you got get the patients height weight and vital signs from the patients and you got get all the measurements
Measuring a Patients Vital Signs
Soon after a patient arrives on the nursing unit you should begin your nursing assessment.
You should take several measurements to establish a baseline for further observations of that patient.
Among these measurements are height, weight, and vital signs.
After completing this lesson, you should be able to:
Cite from a list, three reasons why patients are weighed.
Cite from a list, six principles related to weighing patients.
Match terms related to body temperature with the correct definition.
Cite from a list, the converted Fahrenheit to Centigrade temperature or vice versa.
Identify patients who are at risk of hypothermia.
Soon after a patient arrives on the nursing unit you should begin your nursing assessment. You should take several measurements to establish a baseline for further observations of that patient. Among these measurements are height, weight, and vital signs.
After completing this lesson, you should be able to:
• Cite from a list, three reasons why patients are weighed.
• Cite from a list, six principles related to weighing patients.
• Match terms related to body temperature with the correct definition.
• Cite from a list, the converted Fahrenheit to Centigrade temperature or vice versa.
• Identify patients who are at risk of hypothermia.
• Identify methods for obtaining an oral, rectal, and axillary temperature.
• Identify precautions, which must be taken when obtaining an oral, rectal, and axillary temperature.
• Identify anatomical sites where a pulse may be taken.
• Cite from a list, factors which affect the pulse rate.
• Match terms describing a pulse with the correct definition.
• Match terms related to breathing patterns with the correct definition.
• Match terms related to blood pressure with the correct definition.
• Cite from a list, the correct statements relating to a normal adult blood pressure.
• Identify factors, which influence blood pressure values.
• Identify anatomical sites where the blood pressure may be taken.
• Cite from a list, principles related to obtaining the blood pressure.
HEIGHT AND WEIGHT
The patient's height and weight are recorded on admission for several reasons.
a. Diet Management. The patient's ideal weight may be determined. The health care team will also be able to monitor weight loss or gain.
b. Observation of Medical Status. Taking the patient's height and weight may indicate that the patient is overweight, underweight, or is retaining fluids (edema). The health care team can observe changes in weight caused by specific disease processes and determine the effectiveness of nutrition supplements prescribed to maintain weight.
c. Calculation of Medication Dosages. Drug dosage is often prescribed in relation to a patient's weight when a specific blood concentration of the drug is desired. Larger doses may be required in a heavier person.
MEASURING HEIGHT AND WEIGHING THE PATIENT
1. Have the patient stand on the scale with the back to the measuring bar.
2. Ask the patient to stand straight. Lower the bar so that it lightly touches the top of the patient's head.
3. Record the height in inches or centimeters in accordance with local policy.
4. If the patient cannot stand, obtain an approximate height in bed.
a. Have the patient lie on his back and stretch as much as possible.
b. Place a mark on the bottom sheet at the patient's heel and at the top of the patient's head.
c. Measure between these two marks on the taut bottom sheet.
5. Principles related to weighing the patient.
a. Weigh the patient before breakfast, at the same time each day.
b. Use the same scale each time.
c. Ensure that the scale is properly balanced.
d. Weigh the patient in the same amount of clothing each day (i.e., hospital gown or pajamas).
e. Have the patient void before weighing.
Avoid weighing any equipment attached to the patient such as drainage bags or telemetry units. Hold the equipment while actually weighing the patient.
6. A helpless patient may be weighed while lying down on a litter scale. This scale is a sling-type device that looks like a suspended hammock. You will need assistance to place the patient on the scale.
7. Record the patient's weight on the graphic sheet and in the nurses' notes.
Being human, we are homeothermic; we are warm-blooded and maintain body temperature independently of our environment. Our body generates heat as it burns food. It loses heat through the lungs (breathing), through the skin (sweating), and in body discharges (urine, feces, vomitus, or blood). Body temperature is defined as the measure of the heat inside the body: the balance between heat produced and heat lost.
Heat is produced through the metabolism of food (chemically). Food is used as energy by muscles and glands to generate most of the heat in the body. Heat is also gained (physically) from the environment.
During exercise, the muscles become active and the person feels warm. Increasing muscular tone (shivering or gooseflesh) produces heat. The process of digestion also increases body temperature.
When a person becomes angry or excited, the adrenal glands become very active and the body warms as a result of the action of certain body chemicals such as epinephrine.
Cold, shock, and certain drugs, which depress the nervous system, decreases heat production.
The hypothalamus is the body's thermostat. It is located in the central nervous system at the base of the brain. This heat-regulating center in the brain senses any changes in the temperature of blood it receives and makes the appropriate adjustments.
Heat loss occurs through the following:
• Conduction--direct physical contact with an object.
• Convection--when body heat warms surrounding air which rises and is replaced by cooler air.
• Radiation--body heat warms surrounding objects without physical contact.
• Evaporation--perspiration that is removed from the body surface by change from a liquid to a vapor.
NORMAL BODY TEMPERATURE
A thermometer is placed in the patient's mouth to obtain an oral temperature, in the anal canal to obtain a rectal temperature, and in an axilla (armpit) to obtain an axillary temperature. Table 4-1 shows the average normal temperature for well adults at these various body sites.
ORAL RECTAL AXILLARY
98.6°F 99.5°F 97.7°F
37.0°C 37.5°C 36.5°C
Table 4-1. Average, normal temperatures for well adults.
Temperature is measured on the Fahrenheit (F) or the Celsius (C) scale. The average, normal, oral temperature for an adult is 98.6 degrees Fahrenheit or 37.0 degrees Celsius (old term: centigrade).
You can convert Fahrenheit to Celsius or vice versa.
• To convert Fahrenheit to Celsius, subtract 32 and multiply by 5/9.
• To convert Celsius to Fahrenheit, multiply by 9/5 and add 32.
See Table 4-2 for a conversion chart.
44.0º C 93.2º F
Table 4-2. Celsius/Fahrenheit equivalent temperature.
Body temperature may wary by 0.5ºF either way and still be within normal limits.
FACTORS WHICH INFLUENCE NORMAL BODY TEMPERATURE
• Individual metabolism differs. An increase in the emotional state of the patient may increase the temperature.
• Body temperature is usually lowest in the morning and highest in the late afternoon or evening.
• Normal temperature for infants and children is usually higher than the normal adult temperature. At birth, heat-regulating mechanisms are not fully developed, so a marked fluctuation in body temperature may occur during the infant's first year of life.
In some women, ovulation may be signaled by a slight drop in body temperature 12 to 24 hours before a postovulation rise in temperature of about 0.4ºF to 0.8ºF.
TERMINOLOGY RELATED TO BODY TEMPERATURE
Body temperature rises when heat production increases or when heat loss decreases; both may be going on at the same time.
Everyone has a temperature; when the temperature is elevated, then pyrexia or a fever is present. A fever is a symptom of some disorder. It often accompanies illness; usually when the body is fighting an infection. An antipyretic is a fever-reducing agent such as aspirin.
A temperature significantly below normal is called hypothermia. Such temperatures often precede normal death. Hypothermia may occur as a result of overexposure to winter elements or to cold water. Accidental hypothermia is life threatening and must be treated immediately. Clinical hypothermia is often used to perform surgical procedures because the lowered body temperature slows metabolism and thus decreases the need for oxygen.
The patients most at risk of hypothermia are:
• Postoperative patients.
• Newborn infants exposed to room temperatures before their body temperature has stabilized.
• Elderly or debilitated patients.
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