Nursing: A Concept-Based Approach to Learning, Volume 2, 3rd Ed. | Registered Nurse (RN) School Study Aid
The Nursing Process
- ADPIE
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Assessment
- Health History
- Objective Data
- Subjective Data
- Identify
- Determine
- Obtain Information
- Assessment Always Done Before Treatments
Patient Position Overview
- Trochanter Roll
- Trapeze Bar
- Ankle-Foot Orthotic (AFO) Devices
- Fowlers Position
- Supine Position
- Trendelenburg
- Side-Lying Position
- Prone Position
- Sims' Position
- Reposition q2 Hours/Prevent Skin Breakdown
- Confirm Body Alignment
Patient Needs
- Allergy to Banana, Papaya, Chestnuts and Kiwi
- Asthma
- Spina Bifida
- History of Multiple Surgical Procedures
- Call Light within Reach
- Eliminate Physical Hazards
- Leave Items within Reach
- Bed in Low Position
- Side Rails Up
- Patient Safety
- Health Promotion and Maintenance
- Psychosocial Integrity
Maslow's Hierarchy of Needs
- Oxygen, Water, Nutrition
- Body temperature, Elimination, Shelter, Sexual Expression
- Physical Safety
- Physiological Safety
- Affection and Companionship
- Self Respect and Respect for Others
- Fulfillment
Native American Culture
- No Direct Eye Contact
- No Organ Donation
- No Blood Donation
- Strong Handshakes Offensive
- Tribal Shaman
- Navajo Mother Massage Newborn
Arab American Culture
- Touch Only When Same Gender
- May Request Same Gender Healthcare Provider
- Females Avoid Eye Contact with Males
- Males Often Make Decisions
- Muslims
- Infertility Grounds for Divorce
- No Organ Donation
Asian American Culture
- Avoids Direct Eye Contact
- Conflict Avoidance
- Soft Voice Tone
- Males Make Most Decisions
- Feet Considered Dirty
- Hot-Cold Theory of Illness
- Soups and Rice After Birth
Mexican American Culture
- May Avoid Eye Contact with Authoritative Figures
- Family Involved in Decisions
- Emotional Bereavement
- No Organ Donation
- Curandero (Curandera)
- Hot-Cold Theory of Illness
- Abdominal Binder after Pregnancy
Hydrocephalus
- Increased CSF in Ventricles of Brain
- Signs of Increased ICP
- High Pitched Cry
- Irritability
- Opisthotonus
- Increased Head Circumference
- Bulging Fontanel
- Setting Sun Sign
- Seizure Precautions
- Elevate HOB
- CSF Shunt
Erikson’s Theory of Psychosocial Development - Stage 2 (Toddler)
- Toddler (1-3 Years)
- Autonomy vs. Shame and Doubt
- Toilet Training
- Will
- Anal
Age 2 Months - Developmental Milestones
- Holds Head Up, But Unsteady
- Tracks Objects to the Midline
- Coos
- Social Smile
- Recognizes Parents
Age 4 Months - Developmental Milestones
- Sits With Support
- Rooting Reflex Disappears
- Moro Reflex Disappears
- Reaches Across Midline
- Turns to Voice
- Laughs
- Enjoys Looking Around
Age 6 Months - Developmental Milestones
- Palmar Reflex Disappears
- Sits Propped Up On Hands
- Rolls
- Transfers Objects Hands to Hands
- Raking Grasp
- Babbles
- Responds to Name
- Stranger Anxiety Develops
Age 9 Months - Developmental Milestones
- Pulls to Stand
- Starts Cruising
- Three-Finger Pincer Grasp
- Holds Bottle or Cup
- Starts Sounding "Mama" or "Dada"
- Waves Bye
- Separation Anxiety
- Plays Pat-A-Cake
Age 1 Year - Developmental Milestones
- Stands Well
- First Steps
- Throws Ball
- Points to Objects
- Babinski Reflex Disappears
- Two-Finger Pincer Grasp
- "Mama & Dada"
- One-Step Commands with Gesture
Age 18 Months - Developmental Milestones
- Climbs Up Stairs
- Runs
- Stacks Three Blocks
- Eats with Spoon
- Removes Clothing
- 10-25 Word Vocabulary
- “Mine”
- Pretend Play
Age 2 Years - Developmental Milestones
- Jumps
- Copies a Line
- Stacks Six Blocks
- Turns Pages
- Two-Word Phrases
- Half of Speech is Understandable
- 200 Words by Age 2
- Parallel Play
- Begins Toilet Training
- Rapprochement
Age 4 Years - Developmental Milestones
- Hop on One Foot
- Copies Square
- Uses Fork Well
- 100% Speech Understandable
- Identifies Colors
- Cooperative Play
- Imaginary Friends
Age 3 Years - Developmental Milestones
- Walks Up/Down Steps with Alternating Feet
- Rides Tricycle
- Stack Nine Block Tower
- Copies Circle
- Uses Utensils
- Three-Word Sentences
- 75% Speech Understood by Stranger
- Knows Gender / Age
Age 5 Years - Developmental Milestones
- Skips
- Walks Backward
- Copies Triangle
- Ties Shoelaces
- Independent Dressing / Bathing
- Prints Letters
- Counts to 10
- Five-word Sentences
- Friends
- Uses Toilet Independently