Concept: Assessing Client’s Health

Taking Height and Weight

Weight
Weight is usually measured when a client is admitted to a health agency
Each morning before breakfast
Scales measure in pounds (lb) or kilogram (kg)
One Kilogram is equal to 2.2 pounds.

When accuracy of measuring weight is essential, use:

= the same scale each time,
= take the measurements at the same time each day, and
= make sure client has on a similar kind of clothing and no footwear

To ensure you take reliable measurements using body weight scales you must:
Zero the scales before the client steps onto them
Ask the client to remove any ‘heavy’ items from their pockets (key’s, wallets etc) and remove any heavy
items of clothing or apparel (big jackets, shoes, woolen jerseys etc)

Ensure you note the clients state and time of day for testing to ensure any subsequent tests can be
taken under identical conditions (check state of hydration, food consumed recently etc)
When measuring weight – ask client to look straight ahead and stay still on the scales. Wait for the
needle/digital screen to settle before recording the measurement

Height
When taking measurements of height you must:
Ask your client to remove their shoes prior to taking the measurement

Ask your client to stand with their back to the wall and look directly forward.
The back of their feet, calves, bottom, upper back and the back of their head should all be in contact
with the wall.
They should be positioned directly underneath the drop down measuring device.

Lower the measuring device until it rests gently on the top of your clients head and record the
measurement
Monitoring a client’s VITAL SIGNS should not be an automatic or routine procedure;
it should be a thoughtful, scientific assessment

Vital signs (often shortened to just vitals) are used to measure the body’s basic functions
Objectives:
a. to establish baseline data against which to compare future
measurements
b. to detect actual and potential problems

It is also taken to help assess:

= the general physical health of a person,
= give clues to possible diseases, and
= show progress toward recovery.

The normal ranges for a person’s vital signs vary with:

= age
= weight
= gender, and
= overall health

There are four primary vital signs:

1. body temperature
2. blood pressure
3. pulse (heart rate) and
4. respiratory rate (breathing rate)

However, depending on the clinical setting these may include other measurements called the "fifth vital
sign" or "sixth vital sign".

Fifth vital signs

The "fifth vital sign" may refer to a few different parameters.
Pain is considered a standard fifth vital sign.
Pain is measured on a pain scale based on subjective patient reporting and may be unreliable.

Other "fifth vital signs" include:

= Glasgow Coma Scale
= Pulse Oximetry
 = Blood Glucose level

Sixth vital signs

There is no standard "sixth vital sign"; its use is more informal and discipline-dependent than the above.

Times to assess vital signs:

1. On admission to a health care agency to obtain baseline data
2. When a client has a change in health status or report symptoms such as chest pain or feeling hot or
faint
3. Before and after surgery or an invasive procedure

4. Before and after the administration of a medication that could affect the respiratory or cardiovascular
systems: (ex: before giving digitalis preparation)
5. Before and after any nursing intervention that could affect the vital signs (ex: ambulating a client who
has been on bed rest)
Body Temperature

Definition of related terms:

Body temperature is maintained through a balance of the heat produced and the heat lost from the
body.
Measured in heat units called degrees.

Heat balance- when the amount of heat produced by the body equals the amount of heat lost.
As long as heat production and heat loss are properly balanced, body temperature remains constant.

Factors contributing to heat production (and temperature rise)

1. Basal Metabolic Rate (BMR)
- Is the rate of energy utilization in the body required to maintain essential
activities such as breathing
- BMR decrease with age
- the younger the person, the higher the BMR

2. Muscle activity
- shivering increases the metabolic rate
3. Thyroxine output
- increase thyroxine output increases the rate of cellular metabolism
throughout the body (chemical thermogenesis)

4. Epinephrine, norepinephrine, and sympathetic stimulation/stress response

 - these hormones directly affect liver and muscle cells, thereby
increasing cellular metabolism
5. Fever increases cellular metabolic rate and thus increases the body’s
temperature

Factors contributing to heat loss (and temperature fall)

1. Radiation = the transfer of heat from the surface of one object to the surface of another
without contact between the two objects, mostly in form of infrared rays.

2. Vaporization
= is continuous evaporation of moisture from the respiratory tract and from mucosa of
the mouth and from the skin.
= a continuous and unnoticed water loss is called insensible water loss, and the
accompanying heat loss is called insensible heat loss.

3. Conduction
= is the transfer of heat from one molecule to a molecule of lower
temperature.
= conductive transfer cannot take place without contact between the
molecules and normally accounts minimal heat loss, except, for example, when
a body is immersed in cold water.
= the amount of heat transferred depends on the temperature difference and
the amount and duration of the contact.

4. Convection
= is the dispersion of heat by air currents.
= the body has a small amount of warm air, this warm air rises and is
replaced by cooler air,
= people lose a small amount of heat through convection

Summary:

Two kinds of body temperature:

1. core temperature
2. surface temperature

1. Core temperature is the temperature of the deep tissues of the body, such as the abdominal cavity
and pelvic cavity.
It remains relatively constant

2. Surface temperature is the temperature of the skin, the subcutaneous tissue, and fat.
It rises and falls in response to the environment
Factors affecting body temperature
Age
Diurnal Variations
Exercise
Hormones
Stress
environment

1. Age
= infant is greatly influenced by the temperature of the environment and must be protected from
extreme changes
= children are more variable than adult till puberty
= older people are at risk of hypothermia, (<36oC, or <96.8oF) due to inadequate diet, loss of
subcutaneous fats, lack of activity, etc.

2. Diurnal variations (circadian rhythms)

= Body temperature normally changes throughout the day.
= temperature vary between early morning and late afternoon 1oC (1.8oF)
= highest temperature at 4pm to 6 pm
= Lowest temperature during sleep between 4 am to 6 am.

3. Exercise
= hard work and strenuous exercise can increase body temperature as high as 38.3oC to 40oC
measured rectally.
4. Hormones
= in women, progesterone secretion at time of ovulation raises body temperature about 0.3oC
to 0.6oC above basal temperature.

5. Stress
= stimulation of the sympathetic nervous system can increase the production of epinephrine
and norepinephrine, thereby increasing metabolic activity and heat production

6. Environment
= extremes in environmental temperature can affect a person’s temperature regulatory
systems.
= if the temperature is assessed in a very warm room, the temperature will be
elevated
= if the client has been outside the cold weather without suitable clothing the body
temperature may be low
Alterations in body temperature
Two primary alterations in body temperature:
1. Pyrexia (Hyperthermia)
2. Hypothermia
Alterations in body temperature
1. Pyrexia (Hyperthermia, Fever)
= a body temperature above the usual range.
Hyperpyrexia
= A very high fever, such as 41oC (105oF)
Febrile = a person who has fever
Afebrile = a person who does not have fever

Four common types of fever:

Intermittent Fever= the body temperature alternates at regular intervals between periods of fever and
periods of normal or subnormal temperatures. (e.g., with the disease malaria)
Remittent Fever = a wide range of temperature fluctuations(more than 2oC[3.6oF]) occurs over the 24
hour period, all of which are above normal.

3. Relapsing Fever = short febrile periods of a few days are interspersed with periods of 1 or 2 days of
normal temperature.
4. Constant Fever = the body temperature fluctuates minimally but always remains above normal. (
Example: this can occur with typhoid fever)

Fever Spike = a temperature that rises to fever level rapidly following a normal temperature and then
returns to normal within a few hours. ( a bacterial blood infection often cause fever spikes)

Elevated temperature that are not a true fever:

Examples:
1. Heat Exhaustion = is a result of excessive heat and dehydration.
Signs of heat exhaustion:
- paleness - fainting
- dizziness - vomiting
- nausea - nausea
- and a moderately increased temperature
(101oF-102oF)

2. Heat Stroke = persons exercising in hot weather, have warm, flushed skin, and often do not sweat.
= They usually have a temperature of 106oF or higher, and may be delirious, unconscious, or having
seizures.
Alterations in body temperature (cont’d)
2. Hypothermia = is a core body temperature below the lower limit of normal.
Three physiologic mechanisms of hypothermia are:
a. excessive heat loss
b. inadequate heat production to counteract heat loss
 c. impaired hypothalamic thermoregulation

Hypothermia may be
= Induced or
= Accidental.

Induced hypothermia
– is the deliberate lowering of the body temperature to decrease the need of
oxygen by the body tissues such as during certain surgeries.

Accidental hypothermia
can occur as a result of:
= exposure to a cold environment
= immersion in cold water
= lack of adequate clothing, shelter, or heat

Assessing body temperature

Most common sites for measuring body temperature:

- Oral
- Rectal
- Axillary
- tympanic membrane, and
- skin/temporal artery

Oral

Rectal Axillary
Tympanic Temporal

Advantages and disadvantages of sites for body temperature measurement

Types of thermometers
Mercury in glass thermometers (Glass thermometer)
Electronic thermometers
Chemical disposable thermometers
Temperature-sensitive tape
Infrared thermometers
Temporal artery thermometers
Digital thermometers
Temperature Scales
Body temperature are measured in degrees on 2 scales:
1. Celsius (centigrade)
2. Fahrenheit
Conversion
To convert from Fahrenheit to Celsius, deduct 32 from the Fahrenheit reading and then multiply by the
fraction 5/9; that is:
C = ( Fahrenheit temperature – 32) X 5/9
Example: 100oF
C = (100 – 32) X 5/9 = (68) x 5/9 = 37.8oC

To convert from Celsius to Fahrenheit, multiply the Celsius reading by the fraction 9/5 and then add 32;
that is:
F = (Celsius temperature X 9/5) + 32
Example: when the Celsius reading is 40:
F = (40 X 9/5) + 32 = (72 + 32) = 104oF
Pulse
Pulse
Pulse is the wave of blood created by contraction of the left ventricle of the heart.

Pulse reflects the heart beat (the pulse rate is the same as the rate of the ventricular contractions of the
heart).

Peripheral pulse
= is a pulse located away from the heart (e.g., in the foot or wrist)

Apical pulse or point of maximal impulse (PMI)

Is a central pulse; located at the apex of the heart

Factors affecting pulse rate:

1. Age 6. hemorrhage (hypovolemia)
2. sex 7. stress
3. exercise 8. position changes
4. fever 9. pathology
5. medication
The rate of pulse is expressed in beats per minute (BPM/bpm).

Pulse sites
A pulse may be measured in nine sites
1. Temporal, where the temporal artery passes over the temporal bone of the head. The site is
superior (above) and lateral to (away from the midline) of the eye.
2. Carotid, at the side of the neck where the carotid artery runs between the trachea and the
sternocleidomastoid muscle

3. Apical, at the apex of the heart. In an adult it is located on the left side of the chest, about 8
cm (3 in) to the left of the sternum (breastbone) and at the fourth, fifth, or sixth intercostal space (area
between the ribs).

4. Brachial, at the inner aspect of the biceps muscle of the arm or medially in the ante-cubital space.
5. Radial, where the radial artery runs along the radial bone, on the thumb side of the inner aspect of
the wrist.
6. Femoral, where the femoral artery passes alongside the inguinal ligament
7. Popliteal, where the popliteal artery passes behind the knees.

8. Posterior tibial, on the medial surface of the ankle where the posterior tibial artery passes behind the
medial malleolus
9. Pedal (dorsalis pedis) where the dorsalis pedis artery passes over the bones of the foot, on an
imaginary line drawn from the middle of the ankle to the space between the big and second toes

Reasons for using specific pulse site

Reasons for using specific pulse site (cont’d)
Assessing pulse
A pulse is commonly assessed by palpation (feeling) or auscultation (hearing)
The middle three fingertips are used for palpating all pulse sites except the apex of the heart.
A pulse is palpated by applying moderate pressure with the three middle fingers of the hand
Palpating the radial pulse
Palpating the radial pulse (cont’d)
The pads on the most distal aspects of the fingers are the most sensitive areas for detecting a pulse.
With excessive pressure one can obliterate a pulse, whereas with too little pressure one may not be able
to detect the pulse
The client should assume a comfortable position
Palpating the radial pulse (cont’d)
Before assessing pulse, be aware of:
= any medication that could affect the heart rate
= whether the client has been physically active
= any baseline data about the normal heart rate for the client.
Example: a physically fit athlete may have a heart rate below 60 BPM
= whether a client should assume a particular position
Palpating the radial pulse (cont’d)
When assessing the pulse, the following data should be collected:
- rate
- rhythm
- volume
- arterial wall elasticity
- presence or absence of bilateral equality
Palpating the radial pulse (cont’d)
Tachycardia = an excessively fast heart rate (e.g., over 100 BPM in an adult)
Bradycardia = a heart rate of less than 60 BPM in an adult.
Pulse rhythm = is the patterns of beats and the intervals between the beats
Dysrhythmia or arrhythmia = a pulse with irregular rhythm

Pulse volume or pulse strength or amplitude = refers to the force of blood with each beat
Elasticity of arterial wall = reflects arterial wall expansibility or deformities.
Respirations

Respirations
Respiration is the act of breathing.
Movements of air (Ventilation) in and out of the lungs:
= Inhalation or inspiration refers to the intake of air into the lungs
= Exhalation or expiration refers to breathing out or the movement of gases from the
lungs to the atmosphere.

Inhalation or inspiration refers to the intake of air into the lungs

Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the
atmosphere.
Inhalation and Exhalation

Two types of breathing:

1. Costal (thoracic) breathing
= involves the external intercostal muscles and other accessory
muscles, such as the sternocleidomastoid muscles.
= it can be observed by the movement of the chest upward and outward

2. Diaphragmatic breathing
 = involves the contraction and relaxation of the diaphragm.
= it is observed by the movement of the abdomen, which occurs as a
result of the diaphragm’s contraction and downward
movement.
Assessing respiration
Before assessing respiration, be aware of the following:
- client’s normal breathing pattern
- the influence of client’s health problems on respirations
- any medications or therapy that might affect respirations
- the relationship of the client’s respirations to cardiovascular function

What to assessed on respiration:

- rate
- rhythm
- quality and effectiveness
Respiratory rate is described in breathes per minute (bpm)

Bradypnea = an abnormally slow respiration

Tachypnea or Polypnea = is an abnormally fast respiration
Apnea = is the absence of breathing

Factors affecting respirations:

Those that increase the rate include:
=exercise (increases metabolism)
=stress (readies the body for fight or flight)
= increased environmental temperature
=lowered oxygen concentration at increased altitudes

Factors that may decrease the respiratory rate include:

= decreased environmental temperature
= certain medications (e.g., narcotics)
= increased intracranial pressure (IICP)

Hyperventilation = refers to very deep, rapid respirations

Hypoventilation = refers to very shallow respirations
Respiratory rhythm = refers to regularity of the expirations and the inspirations
Respiratory quality or character = refers to those aspects of breathing that are different from normal,
effortless breathing.
Blood pressure
Blood pressure apparatus
Stethoscope

Why blood pressure is measured?

 1. to aid in diagnosis and prognosis
2. to ascertain the condition of the circulatory mechanism such as:
a. the working of the valves of the blood vessels
b. the muscular tonus or elasticity of the walls of the blood vessels, and
c. the efficiency of the heart

3. to acquire information about the volume and quality of the blood, and in particular,
its viscosity.
Blood pressure
Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the
arteries.
Two blood pressure measures:
1. systolic pressure
2. diastolic pressure

Systolic pressure = is the pressure of the blood as a result of contraction of the ventricles, that is, the
pressure at the height of the blood wave.
Diastolic pressure = is the pressure when the ventricles are at rest. Diastolic pressure , then, is the lower
pressure, present at all times within the arteries.

Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as fraction: systolic
pressure over the diastolic pressure.
A typical blood pressure for healthy adult is 120/80 mm Hg (pulse pressure of 40)

Pulse pressure = is the difference between the systolic and the

diastolic pressure
Normal pulse pressure is about 40 mm Hg but can be as high as 100 mm Hg during exercise.

A consistently elevated pulse pressure occurs in arteriosclerosis.

A low pulse pressure (e.g., less than 25 mm Hg) occurs in conditions such as severe heart failure

Factors affecting blood pressure

-Age -Medications
-Exercise -Emotions (Stress)
-Race -Gender (sex)
-Obesity -Diurnal Variations
(climate)
-Disease process

Hypertension = a blood pressure that is persistently above normal

Primary hypertension = an elevated blood pressure of unknown cause
Secondary hypertension = an elevated blood pressure of known
cause

Hypotension = is a blood pressure that is below normal

Orthostatic hypotension = is a blood pressure that falls when
the client sits or stands.
Assessing blood pressure
Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a stethoscope

Blood pressure cuffs comes in various sizes because the bladder must be the correct width and length
for the client’s arm.
If the bladder is too narrow, the blood pressure reading will be erroneously elevated
If the bladder is too wide the reading will be erroneously low.
Blood pressure sites
The blood pressure is usually assessed in the client’s upper arm using the brachial artery and a standard
stethoscope
Methods in taking blood pressure
Blood pressure can be assessed :
1. Directly (invasive monitoring) measurement involves the insertion of a catheter into
the brachial, radial, or femoral artery.
= arterial pressure is represented as wave forms in monitor
= the pressure reading is highly accurate

2. Noninvasive indirect methods

a. auscultatory = with the use of stethoscope and a
sphygmomanometer
b. palpatory = sometimes used when Korotkoff’s sounds cannot be heard and
electronic equipment to amplify the sounds is not available, or to prevent misdirection
from the presence of an auscultatory gap.

Korotkoff’s sounds:
Phase 1- the pressure level at which the first faint, clear tapping or thumping sounds are heard. This
sounds gradually become more intense. To ensure that they are not extraneous sounds. The nurse
should identify at least two consecutive tapping sounds. The first tapping sound heard during deflation
of the cuff is the systolic blood pressure

Phase 2 – the period during deflation when the sounds have a muffled, whooshing, or swishing quality.
Phase 3 – the period during which the blood flows freely through an increasingly open artery and the
sounds become crisper and more intense and again assume a thumping quality but softer than in phase
1
Phase 4 – the time when the sounds become muffled and have a soft, blowing quality
Phase 5 – the pressure level when the last sound is heard. This is followed by a period of silence. The
pressure at which the last sound is heard is the diastolic blood pressure in adults

In agencies where the 4rth phase is considered the diastolic pressure, three measures are
recommended (systolic pressure, diastolic pressure, and phase 5). These may be referred to as systolic,
first diastolic, and second diastolic pressures.

Common errors in assessing blood pressure

Equipment:
1. sphygmomanometer = used to measure the blood pressure in the arteries, consists of:
a. flat inflatable rubber bag (bladder) covered with cloth serving as a
cuff.
b. rubber bulb, serving as an air pump, connected to the bag by a rubber
tube
c. needle valve or screw for releasing the air from the bag
d. manometer, or the pressure gauge proper, connected to the bag
by a rubber tube.
2. stethoscope