Ch 33 Body Measurements and Vital Signs

Mensuration

The process of measuring; in patient care, it refers to body measurements such as height, weight, extremity length, and infant circumferences.

Infant and Child Mensurations

Height, weight, and circumferences (head, chest, abdominal) measured to ensure proper growth and development.

Adult Height and Weight Significance

Measured to track abnormal changes indicating disease/disorders and to determine treatments, diagnostic testing, and medication dosages.

The Four Vital Signs

Temperature, pulse, respiration, and blood pressure (TPR and B/P).

The Fifth Vital Sign

Pain (considered as a vital indicator by some medical providers).

Vital Signs Indicators

Body functions showing heat control (temp), heart activity (pulse), breathing quality (respiration), and heart force/blood vessel condition (B/P).

Most Accurate Temperature Routes

Rectal and Temporal Artery (TA) methods.

Least Accurate Temperature Route

Axillary (armpit) method.

Normal Body Temperature Ranges

Aural (Ear): 99.1°F | Axillary (Armpit): 97.6°F | Oral (Mouth): 98.6°F | Temporal Artery/Rectal: 99.6°F.

Febrile

A term used to describe a patient running a fever.

Oral Temperature Contraindications

Infants/small children, patients with respiratory complications/nasal obstructions, recent oral surgery/dental injuries, facial paralysis, or those confused/disoriented.

Normal Adult Pulse Range

60 to 100 beats per minute (bpm).

Factors Affecting Pulse Rate

Exercise/activity, age, gender, size, physical condition, and emotions (fear, anxiety, pain, anger).

Volume (Pulse Quality)

Refers to the force or strength of the pulse

Pulse force is recorded using a four-point scale:

• 3+ Full, bounding

• 2+ Normal/strong

• 1+ Weak, diminished, thready

• 0 Absent/non-palpable

Rhythm (Pulse Quality)

Refers to the regularity of spacing between heartbeats (described as regular, irregular, regularly irregular, or intermittent).

Radial Pulse Site

Located at the wrist; the most frequently used site for measuring an adult's pulse rate.

Brachial Pulse Site

Located at the inner elbow; used to palpate and auscultate blood pressure.

Carotid Pulse Site

Located in the neck; palpated during cardiopulmonary resuscitation (CPR) lifesaving maneuvers.

Femoral, Popliteal, and Dorsalis Pedis Sites

Pulse sites located in the lower body primarily used to evaluate circulation in the lower extremities.

Apical Pulse Measurement

Pulse taken with a stethoscope over the apex of the heart; indicated for infants, small children, and patients with heart conditions or irregular radial pulses.

Why Respirations are Measured Secretly

Counted immediately after the pulse while keeping your hands on the site so the patient believes you are still counting the pulse and does not alter their breathing.

Inspiration and Expiration

The two components that combine to equal one total respiration (also known as inhaling and exhaling).

Dyspnea

Difficult or labored breathing.

Apnea

The complete absence of breathing.

Hyperventilation

Excessively rapid and deep respirations.

Normal Adult Respiration Rate

16 to 20 breaths per minute.

Blood Pressure (B/P)

The fluctuating pressure that blood exerts against the arterial walls as the heart alternately contracts and relaxes.

Systole

Systole is defined by the following characteristics:

• when the heart muscle contracts

• pushing the blood out of the heart and into the large blood vessels of the circulatory system

• the blood goes to all of the organs and tissues of the body

• a person’s blood pressure increases

Diastole

Diastole is defined by the following characteristics:

• when the heart muscle relaxes

• the chambers of the heart fill with blood

• a person’s blood pressure decreases

• the blood returns to the heart from the organs and tissues throughout the body

Auscultatory Gap

The silent interval that sometimes occurs between systolic and diastolic pressures during blood pressure measurement.

Sphygmomanometer

The medical instrument used to measure blood pressure; features an aneroid dial or electronic display and an inflatable cuff.

Essential or Idiopathic Hypertension

An elevated blood pressure that occurs without an apparent, identifiable medical cause.

Normal Adult Blood Pressure

A systolic pressure less than 120 mm Hg AND a diastolic pressure less than 80 mm Hg.

Stage 1 Hypertension

A blood pressure reading with a systolic range of 130–139 mm Hg OR a diastolic range of 80–89 mm Hg.

Stage 2 Hypertension

A blood pressure reading with a systolic of 140 mm Hg or higher OR a diastolic of 90 mm Hg or higher.

Lifestyle Factors Causing Hypertension

Stress, obesity, high salt intake, sedentary lifestyle, and aging.

Medical Conditions Causing Hypertension

Kidney disease, thyroid dysfunction, neurological disorders, and vascular conditions like atherosclerosis or arteriosclerosis.