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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. –  – 

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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.

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Recording Blood Pressure

Blood Pressure Classification

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.

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Thigh – 

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Primarily used to assess for dehydration as cause for feeling light headed or faint – 

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Hypotensive

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

100 10-15mmHg suggests arterial compression or obstruction on side with lower pressure

Blood Pressure  

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Normal Pre-hypertension Hypertension stage 1 Hypertension stage 2

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Palpation – 

Used for patients whose arterial pulsations are too weak to create Korotkoff sounds

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Assess systolic pressure by palpation, but not diastolic Record as 90/-, palpated

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Ie Blood loss or decreased heart contractility

MAP: Mean Arterial Pressure  

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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.

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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

Vital Signs: Pulse Oximetry

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Pulse Oximetry (SpO2)

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Indication of oxygen saturation Normal range typically 95-100% @ sea level.

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May place clip on:

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–  –  –  – 

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>92% in Colorado Finger Toe Nose Earlobe

Vital Signs: Pain Assessment

Include the use of any type of oxygen equipment, including route and flow rate

, Inc.

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                      

Sample Charting

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

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