Measurements, Vital Signs, &
Pain Assessment
MEASUREMENTS
Measurements
Why Height & Weight?
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Height
Weight
Head Circumference
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Height & weight reflects a person’s general
level of health
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Children only
Body Mass Index
Waist to Hip Ratio
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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

Increased or Decreased Height
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Increased
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Height
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Gigantism
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–
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Malnutrition
Dwarfism
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Hypopituitary
Achrondroplastic
Height (>2 y/oadulthood)
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Decreased
–
Weight also necessary for dosing of medication
–
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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.
1
Increased or Decreased Weight
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Increased
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Eating Disorder
Mental Illness
Why Head Circumference?
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Assess for brain growth and abnormalities
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Consider cancer
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Measured at birth and each
well child visit and then
yearly until age 6 years.
Hydrocephalus
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
Normal
Overweight
Obesity I
Obesity II
Obesity III
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
>40
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
Head Circumference
Microcephaly
Macrocephaly

Remove shoes and
heavy outer clothing
Record in pounds or
kilograms (often kg for
children)
Record to nearest ¼ lb
Weight (< 2y/o)
–
Malnutrition
Acute or Chronic illness

Weight (2 y/o-adult)
–
Excess Nutrition
Cushing’s syndrome
Fluid retention
Decreased
–
Weight
(Well child visits: 1 wk, &
months 1, 2, 4, 6, 9, 12, 15,
18, 24)
Circle tape at widest point
and record in centimeters
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Above pinna or ears and
around occipital prominence
–
May need to repeat a few
times.
BMI: Body Mass Index
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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
2
Waist to Hip Ratio
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Assesses body fat distribution as an indicator of
health risk
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Waist Circumference/Hip Circumference
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Android obesity with increased risk for obesity related
disease and early mortality.
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
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VITAL SIGNS
Temperature (T)
Pulse (P)
Respiratory Rate (R)
Blood Pressure (BP)
Pain (5th vital sign)
Use of Vital Sign Measurements
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Establish patient’s baseline
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Monitor current condition & identify problems
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Often included
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Pulse ox
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Use of Vital Sign Measurements
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Evaluating Response to Intervention
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Temperature
Pulse
  Blood pressure
  Respiration
  Pain
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
Guidelines for Nursing Practice
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After administration of medications or
interventions to address:
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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
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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:
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Medical history
Prescribed medications and therapies
Baseline vital signs
3
Guidelines for Nursing Practice

Know the minimum required frequency for obtaining
vital sign measurements.
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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.
Temperature Conversions

Convert Fahrenheit to Celsius
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Vital Signs: Temperature
How to Measure
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C = (F -32°) x 5/9
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Convert Celsius to Fahrenheit
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Surface Sites
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F = (9/5 x C) + 32°
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Oral
Axillae
Skin
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Core Sites
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Oral
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Axillary temperature is 0.9°F lower than oral temp
Typically used with newborns and unconscious patients
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.
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How to use:
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
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Axillary
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Oral sublingual site with rich blood supply from carotid
arteries
How to use:
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Rectum
Tympanic Membrane
Temporal Artery
Esophagus
Pulmonary Artery
Urinary Bladder
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Not recommended for fever in infants or young children
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.
4
Skin
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Tempa-Dot
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Chemically impregnated dots that change color at
different temperatures
Typically single use
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Skin
Good for children and patients on isolation
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Higher than oral temps by 0.9 °F (average 99.3-99.6°F )
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
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Tympanic
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Higher (1°F ) than oral temperature.
Senses infrared emissions of the tympanic
membrane
How to use:
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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
Inexpensive, provides continuous reading, safe
and noninvasive, and used for neonates
Disadvantages:
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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
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Infants/Children-Rectal temp higher than adult (100 °F)
Measures temperature from blood vessels in rectal wall
How to use:
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Applied to forehead
or abdomen
Rectal Temperature
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Advantages:
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Temperature sensitive patch/tape
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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
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Advantages
–
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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
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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.
5
Temporal Artery (TAT)
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Enfrared sensor tip detects temperature of cutaneous
blood flow through superficial temporal artery.
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How to Use:
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Temporal Artery (TAT)
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Often used for infants, newborns, and children
Ensure forehead is dry. Place probe flush on skin. Push button
and hold as move across
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Normal Range
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(36 °- 38 °C)
Increased: Fever/Hyperthermia
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> 100.4 °F
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Hypothermia
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< 96.8 °F
Severe:
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< 86.0
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Fever (Pyrexia)
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Mild temp elevation up to 102.2F (39C) enhances
immune system
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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
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Risk of Febrile seizures & dehydration in children
Inaccurate with head covering or hair on
forehead. Affected by diaphoresis and sweating.
What do the Values Mean?
Fever/Hyperthermia
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96.8 – 100.4 °F
Fast, convenient, and comfortable. No risk to
patient or nurse. Reflects rapid change in core
temp. Sensor cover not required.
Disadvantages:
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forehead from center
of hairline and ending
with a touch behind
earlobe. Release button
and clean probe with
alcohol.
What do the Values Mean?
Advantages:
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
Hyperthermia- Additional S & S
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Sweating/Diaphoresis
Skin warm to touch
Inactivity
Confusion
Excessive thirst
Nausea
Muscle cramps
Visual disturbances
Incontinence
 Increased
heart rate
BP
 Decreased
If progresses
 Unconscious
 Nonreactive pupils
 Permanent
neurological
damage
6
What do the Values Mean?
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Hypothermia- Additional S & S
Decreased: Hypothermia
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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
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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.
Skin cool to touch
  Decreased blood
pressure
Voluntary muscle
contraction
  Skin cyanotic
Shivering
Memory loss
If progresses
Poor judgement
–  Cardiac dysrhythmias
–  Loss of consciousness
Decreased heart rate
–  Unresponsive to
Decreased respiratory
painful stimuli
rate
Vital Signs: Pulse
32 - 39
Pulse Basics
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)
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Cardiac output = heart rate x stroke volume
Abnormally slow, rapid, or irregular pulse alters CO
Changes in pulse rate caused by:
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Heart disease/dysrhythmias (decreased CO)
Age
Exercise
Positions changes
Fluid balance (ie hemorrhage)
Medications
Temperature
Sympathetic stimulation
7
Radial & Carotid
Pulse Site
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Radial
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Radial & Carotid Pulse Sites
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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)
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If pulse is regular then count for 30 seconds and
multiply by 2.
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Normal Range
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Infants/Children: See Box 32-3
Abnormal
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Carotid
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Rate (beats/minute)
Place pads of first 2-3 fingers along medial edge
of sternocleidomastoid muscle in neck
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If pulse irregular or weak count for 1 minute at apical site
Adult60-100 bpm
> 100 bpm = Tachycardia
< 60 bpm = Bradycardia
Radial & Carotid Pulse Sites
Radial & Carotid Pulse Sites
  Rhythm
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–  Normal
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Normal
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Abnormal
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 Regular
 Sinus
Strength (Amplitude)
Arrhythmia in children
–  Irregular/Dysrhythmia
 Regularly
irregular
 Irregularly irregular
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Strong (2+)
Weak or thready (1+)
Bounding (3+)
Equality
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Radial: Assess on both sides to determine if equal
Carotid: Never palpate simultaneously. Only one
at a time.
Apical Pulse Site
Apical Pulse Site
  Auscultation

  Often
of heart sounds
used when:
Heart rate is irregular
Peripheral pulse is weak
–  Patient taking medication that affects pulse
rate
–  Patient is < 2 y/o
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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
8
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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.
Vital Signs: Respiratory Rate
32 - 49
Respiratory Rate
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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
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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Rate:
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Adults: 12-20/min
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Bradypnea–>12/min
Tachypnea: >20/min
Apnea
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Infants/children: Table 32-5
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Rhythm:
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Depth:
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Regular
Hypoventilation–shallow respirations
Hyperventilation–deep, rapid respirations
Vital Signs: Blood Pressure
32 - 53
9
Blood Pressure
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:
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Cardiac output
Peripheral vascular resistance
Volume of circulating blood
Viscosity
Elasticity of vessel walls
Blood Pressure

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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
–
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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)
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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
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Blood Pressure

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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.
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–
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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.
10
Recording Blood Pressure
Blood Pressure Classification
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.
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Thigh
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Primarily used to assess for dehydration as cause for
feeling light headed or faint
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Hypotensive
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
<120/<80
120-139/80-89
140-159/90-99
>160/>100
<90 systolic
depending on
baseline BP
Blood Pressure

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
Orthostatics
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>10-15mmHg suggests arterial compression or
obstruction on side with lower pressure
Blood Pressure

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Normal
Pre-hypertension
Hypertension stage 1
Hypertension stage 2

Palpation
–
Used for patients whose arterial pulsations are too
weak to create Korotkoff sounds
–
Assess systolic pressure by palpation, but not
diastolic
Record as 90/-, palpated

–
Ie Blood loss or decreased heart contractility
MAP: Mean Arterial Pressure

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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.
11
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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
Vital Signs: Pulse Oximetry
32 - 67
Pulse Oximetry (SpO2)

Indication of oxygen saturation
Normal range typically 95-100% @ sea level.

May place clip on:

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–
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>92% in Colorado
Finger
Toe
Nose
Earlobe
Vital Signs: Pain Assessment
Include the use of any type of oxygen equipment,
including route and flow rate
, Inc.
Pain
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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
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–
Pharmacologic
Non - pharmacologic
12
Acute Pain Behaviors
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Sample Charting
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
13