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DUAL PN Rankin
Maslow's Hierarchy of Needs
Physiological Needs
Oxygen, Water, Nutrition
Body temperature, Elimination, Shelter, Sexual Expression
Safety and Security
Physical Safety
Physiological Safety
Love and Belonging
Affection and Companionship
Esteem
Self Respect and Respect for Others
Self Actualization
Fulfillment
2 mins
Patient Position Overview
Position Techniques
Trochanter Roll
Trapeze Bar
Ankle-Foot Orthotic (AFO) Devices
Positions
Fowlers Position
Supine Position
Trendelenburg
Side-Lying Position
Prone Position
Sims' Position
Nursing Considerations
Reposition q2 Hours/Prevent Skin Breakdown
Confirm Body Alignment
2 mins
Vital Signs - Adult
Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
Rectal
Tympanic
Oral
Axillary
Temporal
Respiration (12-20)
Oxygen Saturation (95%-100%)
Pulse (60-100)
Blood Pressure (<120/80)
Pain
2 mins
Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
1 min
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
1 min
Pain Assessment
Types of Pain
Acute Pain
Chronic Pain
OPQRST Mnemonic
Onset
Provoking or Palliative
Quality
Radiation
Severity
Timing
Nursing Considerations
Subjective Findings
Objective Findings
Reassessment of Pain
2 mins
Child and Elder Physical Abuse Assessment
Physical Abuse
Inconsistent Injuries
Delay in Treatment
Various Stages of Healing
Child Abuse
Symmetrical Burns
Sexually Transmitted Infection
Bloody/Torn Undergarments
Shaken Baby Syndrome
Elder Abuse
Poor Hygiene
Overmedication
2 mins
Fever
Flushed skin, warm to touch
Chills
Sweating
Change in LOC
Provide adequate fluids
Monitor Electrolytes and Fluid
Monitor vital signs, esp temperature
Remove excess clothing and blankets
Sponge bath with tepid water
2 mins
Care for the Hard of Hearing
Assessment
Normal: 0-15 dB
Rinne's Test
Weber's Test
Tinnitus
Difficulty Following Conversations
Nursing Considerations
Face Patient/Speak Clearly
Rephrase Misunderstood Statements
Repeat Statements Back
Hearing Aids
Sign Language
2 mins
I-SBAR-R
Identify
Situation
Background
Assessment
Recommendation
Readback
1 min
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
1 min
Religion and Dietary Preferences Overview
Buddhism
Natural Foods of Earth
Hinduism
Cow is Sacred
Islam (Muslim)
Halal Foods
No Alcohol
Judaism
Kosher Meals
No Pork or Shellfish
Mormonism (Latter Day Saints)
The Word of Wisdom
1 min
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
2 mins
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
Location
Lower Lobes
Description
Fine/Coarse
Sounds Like
Fine: Twisting Hair through Fingers
Coarse: Velcro
Cause
Collapsed Small Airways and Alveoli "Popping Open"
1 min
Lung Sounds - Rhonchi
Location
Trachea and Bronchi
Description
Low Pitched Rumbling
Sounds Like
Gurgling
Cause
Narrowed Airway
Secretions or Bronchospasm
49 secs
Lung Sounds - Pleural Friction Rub
Location
Anterior Lateral Lung
Description
Dry, Rubbing, or Squeaking
Sounds Like
Rubbing a Balloon with Finger
Cause
Inflamed Pleura
50 secs
Age 2 Months - Developmental Milestones
Gross Motor
Holds Head Up, But Unsteady
Fine Motor
Tracks Objects to the Midline
Language
Coos
Social / Cognitive
Social Smile
Recognizes Parents
1 min
Age 4 Months - Developmental Milestones
Gross Motor
Sits With Support
Rooting Reflex Disappears
Moro Reflex Disappears
Fine Motor
Reaches Across Midline
Language
Turns to Voice
Laughs
Social / Cognitive
Enjoys Looking Around
2 mins
Age 6 Months - Developmental Milestones
Gross Motor
Palmar Reflex Disappears
Sits Propped Up On Hands
Rolls
Fine Motor
Transfers Objects Hands to Hands
Raking Grasp
Language
Babbles
Responds to Name
Social / Cognitive
Stranger Anxiety Develops
2 mins
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