Chapter 24

Measuring Height, Weight,

and Vital Signs

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 Measuring Weight and Height
(1 of 3)
 Measuring weight and height
 Weight and height are measured on admission to
the agency, and as directed.
 Balance beam scales, chair scales, lift scales,
wheelchair weigh scales, and digital scales are
used

• See textbook procedure: Measuring Height and Weight

• See textbook procedure: Measuring Height: The Client in
Bed

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Measuring Weight and Height
(2 of 3)

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Measuring Height and Weight
(3 of 3)
 Follow these guidelines:
• The client only wears a gown or pyjamas.
• The client voids before being weighed. (If a urine
specimen is needed, collect it at this time.)
• Weigh the client at the same time of day each time.
• Use the same scale for daily, weekly, and monthly
weights.
• Balance the scale at zero (0) before weighing the client.
• Record weight in kilograms.

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 Measuring and Reporting
Vital Signs (1 of 5)
 Vital signs reflect the function of three body
processes essential for life:
 Regulation of body temperature
 Breathing
 Heart function
 The four vital signs of body function are:
Temperature
 Pulse
 Respirations
 Blood pressure
 Some agencies also consider oxygen saturation (SPO ) to
2
be a vital sign.
• This will require you to engage in special training to measure.

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 Measuring and Reporting
Vital Signs (2 of 5)
 A person’s vital signs vary within certain
limits.
 Vital signs:
 Are measured to detect changes in normal body
function
 Tell about responses to treatment
 Often signal life-threatening events
 Are part of the assessment process

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 Measuring and Reporting
Vital Signs (3 of 5)
 Vital signs are measured:
 During physical exams
 When the client is admitted to a facility
 As often as required by the client’s condition
 Before and after surgery or complex procedures or
diagnostic tests
 After some care measures
 After a fall or other injury

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 Measuring and Reporting
Vital Signs (4 of 5)
 Vital signs are measured:
 When medications affect the respiratory or circulatory
system
 When there are complaints of pain, dizziness, light-
headedness, feeling faint, shortness of breath, a rapid
heart rate, or not feeling well
 As dictated by the client’s condition or stated on the care
plan or doctor’s orders
 As instructed after the client has been given medication to
relieve a fever

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 Measuring and Reporting
Vital Signs (5 of 5)
 Vital signs show even minor changes in the
person’s condition.
 Accuracy is essential when you measure, record,
and report vital signs.
 Unless otherwise ordered, take vital signs with the
client lying or sitting.
 Report the following at once:
 Any vital sign that is changed from a prior
measurement
 Vital signs above the normal range
 Vital signs below the normal range
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 Body Temperature (1 of 3)
 Body temperature is a balance between the
amount of heat produced and the amount lost
by the body.
 Thermometers are used to measure
temperature.
 Temperature sites are the mouth, rectum, axilla,
and tympanic membrane.
 Each site has a normal temperature range.
• Always report temperatures that are above or below the normal
range.

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 Body Temperature (2 of 3)
 Temperature sites are the mouth, rectum,
axilla, and tympanic membrane.
 Each site has a normal temperature range.
• Always report temperatures that are above or below the normal
range.

 See textbook Table 24.1: Normal Body

Temperature
 See textbook box: Focus on Older Persons: Body
Temperature and Fevers

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 Body Temperature (3 of 3)
 Types of thermometers used:
 Electronic thermometers
• Battery operated
• Some have oral and rectal probes with disposable covers
• Tympanic membrane thermometers
 Dot matrix thermometers
 Temperature-sensitive tape
 Glass thermometers (considered safety hazard
and now rarely used)
 SUPPORT WORKERS ARE NOT AUTHORIZED
TO TAKE RECTAL TEMPERATURES.

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 Pulse (1 of 3)
 The pulse is the beat of the heart, felt at an
artery as a wave of blood passes through the
artery.
 Pulse sites:
• The temporal, carotid, brachial, radial, femoral, popliteal,
posterior tibial, and dorsalis pedis (pedal) pulses are on
each side of the body.
• The radial pulse is used most often.
• The carotid pulse is taken during CPR and other
emergencies.
• The apical pulse is felt over the heart.

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 Pulse (2 of 3)
 The pulse rate is the number of heartbeats or
pulses felt in 1 minute.
• The rate varies for each age group.
 The adult pulse rate is between 60 and 100 beats
per minute.
• See textbook procedure: Taking a Radial Pulse
 Report abnormal pulses to the nurse at once:
• Tachycardia is a heart rate of more than 100 beats per
minute.
• Bradycardia is a heart rate of less than 60 beats per
minute.

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 Pulse (3 of 3)
 Rhythm and force of the pulse
• 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.
• Electronic blood pressure equipment can count pulses.
 They do not give information about pulse rhythm and force.
• You need to feel the pulse to determine rhythm and force.

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 Pulse Oximeter
 A device that measures both the pulse rate
and the oxygen level in the blood
 Placed on the client’s index finger
 Expressed as a % or SpO2 (peripheral
capillary oxygen saturation)

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Slide 16
 Respirations
 Count respirations when the person is at rest.
 Position the person so you can see the chest rise and
fall.
 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.
 To count respirations, watch the chest rise and fall for
30 seconds and then multiply number by 2; if you get
an abnormal result, count for a full minute.
 Healthy adults have12 to 20 respirations per minute.

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 Blood Pressure (1 of 4)
 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.

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 Blood Pressure (2 of 4)
 The systolic pressure is the amount of force
needed to pump blood out of the heart into the
arterial circulation.
 The diastolic pressure is the pressure in the
arteries when the heart is at rest.
 Blood pressure is measured in millimetres (mm) of
mercury (Hg).
• The systolic pressure is recorded over the diastolic
pressure.
• Blood pressure has normal ranges:
 Systolic pressure—100 to 140 mm Hg
 Diastolic pressure—60 to 90 mm Hg

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 Blood Pressure (3 of 4)
 Hypertension is a consistent BP that is more than
140/90 mm Hg.
 Hypotension is a BP that is less than 90/60 mm
Hg.
 Normal BP is below 120/80 mm Hg.
 You need to 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

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 Blood Pressure (4 of 4)
 A stethoscope and a sphygmomanometer are
used to measure blood pressure.
• The sphygmomanometer has a cuff and a measuring
device.
• The following types of sphygmomanometers are used:
 Aneroid type
 Mercury type
 Electronic type
 Blood pressure is normally measured in the
brachial artery.
 Check with your employer if you are expected to
measure blood pressure.

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 Stethoscope
 An instrument used to listen to the sounds
produced by the heart, lungs, and other body
organs
 One use is to measure BP
 Clean well between use on clients to prevent
spread of microbes.

 See textbook Table 24.4: Normal Blood Pressure

Ranges by Age

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Slide 22
 Using a Stethoscope
 Wipe the earpieces and diaphragm with
antiseptic wipes before and after each use.
 Warm the diaphragm in your hand before
touching the client with it.
 Place the earpiece tips in your ears with the
bend of the tips pointing forward.
 Place the diaphragm over the client’s brachial
artery, and hold it in place.
 Prevent noise.

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Slide 23
 Measuring Blood Pressure
 Measuring BP is a delegated act in some
work places.
 If you are expected to take a BP, ensure:
 Your employer allows you to perform this
procedure.
 The procedure is in your job description.
 You have received special training.
 You have reviewed the procedure with a nurse.
 A nurse is available to answer questions and
supervise you.

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Slide 24