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
- Moves Both Arms and Both Legs
- Opens Hands Briefly
- Tracks Objects to the Midline
- Produces Sounds Aside from Crying
- Reacts to Loud Noise
- Social Smile
- Recognizes Parents
- Soothed When Spoken to or Picked Up
Age 4 Months - Developmental Milestones
- Keeps Head Steady Without Support
- Pushes Up on Elbows While on Tummy
- Holds a Toy in Hands
- Moves Hands Towards Mouth
- Cooing
- Turns to Voice
- Chuckles
- Enjoys Looking Around
- Looks at Hands With Interest
- Opens Mouth When Hungry
Age 6 Months - Developmental Milestones
- Sits Propped Up On Hands
- Rolls
- Raking Grasp
- Makes Squealing Noises
- Blows "Raspberries"
- Turn-Taking in Sounds
- Laughs
- Enjoys Looking at Self in a Mirror
- Recognizes Familiar People
- Closes Lips to Signal Fullness
- Puts Objects in Mouth
- Reaches for Desired Toys
Age 9 Months - Developmental Milestones
- Sits Up Independently
- Transfers Objects Between Hands
- Uses Fingers to Pull Food Toward Self
- Produces Various Sounds Like "mamamama" and "bababababa"
- Raises Arms to be Lifted Up
- Separation Anxiety
- Shows Facial Expressions
- Looks When Calling Name
- Smiles or Laughs at Peek-a-boo
- Looks for Dropped Objects Out of Sight
- Bangs Two Items Together
Age 1 Year - Developmental Milestones
- Pulls Up to Stand
- First Steps
- Drinks From an Open Cup with Assistance
- Two-Finger Pincer Grasp
- Understands “No”
- Waves "Bye-Bye"
- "Mama & Dada"
- Plays Pat-A-Cake
- Puts Block in Cup
- Searches for Hidden Toys
Age 18 Months - Developmental Milestones
- Walks Independently
- Climbs On/Off Furniture Without Help
- Drinks from Open Cup Independently
- Scribbles
- Eats with Fingers
- Tries to Use a Spoon
- Stacks Three Blocks
- Attempts Three-word Phrases
- Follows One-step Commands
- Checks While Moving Away
- Points to Objects
- Engages With Toys Simply
- Copies Parent Doing Chores
- Extends Hands for Washing
Age 2 Years - Developmental Milestones
- Kicks a Ball
- Runs
- Walks Up Stairs With Help
- Stacks Six Blocks
- Feeds Self With a Spoon
- Two-Word Phrases
- Points to Book Items as Prompted
- Demonstrates Varied Gestures
- Identifies Body Parts When Prompted
- Shows Empathy
- Holds and Manipulates Objects Simultaneously
- Engages With Multiple Toys
Age 4 Years - Developmental Milestones
- Unbuttons Some Buttons
- Catches a Large Ball
- Serves Food or Pours Water With Help
- Copies Line, Circle, Stick Figure
- 100% Speech Understandable
- Identifies Colors
- Cooperative Play
- Imaginary Friends
- Likes Being a “Helper”
- Avoids Danger
Age 3 Years - Developmental Milestones
- Starts Dressing Independently
- Rides Tricycle
- Stack Nine Block Tower
- Threads Items Together
- Copies Circle
- Uses Fork
- Engages in Two-way Conversation
- 75% Speech Understood by Stranger
- Says First Name
- Avoids Hot Objects When Warned
- Joins Other Kids in Play
Age 5 Years - Developmental Milestones
- Buttons Some Buttons
- Hops on One Foot
- Prints Letters
- Counts to 10
- Uses Simple Rhymes
- >3 Back-and-forth Exchanges
- Answers Simple Questions
- Tells a Story
- Names Some Letters When Pointed
- Follows Rules
- Sings, Dances, Acts
- Does Simple Chores