Vital Signs
Measuring Height and Weight
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- » Measuring Height and Weight
Take the Review Test:
Safety
- Determine the patient’s ability to bear his or her own weight and stand safely on a scale. Use a chair or bed scale, if needed.
Equipment
(Roll cursor over items to see labels)
Standing Scale
Sling Scale
Wheelchair Scale
PrintableDelegation
Measurement of a patient’s height and weight can be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:
- Measure the patient’s weight after he or she voids. Weigh the patient on the same scale, at the same time of day, and wearing the same type of clothing each time.
- Use the internal bed scale to measure a patient’s weight according to agency policy, if applicable.
- Report the inability to measure height if a patient is nonambulatory.
Preparation
- Assess the patient’s knowledge of the procedure to measure height and weight.
- Ask the patient to report his or her usual body weight, noting any recent changes in weight. If the patient has lost weight, ask if the weight loss was intentional or unintentional.
- Obtain a complete and thorough nursing history, including social, economic, and psychological factors affecting nutrition. Determine the patient’s current nutritional habits.
- Perform a physical assessment, including an assessment of the condition of the skin, hair, nails, and oral mucosa. Assess muscle mass and strength. Note any mental status changes.
- Review the results of the patient’s relevant laboratory tests, such as albumin or prealbumin.
- Determine which medications and dietary supplements the patient is taking, both over-the-counter and prescribed. Be aware of common drug-drug and drug-nutrient interactions.
Follow-up
- Review the patient’s history and physical findings. Note any abnormal findings or areas of concern.
- Compare the patient’s weight for height to identify a healthy weight.
- Compare normal laboratory values with the patient’s results.
- Monitor the patient's body weight daily or weekly. Note any changes and report to health care provider if there is a sudden increase or decrease in weight.
- Review diet order for the patient and consult with the health care provider if a diet order change is applicable.
Documentation
- Record your assessment findings.
- Notify the health care provider of any abnormal findings.
- Make a referral to the registered dietitian (RD) if necessary.
Review Questions
1. When preparing to measure the height and weight of a newly admitted patient, why would the nurse ask about the patient’s ability to stand?
To determine if a wheelchair should be requested
To determine if the patient is steady enough to stand without assistance- To determines if a bed scale must be obtained to measure the patient’s weight
- To establish how much help the patient will need with personal care
INCORRECT. Use of a wheelchair is determined only after the nurse determines if the patient can’t stand without assistance, and that he or she is able to transfer to a wheelchair.
CORRECT. Before measuring height and weight, the nurse asks about the patient’s ability to stand in order to determine if the patient is steady enough to stand without assistance while having his or her height measured.
INCORRECT. Use of a bed scale is determined only after the nurse determines if the patient can’t stand without assistance or get out of bed.
INCORRECT. Personal care needs of a patient do not come into consideration when measuring weight and height.
2. A nursing assistive personnel (NAP) is preparing to weigh a resident in a skilled nursing facility. The patient is usually weighed in street clothing and socks, with his shoes off. The patient is currently wearing street clothing with shoes and socks. What will the NAP do to ensure that the patient’s weight is correctly measured?
- Take off the patient’s street clothing.
- Take off the patient’s shoes, but leave his socks on.
- Take off the patient’s shoes and socks, and put on slippers.
- Take off the patient’s street clothing and put on a hospital gown and nonskid socks.
INCORRECT. The patient’s street clothing need not be removed. Since the patient is usually weighed in street clothing and socks, the NAP should remove the patient’s shoes and leave his socks on.
CORRECT. Since the patient is usually weighed in street clothing and socks, the NAP should remove the patient’s shoes and leave his socks on.
INCORRECT. The patient need not wear slippers. Since the patient is usually weighed in street clothing and socks, the NAP should remove the patient’s shoes and leave his socks on.
INCORRECT. The patient need not wear a hospital gown and nonskid socks; however, his shoes must be removed and his own socks left on. Since the patient is usually weighed in street clothing and socks, the NAP should remove the patient’s shoes and leave his socks on.
3. Which step must be taken to ensure accurate measurement of a patient’s daily weight?
- Weigh the patient at a different time each day.
- Ask the patient to void before he or she is weighed.
- Ask the patient to list all food and beverages consumed since the last weight measurement was taken.
- Weigh the patient using two different scales, and compare the weights.
INCORRECT. To ensure accurate measurement of a patient’s daily weight, the patient should be weighed at the same time of day, wearing the same clothes, and he or she should be asked to void first.
CORRECT. To ensure accurate measurement of a patient’s daily weight, the patient should be weighed at the same time of day, wearing the same clothes, and he or she should be asked to void first.
INCORRECT. To ensure accurate measurement of a patient’s daily weight, the patient should be weighed at the same time of day, wearing the same clothes, and he or she should be asked to void first. The patient need not need list all food and drink consumed since the last time he or she was weighed.
INCORRECT. To ensure accurate measurement of a patient’s daily weight, the patient should be weighed at the same time of day, wearing the same clothes, and he or she should be asked to void first. The nurse need not weigh the patient with two different scales in order to compare the weights.
4. As the nurse is conducting an admission interview, the patient states, “I’ve lost 30 pounds over the last 4 months.” Which question might the nurse ask to determine if the weight loss was intentional or unintentional?
- “Is your health care provider aware of this weight loss?”
- “Has your weight fluctuated like this before?”
- “Have you been following a specific diet?”
- “Is it easy for you to lose weight?”
INCORRECT. This question will not help determine if the patient’s weight loss was intentional or unintentional. Whether the patient has reported the weight loss to a health care provider is irrelevant.
INCORRECT. This question will not help determine if the patient’s weight loss was intentional or unintentional. It merely asks about the patient’s history of weight loss.
CORRECT. This question will help determine if the patient’s weight loss was intentional or unintentional because it asks the patient to offer a possible explanation for the weight loss.
INCORRECT. This question will not help determine if the patient’s weight loss was intentional or unintentional. It merely asks about the patient’s history of weight loss.
5. For which patient would the nurse instruct nursing assistive personnel (NAP) to weigh a patient with a bed scale?
- Patient with an ostomy device
- Patient with chronic renal failure who receives hemodialysis three times a week
- Patient who is using a walker after knee replacement surgery
- Patient who has heart failure and a consequent inability to bear weight
INCORRECT. A bed scale would not be needed for the patient with an ostomy device. There is no reason why this patient cannot stand on a scale.
INCORRECT. A bed scale would not be needed for a patient with chronic renal failure who receives hemodialysis. If the patient is weak, a chair scale can be used.
INCORRECT. A bed scale would not be needed for a patient who is using a walker after knee replacement surgery. If the patient is unable to stand without assistance, a chair scale can be used.
CORRECT. A bed scale would be needed for a patient with heart failure and a consequent inability to bear weight. The patient is unable to stand without assistance and most likely would not be able to tolerate sitting for a chair weight.
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