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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.

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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

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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

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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.

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.

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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.

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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

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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.

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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

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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.

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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.

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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.

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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.

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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

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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