section name header

Purpose ⬇

Nursing Procedure 3.7

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Assessment should focus on the following:

Nursing Diagnoses ⬆ ⬇

Nursing diagnoses may include the following:

Outcome Id ⬆ ⬇

Outcome Identification and Planning

Desired Outcomes navigator

Sample desired outcomes include the following:

Special Considerations in Planning and Implementation

General navigator

If the client cannot stand independently for a long enough period to safely measure weight, consider alternate methods, such as chair or bed scales. Use the same scale at approximately the same time of day for each daily weight to ensure the best basis for comparison and trending over time. Always note the type of equipment used to obtain weight measurement so that the same equipment is used for future weights.

Pediatric navigator

Weigh infants and small toddlers on pediatric scale for accuracy.

Geriatric navigator

Anticipate need for assistant to help client in ambulation to scale or movement to chair scale. Be alert for orthostatic hypotension, a common finding in older adults.

Delegation navigator

Weight assessment can be performed by unlicensed personnel if risk to client is minimal and if client is able to ambulate safely. The nurse should perform procedure with assistance as needed if client is weak or immobile.

[Outline]

Implementation ⬆ ⬇

ActionRationale
1Explain procedure to client and family.Reduces anxiety; promotes cooperation
2Perform hand hygiene and organize equipment (balance scale to “0” and place close to client’s bed or chair).Reduces microorganism transfer; promotes efficiency
3Remove excess clothing and shoes from client (leave on underwear and gown, or light top and bottom if outpatient). Record clothing being worn for weight.Prevents false increase in weight
Standing or Chair Scale Weight
1Assist client to edge of bed or chair and help to standing positionPlaces client in position to step onto scale
2Assist client to step up onto scale (Fig. 3.7) and balance self in a standing position, or assist client into chair scale (Fig. 3.8).Provides for client safety
3As the client stands independently (or is securely sitting in chair), move weights on scale to the level at which the weight lever reads “0,” or note digital reading after stabilization within 1 lb.Obtains weight reading
4Note reading on scale and record promptly.Avoids loss of data and need for reweighing of client
5Assist client back to chair or bed and move scale away from chair or bed.Promotes comfort
6Restore equipment.Prepares for next use
7Perform hand hygiene.Reduces microorganism transfer

Evaluation ⬆ ⬇

Were desired outcomes achieved? Examples of evaluation include:

Documentation ⬆

The following should be noted on the client's record: