1. 8/30/2011
Deficit Needs
Physiological
Safety
Love and belonging
Nursing Fundamentals Focus II
Mrs. Judy Ontiveros, RN, MSN
Fall 2010 Self esteem
Maslow’’s Characteristics of
Objectives the Self-actualized Person
• Identify the basic human needs and explain the Realistic, sees life clearly, and is objective
hierarchy of according to Maslow’’s view Judges people correctly
Has superior perception, is more decisive
• Explain how nurses use the hierarchy of basic Has clear notion of right and wrong
needs taking into consideration human diversity in Is usually accurate in predicting future events
carrying out the nursing process. Understands art, music, politics, and philosophy
• Define ““health”” and ““illness””. Explain why the
concept of the health illness continuum is useful
in the nursing practice.
Maslow’’s Characteristics of
Maslow’’s Pyramid
the Self-actualized Person
Possesses humility, listens to others carefully
Is highly creative, flexible, spontaneous, courageous,
and willing to make mistakes
Is open to new ideas
Is self-confident and has self respect
Has low degree of self-conflict; personality is
integrated
Respects self, does not need fame, possesses a feeling
of self control
Is highly independent, desires privacy
1

2. 8/30/2011
Maslow’’s Characteristics of
Maslow’’s Basic Hierarchy
the Self-actualized Person
Can appear remote and detached
Is friendly, loving, and governed more by inner Basic Physiologic Needs
directives than by society
Can make decisions contrary to popular opinion
Is problem-centered rather than self-centered
Accepts the world for what it is Nurses Priority
Nursing Process Maslow’’s Basic Hierarchy
Ineffective breathing pattern
related to obstructed airway
Ca of lung
Fluid build up in lungs
Figure 11-2 The five overlapping phases of the nursing process. Each phase
depends on the accuracy of the other phases. Each phase involves critical
thinking. Berman, pg. 180
Maslow’’s Basic Hierarchy Maslow’’s Basic Hierarchy
Basic Physiologic Needs:
Imbalanced nutrition: less than
body requirements, related to
Mrs. C came in with advanced lung cancer nausea and vomiting
Struggling to breathe
Chemo therapy
Nauseated from chemotherapy
Coughing from cancer
Too weak to get up alone
Knows she will die soon
2

3. 8/30/2011
Maslow’’s Basic Hierarchy Maslow’’s Basic Hierarchy
Bathing/hygiene self-care deficit Love and Belonging
related to generalized weakness Client is important part of health
Advanced disease state care team
Nausea and vomiting
Family members important
Lack of nutritious diet
Maslow’’s Basic Hierarchy Maslow’’s Basic Hierarchy
Hopelessness related to coping Self Esteem
with the diagnosis of a terminal
illness
Develops out of
relationships with others
Depression
Non-compliance
Maslow’’s Basic Hierarchy Maslow’’s Basic Hierarchy
Safety and Security: Self Actualization
A being need
trusting nurse client relationship
Grows out of motivation to be all
you can be
3

4. 8/30/2011
Nursing Health
Assessment Nurse as Detective
Definition Job: Nurse
Tools: Senses
Clues:
Essential part of the Modus Operandi:
nursing process Mission:
Determine overall health status
Homeostasis vs. Disease
Assessment Process
Identify Priority Areas
Determine data
Establish a data base
Analyze the data
Follow up
4 Major Steps in
Nursing Assessment
1. Subjectivedata collection
2. Objective data collection
3. Validation of data
4. Documentation of data
4

5. 8/30/2011
Health Assessment Symptom Analysis
Components COLDSPA
C haracteristics, S/S, look/feel
Subjective Data O nset
History L ocatition
D uration
Symptoms S everity
Objective Data P attern
A ssociated factors
Physical Examination
Signs
Critical Thinking Types of Assessment
Initial
Focus
Emergency
Ongoing
Symptom Analysis
Data Collection Methods
OLDCARTS
Onset Active listening + processing
Location
Duration
Characteristics Observing
Aggravating or Alleviating Factors
Related Symptoms
Treatment Interviewing
Severity
5

6. 8/30/2011
The Interview Physical Assessment
TYPES Head to Toe Circulatory
Directed Assessment
Non Directed VS, (Pain) Allergies Musculoskeletal
Symptom Analysis- GI
Presence of Pain GU
Stages of Interview (COLDSPA Energy level
Opening mnemonic)
Body Neuro Use of Assistive
Closing Skin devices,
Organizing Data Assessment Basic Needs
Psychosocial Assessment Interview:
Health History
Observing behaviors
- Demographic data
- Expectations and goals Health Functional Patterns
- Reason for visit Self concept
- Medical history Role
- Family history Coping
- Functional health patterns Value beliefs
Culture
Review Functional Health
Patterns
Health Perception - Health Maintenance
Pattern
Nutritional-Metabolic Pattern
Elimination Pattern
Activity- Rest Pattern
Sleep-Rest Pattern
Cognitive - Perceptual Pattern
6

7. 8/30/2011
Framework of Nursing Framework of Nursing
Process Process
Assessment Goal setting:
Objective data: Example Expected Outcomes:
Awake, anxious, Agitated. Skin warm, moist, color pale. Increased gas exchange as Evidenced by:
VS: SPO2 93%, T101F, BP –– 118/70, P-100, R-30.
Diminished breath sounds bil lungs. Dyspnea results on Ease of breathing
activity. Dyspnea at rest not present
Subjective data: Cyanosis not present
c/of pain in lower left chest with inspiration O2 sat WNL (98-100)%
States she is very frightened.
Framework of Nursing Framework of Nursing
Process Process
Diagnosis: Planning/Intervention:
analysis of data
identification of the problem to determine dx. Example Nursing Interventions:
A problem statement derived from assessment
data Clear oral, nasal and tracheal secretions as
needed
Problem Statement Set up O2 equipment and administer
+ related to assessment data (NANDA) through a heated humidified system
Administer 4L or O2 via NC
Example Nursing Framework of Nursing
Diagnosis Process
Impaired Gas Exchange Evaluation/modification:
Example Evaluation Data:
related factor excess secretions,
O2% sat 97%
weakness, pain 2nd to Sat in chair 20 minutes respirations 16, p 88,
pneumonia 130/90
Temp 99.6F
Cough non - productive and tiring, antitussive
given
7

8. 8/30/2011
Health-Illness Continuum Wellness and Well-Being
What is Health? Well-being
Subjective perception of vitality and
Traditional feeling well
Florence Nightengale Described objectively, experienced,
WHO measured
Sick Role Plotted on a continuum
1953 President’’s Commission
Personal Definition A component of health
Wellness and Well-Being Health Illness Continuum
Wellness What is Illness?
Seven components of wellness Highly personal state
Physical
Social
Seven areas of well being diminished.
Emotional Not synonymous with disease
Intellectual May or may not be related to a disease
Spiritual
Occupational
Environmental
Dimensions of Wellness Health Illness Continuum
Disease
Alteration in body functions
Results in reduction of capacities
Results in shortened life span
Etiology
Causation of disease
8

9. 8/30/2011
Health Illness Continuum Internal Variables
:
Biology:
Genetic makeup
Family history
Past Medical History
Variables Influencing Health
Beliefs, Practices, Promotion of Risk Factors of Illness
Health
Internal Lifestyle
Biologic Overeating
Psychological
No exercise
Cognitive Dimensions
Too much salt
Non Modifiable Overweight
Regular Health Exams
Smoking
Appropriate Screening
Religious Beliefs
Variables Influencing Health
Beliefs, Practices, Promotion External Variables
of Health
External Variables Social Environment:
Environment
Social Interaction
Standards of Living
Social Institutions
Family and Cultural Beliefs
Intellectual Factors
Social Support Networks
Social Networks
9

10. 8/30/2011
Factors that Influence
External Variables
Behavior Change
Culture and Worldview
Behaviors: Communication
Personal Choices Cognition and Perception
Age and Development Level
Lifestyle Factors
Lifestyle and Habits
Family Health Practices Economic Resources
Cultural Factors Roles and Relationships
Coping Stress Tolerance
Workplace and Environmental Conditions
External Variables Prevention of Illness
Public Policy: Primary
Health Promotion and Disease
Prevention- for individual and the
community
Secondary
Equitable Access to Health Care
Tertiary
External Variables
The Environment:
Work Life
Safety and Security
Environmental Ecosystem
10