L2P1: Preparing the environment prior to Health Assessment

Question 1

It is required before physical assessment is done depending on what to assess.

Answer 1

Positioning

Question 2

Examples of Positions

Answer 2

1. Dorsal Recumbent
2. Supine (Horizontal Recumbent)
3. Sitting
4. Lithotomy
5. Sims’
6. Prone

Question 3

Equipment & Supplies

Answer 3

1. Flashlight/Penlight
2. Ophthalmoscope
3. Otoscope
4. Percussion (inflexed) Hammer
5. Tuning Fork
6. Cotton Applicators
7. Gloves
8. Tongue Blade (Depressor)

Question 4

Vital Signs

Answer 4

1. Temperature
2. Pulse Rate
3. Respiratory Rate
4. Blood Pressure
5. Pain
6. Oxygen Saturation (Traditional)

Question 5

Things to do when we check Vital Signs

Answer 5

1. Monitor changes in the body.
2. Signs reflect changes in bodily functions.
3. Should be thoughtful and scientific.
4. Evaluated with reference.
5. Must have frequency.

Question 6

Times to assess Vital Signs

Answer 6

1. Upon admission to healthcare agency (baseline data).
2. Changes in patient’s health status or reports of symptoms.
3. Before and after invasive procedure.
4. Before and after administration of medication.
5. Before and after any nursing interventions.

Question 7

Reflects the balance between the heat and the heat loss from the body. It is measured in degrees.

Answer 7

Body Temperature

Question 8

2 Kinds of Body Temperature

Answer 8

1. Core Temperature
2. Surface Temperature

Question 9

Average Body Temperature

Answer 9

Celsius: 36 — 37.5
Fahrenheit: 96.8 — 98.6

Question 10

Below Average Temperature

Answer 10

Adults: < 35.9 C
Children: < 36.4 C

Question 11

Average Temperature

Answer 11

Adults: 36.0 — 37.0 C
Children: 36.5 — 37.5 C

Question 12

Above Average Temperature

Answer 12

Adults: 37.1 — 38.0 C
Children: 37.5 — 38.4 C

Question 13

Fever Temperature

Answer 13

Adults: 38.1 — 42.2 C
Children: 38.5 — 42.2 C

Question 14

Factors that affect the heat production of the body

Answer 14

1. Basal Metabolic Rate (BMR)
2. Muscle Activity
3. Thyroxine Output
4. Hormones
5. Fever

Question 15

Causes of Body Heat Loss

Answer 15

1. Radiation
2. Conduction
3. Convection
4. Evaporation

Question 16

Heat loss that involves surfaces without contact, mostly in the form of infrared rays.

Answer 16

Radiation

Question 17

Transfer of heat from one molecule to a molecule of lower temperature (TSB)

Answer 17

Conduction

Question 18

Dispersion of heat by air currents.

Answer 18

Convection

Question 19

Continous vaporization of moisture from the respiratory tract from the mucose of the mouth and from the skin.

Answer 19

Evaporation

Question 20

The unnoticed heat loss. Accounts 10% of basal heat loss.

Answer 20

Insensible Heat Loss

Question 21

Factors affecting Body Temperature

Answer 21

1. Age
2. Diurnal Variations Circadian Rhythm
3. Exercise
4. Hormones
5. Stress
6. Environment

Question 22

Generally controls the body’s temperature through sensors and receptors.

Answer 22

Hypothalamus