FOUNDATION OF NURSING II

MRS. OYEBODE'S
ASSIGNMENT DUE SATURDAY, 4TH MAY.
Write on the process of:
1. Observation and Recording of
a. Height
b. Weight
c. Anthropometric measures.
2. Collection and observation of specimen and the precautionary measures of;
a. Sputum
b. Vomitus
c. Urine
d. Stool

ANSWER
The nursing process is a systematic, rational method of planning that guides all
nursing actions in delivering holistic and patient-focused care. It is defined as a form
of scientific reasoning and requires the nurse’s critical thinking to provide the best
care possible to the client. The nursing process consists of five steps, summarized by
the acronym ADPIE: Assessment, Diagnosis, Planning, Implementation, and
Evaluation.
Nursing Process for Height, Weight, and Anthropometric Measures;

1. Assessment (Data Collection):

 a) Height:
o Observation: Visually assess the patient's posture for any limitations
(e.g., kyphosis, contractures) that might affect measurement accuracy.
o Measurement:
 Adults: Use a stadiometer, a vertical scale mounted on a wall
with a sliding headboard. Ensure the patient stands barefoot,
with heels together, shoulders relaxed, and head level. Slide the
headboard to touch the top of the head, and record the height in
centimeters (cm) or meters (m).
 Infants/Children: For infants less than 2 years old, use an
infantometer, a flatboard with a fixed headboard and a movable
footboard. Lay the infant supine (on their back), with the head
against the headboard and legs extended. Slide the footboard to
meet the infant's heels, and record the length in cm. For older
children who cannot stand straight, alternative methods might
be used by a healthcare professional.
 b) Weight:

o Observation: Note any recent changes in weight reported by the

patient or evident from their appearance.
o Measurement:
 Use a calibrated digital weighing scale. Ensure the patient is
weighed in light clothing and without shoes. Assist as needed
for safe transfer to and from the scale. Record the weight in
kilograms (kg) or pounds (lbs).
  c) Anthropometric Measures:

o Observation: Visually assess for any body composition changes or

areas of concern relevant to the specific measurements being taken.
o Measurement: Specific techniques and equipment vary depending on
the anthropometric measure being obtained. Some common examples
include:
 Body Mass Index (BMI): Calculated using height and weight.
A formula is used to determine BMI, which helps assess weight
status (underweight, normal weight, overweight, obese).
 Waist Circumference: Measured at the midpoint between the
lowest rib and the iliac crest (upper hip bone) using a non-
stretching tape measure.
 Mid-Upper Arm Circumference (MUAC): Measured on the
upper arm midway between the elbow and shoulder using a
specific MUAC tape. Primarily used in resource-limited
settings to assess malnutrition.
 Skinfold Thickness: Measured using calipers at specific body
sites to estimate body fat percentage. Requires specific training
and technique.

2. Diagnosis:

 Analyze the collected data (height, weight, anthropometric measures)

alongside other assessment findings.
 Identify any potential problems or risks indicated by the measurements (e.g.,
malnutrition, obesity, growth delays).

3. Planning (Developing Goals and Interventions):

 Based on the diagnosis, develop goals and interventions specific to the

patient's needs.
 Interventions might include:

o Nutritional counseling for weight management or to address

deficiencies.
o Exercise programs to promote healthy weight and muscle mass.
o Monitoring growth charts for children.
o Referral to a healthcare professional for further evaluation or
management of identified problems.

4. Implementation (Carrying Out the Plan):

 Implement the planned interventions in collaboration with the patient, other

healthcare team members, and relevant specialists.

5. Evaluation:

 Continuously monitor the patient's response to the interventions and reassess

height, weight, and anthropometric measures at regular intervals.
  Evaluate the effectiveness of the plan and modify it as needed based on the
patient's progress.

Additional Considerations:

 Patient Privacy: Maintain patient privacy during measurements by ensuring a

private environment and proper draping.
 Cultural Sensitivity: Be sensitive to cultural practices related to weight and
body image.
 Documentation: Accurately document all measurements, observations,
interpretations, and interventions in the patient's medical record.