Introduction to the Role of RN and Components Combined Lectures NURN 155 Exam 1

What are the main purposes of a physical examination?

Gather baseline data, compare findings with the nursing history, identify/confirm nursing problems, make clinical decisions, and evaluate outcomes of care.

What is baseline data and why is it important?

The patient’s initial assessment findings used as a comparison point. It helps the nurse recognize improvement, worsening, or other changes in condition.

What is the difference between subjective and objective data?

Subjective: what the patient reports, such as “My stomach hurts.” Objective: what the nurse observes or measures, such as BP, temperature, swelling, or lung sounds. Your notes specifically emphasize this distinction.

Why compare the physical examination with the nursing history?

To confirm, clarify, or investigate what the patient reported and identify additional problems. Because the nursing history is what the patient tells you, while the physical exam is what you observe and assess. Subjective and objective.

How does physical assessment help the RN make clinical decisions?

The nurse uses assessment findings and patient data to make quick, informed nursing decisions based on how the patient is presenting.

What does evaluating outcomes of care mean?

Reassessing the patient to determine whether interventions worked, the patient improved, or the plan of care needs to change.

What is triage?

Rapidly assessing patients and prioritizing care based on urgency and severity; the most serious conditions are treated first. Choosing which patient to treat first

What is routine screening?

A regular health assessment, such as an annual physical, used to evaluate overall health and detect possible problems early.

What other reasons may a physical examination be performed?

To determine eligibility for health insurance, military service, a new job, or patient admission.

What is a comprehensive assessment?

A thorough assessment of the patient’s overall health, usually including a complete head-to-toe examination.

What is a focused assessment?

An assessment of a specific problem or body system, such as assessing the respiratory system in a patient with shortness of breath.

What is an emergency assessment?

A rapid assessment of life-threatening problems, with immediate attention to ABCs: airway, breathing, and circulation.

What is a time-lapsed assessment?

A reassessment performed after time has passed to identify changes in condition, such as neurological checks every 4 hours.

What characteristics should every nursing assessment have?

It should be purposeful, relevant, prioritized, complete, systematic, factual/accurate, and recorded in a standard manner.

What do purposeful, relevant, and prioritized mean?

Purposeful: performed for a specific reason. Relevant: information relates to the patient’s condition. Prioritized: urgent problems are assessed first.

What do complete, systematic, and factual/accurate mean?

Complete: includes all necessary assessment information. Systematic: follows an organized sequence. Factual/accurate: based on what was actually observed, measured, or reported.

What is cultural competence in nursing?

Providing respectful care while considering the patient’s individual cultural beliefs, values, behaviors, and needs.

What is stereotyping vs. implicit bias?

Stereotyping: assuming characteristics about someone because they belong to a group. Implicit bias: unconscious attitudes or beliefs that may influence care.

What patient factors should nurses consider when providing culturally sensitive care?

Physiologic variations, assigned sex roles, family support, socioeconomic factors, personal space, preferred language, and nutritional habits.

Why are family support and socioeconomic factors important?

Family can affect coping and recovery, while finances, transportation, food access, and healthcare access may affect the patient’s ability to follow the plan of care.

Why are personal space and preferred language important?

Comfort with touch/distance varies between patients, and communication must occur in a way the patient can understand for accurate and safe care.

What is the difference between sexual orientation and gender identity?

Sexual orientation: pattern of attraction to others. Gender identity: a person’s internal sense of gender. The slide gives examples including man, woman, and nonbinary.

How can a nurse create an inclusive environment?

Avoid assumptions, educate yourself, respect the patient’s name and pronouns, maintain privacy, and provide equal patient-centered care.

What is misgendering and why should it be avoided?

Using a gender or pronoun that does not match how the patient identifies. It can damage trust and make the healthcare environment feel disrespectful or unsafe.

What should the nurse prepare before a physical examination?

Assessment priorities, environment, infection control, equipment, patient physical preparation, positioning, psychological preparation, and age-specific needs.

How should the examination environment be prepared?

Provide privacy, adequate lighting, appropriate temperature, enough space, and minimal unnecessary interruptions.

What infection-control measures are important during assessment?

Hand hygiene, appropriate PPE when indicated, and properly cleaned equipment.

How should the patient be physically and psychologically prepared?

Provide appropriate clothing/draping and positioning, explain what will happen, answer questions, maintain privacy, and reduce anxiety.

What examination positions were listed in the lecture?

Standing, supine, Sims’, lithotomy, sitting, dorsal recumbent, prone, and knee-chest.

What are the common purposes of supine, prone, sitting, and lithotomy positions?

Supine: patient on back; useful for anterior-body assessment. Prone: face down; useful for posterior body/back. Sitting: useful for head, neck, chest, lungs, and heart. Lithotomy: back with hips/knees flexed; used for pelvic/genital examination.

What are Sims’, dorsal recumbent, and knee-chest positions?

• Sims’ position: Lie on your side, usually the left side. The top leg is bent forward.

• Dorsal recumbent: Lie on your back with your knees bent and feet flat/supporting you.

• Knee-chest: Rest on your knees and chest, with your butt/hips raised up

How can the nurse organize a physical examination?

Using a head-to-toe sequence or body-system sequence while remaining systematic and organized.

Why should a physical examination be systematic?

An organized sequence reduces the chance of missing important information and makes the assessment more efficient.

What are the four physical assessment techniques?

Inspection → Palpation → Percussion → Auscultation (IPPA)

One important exception: for the abdomen, use:

Inspection → Auscultation → Percussion → Palpation (IAPP)

What is the usual order of physical assessment techniques?

Inspection → Palpation → Percussion → Auscultation (IPPA).

What sequence is used for the abdomen/GI system and why?

Inspection → Auscultation → Percussion → Palpation (IAPP). Auscultation comes before percussion and palpation because touching/tapping the abdomen can alter bowel sounds.

What is inspection?

Careful observation of the patient, mainly using sight, beginning with first patient contact and continuing throughout the examination. Adequate lighting is important.

What senses besides sight may be used during inspection?

Hearing and smell. For example, the nurse may hear coughing/wheezing or notice an unusual odor. Your notes specifically mention using other senses.

What characteristics are commonly observed during inspection?

Size, color, shape, position, movement, and symmetry.

Give examples of findings assessed during inspection.

Compare pupil size, observe skin color, assess body shape/contour, observe positioning, watch chest movement, and compare both sides of the body for symmetry.

What is palpation and what can it assess?

Using touch to assess temperature, turgor, texture, moisture, vibrations, structures, firmness, contour, shape, tenderness, and consistency.

What is the difference between the dorsal and palmar surfaces of the hand?

Dorsal: back of the hand; useful for assessing temperature. Palmar: front/palm of the hand; useful for feeling texture, firmness, contour, and other characteristics.

What is skin turgor?

The skin’s elasticity and ability to return toward its normal position after being gently lifted or pinched.

What is the difference between light and deep palpation?

Light: gentle pressure for superficial findings such as tenderness, texture, or temperature. Deep: firmer pressure used when appropriate to assess deeper structures or organs.

What is percussion?

Tapping the body with the fingertips to produce vibrations and sounds that provide information about underlying tissues.

What does percussion assess?

The location, shape, size, and density of underlying tissues or organs. Different tissues such as air, fluid, and solid tissue produce different sounds.

What is auscultation?

Listening with a stethoscope to sounds produced inside the body.

What is the difference between the diaphragm and bell of a stethoscope?

Diaphragm: high-frequency/high-pitched sounds. Bell: low-frequency/low-pitched sounds.

What characteristics are assessed during auscultation?

Pitch, loudness, quality, and duration.

What is nursing documentation?

The written or electronic legal record of pertinent interactions, assessments, and care involving the patient.

How should physical-assessment findings be documented?

Objectively and specifically. Record what was actually observed or measured and avoid vague generalizations.

What words should nurses avoid when documenting assessment findings?

Vague terms such as “good,” “average,” “normal,” and “sufficient.” Instead, describe the actual finding.

Why should error-prone abbreviations be avoided?

They may be misread or misunderstood and can contribute to healthcare errors.

What are the four formats of documenting an assessment listed in the lecture?

Initial nursing assessment, flowsheets, patient care summaries, and progress notes.

What is the difference between these documentation formats?

Initial assessment: establishes baseline information. Flowsheet: structured documentation for repeated/routine findings. Patient care summary: summarizes important patient information and care.

What is health?

Health involves the whole person. It includes physical health as well as emotional, intellectual, spiritual, environmental, and social well-being.

Why are the human dimensions important in nursing?

The dimensions of health affect one another. A physical illness can also affect a patient’s emotions, relationships, thinking, and ability to function.

What is health promotion?

Health promotion includes actions that help people gain more control over their health and improve their overall well-being.

What is Healthy People 2030?

Healthy People 2030 sets national health goals that are based on data. Its purpose is to improve health and well-being across the United States.

What are Leading Health Indicators?

They are major health issues used to track the nation’s progress. Examples from the lecture include vaccination rates, food insecurity, overdose deaths, insurance coverage, and HIV-status awareness.

What are social determinants of health?

They are conditions in a person’s everyday life that can affect health. Where someone lives, learns, works, and receives care can improve or worsen health outcomes.

How can economic stability affect health?

Income and employment affect whether a person can afford things such as housing, food, medications, and healthcare.

How can a person’s neighborhood affect health?

Safe housing, transportation, clean surroundings, and places to exercise can support health. Unsafe or unhealthy environments can increase health risks.

How can education affect health?

Education can affect employment and a person’s ability to understand health information. Limited health literacy may make it harder to follow healthcare instructions.

How can food access affect health?

A person who cannot consistently obtain enough nutritious food may have a greater risk of poor health and nutrition problems.

How can social and community factors affect health?

Supportive relationships and community involvement can improve well-being. Isolation or discrimination may negatively affect health.

How can access to healthcare affect health?

Insurance, available providers, and quality care can make it easier to prevent, identify, and treat health problems.

What is the difference between disease and illness?

A disease is a pathologic change in the body or mind. Illness is the person’s individual response to or experience of that disease.

What is an acute illness?

An acute illness usually begins quickly and lasts for a relatively short period of time.

What is a chronic illness?

A chronic illness lasts a long time and may cause permanent changes. It may require ongoing care and can have periods when symptoms improve.

What is remission?

Remission is a period when the symptoms of a chronic disease decrease or temporarily disappear.

What models of health promotion and illness prevention are in this lecture?

The lecture covers Maslow’s Hierarchy of Needs, the Health Belief Model, Health Promotion Model, Health-Illness Continuum, Agent-Host-Environment Model, and Stages of Change Model.

What is the order of Maslow’s Hierarchy of Needs?

From lowest to highest: physiological → safety → love/belonging → self-esteem → self-actualization.

What are physiological needs?

These are basic survival needs such as breathing, food, water, sleep, and shelter. They are usually the highest nursing priority.

What are safety needs?

Safety needs involve protection and stability. Examples include physical safety, health, housing, and financial security.

What are love/belonging and self-esteem needs?

Love and belonging involve relationships and connection with others. Self-esteem involves confidence, achievement, and feeling respected.

What is self-actualization?

Self-actualization is reaching personal potential and finding purpose or personal growth.

How does Maslow help nurses prioritize care?

Nurses generally address basic survival needs before higher-level psychosocial needs. A breathing problem would therefore take priority over a self-esteem concern.

What is the Health Belief Model?

It explains why people choose to participate in health behaviors. A person is more likely to act when they believe a health problem is threatening and believe the action will help.

How do benefits and barriers affect the Health Belief Model?

A person is more likely to change when the expected benefit seems greater than the difficulty or barriers involved.

What is an example of the Health Belief Model?

A person may decide to get screened for cancer because they believe they are at risk and believe early detection would benefit them.

What is the Health Promotion Model?

It explains how people interact with their environment while trying to improve their health.

What influences health behavior in the Health Promotion Model?

Past experiences, personal beliefs, knowledge, and relationships can influence whether someone chooses a healthier behavior.

Why are previous experiences important in health promotion?

A positive or negative past experience can affect whether a person wants to continue or repeat a health behavior.

What is the Health-Illness Continuum?

It shows health as something that can change over time. A person may move toward greater illness or toward a higher level of wellness.

Can a person move in both directions on the Health-Illness Continuum?

Yes. Illness or unhealthy behaviors may move someone toward poorer health. Treatment, education, and healthier behaviors can move someone toward wellness.

What is the Agent-Host-Environment Model?

It explains disease as the interaction between an agent, a susceptible host, and the environment.

What are the agent, host, and environment?

The agent is what can cause the disease. The host is the person who can become affected. The environment includes outside conditions that influence exposure.

What is an example of the Agent-Host-Environment Model?

With influenza, the virus is the agent. The patient is the host. Conditions that make the virus easier to spread are part of the environment.

What is the Stages of Change Model used for?

It helps determine how ready a person is to change a behavior. This allows nurses to provide teaching that matches the patient’s readiness.

What is precontemplation?

The person is not planning to change the behavior within the next 6 months.

What is contemplation?

The person recognizes or considers the problem and intends to make a change within the next 6 months.

What is preparation?

The person plans to take action within the next 30 days and may already be making plans to change.

What is the action stage?

The person has started changing the behavior and has maintained the change for less than 6 months.

What is the maintenance stage?

The person has maintained the new behavior for more than 6 months.

What is relapse?

Relapse means returning to an old behavior. It does not always mean the person has to completely start over because they can re-enter the change process at another stage.

What is a risk factor?

A risk factor is something that increases a person’s chance of developing an illness or experiencing an injury.

What is the difference between modifiable and nonmodifiable risk factors?

A modifiable risk factor can be changed, such as smoking or physical activity. A nonmodifiable risk factor cannot be changed, such as age or genetics.

What are the three levels of prevention?

Primary prevention prevents a problem before it develops. Secondary prevention finds disease early. Tertiary prevention helps manage an existing disease and reduce disability.

What is primary prevention?

Primary prevention happens before disease or injury occurs. Examples include vaccinations, health education, and injury-prevention measures.