Assessment B4 According to Human Needs · PDF fileAssessment According to Human Needs Approach 51 Refer to Chapter 2 “Assessment,” p. 65: Care Plans Developed Using

AssessmentAccording toHuman NeedsApproach

51

Refer to Chapter 2 “Assessment,” p. 65: Care Plans Developed Using TheHuman Needs Approach: Maslows’s Hierarchy of NeedsClient’s name: Mr. George KingAge: 68

Activity 1Read the scenario to assist in proper identification of the client.

Activity 2Carefully examine the pathoflow sheet for pneumonia to get a clear under-standing of the pathophysiological cause and effect relationship of the client’sdiagnosis (pneumonia). Begin to formulate teaching actions to help him to pre-vent recurrences and to better his present condition.

Activity 3Read Mr. King’s assessment (in this appendix). Carefully develop an apprecia-tion for the differences in the previous assessment models and compare thesewith this model (Human Needs Approach—Maslow’s Hierarchy).

B4

Appendix

Activity 4Identify the five physiological needs and the three psychological needs as listed.

Activity 5Show appreciation for safety and security as both physiological and psycho-logical (see D—oxygenation).

Activity 6Carefully examine the assessment of Mr. King under each need (physiologicaland psychological). Begin to determine how you would use this assessmentmodel to assess another client with a different medical diagnosis.

Activity 7Examine the individualized nursing care plans and determine reasons for prioritorizing each as written.

Activity 8Rexamine the individualized care plans, determine the sequencing and corre-lation between each section (ordered and selected data to evaluation).Determine reasons for recording goals met. Be sure to use this assessment for-mat for some of the clients assigned to your care.Note: Be aware that some physiological needs are combined in this document,for example: comfort/warmth/pain.

NURSING CARE PLAN DEVELOPED ACCORDINGTO HUMAN NEEDS APPROACH—MASLOW’SHIERARCHY OF NEEDS

Scenario: Mr. George King is a 68-year-old client who had a stroke threemonths ago. He suffered from marked weakness of his lower extremities, whichshowed improvement after three days of hospitalization. He was transferred toHill Crest Rehabilitation Center when after ten days he was assigned to homecare. Because his hospital insurance was depleted, he received only one homevisit. Mr. King lives alone and has only one distant relative who visited for twodays during his initial hospitalization. He has been in bed since his dischargefrom the rehabilitation center. A neighbor found him coughing (purulent spu-tum), very warm to touch, and complaining of chest pain. He was pale anddehydrated. He stated he had not eaten for five days. He was soiled with both

52 Appendix B4

Decreased ability to expel foreign body from respiratory tract

Altered B and T lymphocyte function

Decreased production and/or impairedfunction of neutrophils and macrophages

Pneumococci in saliva—invades alveoliAccumulation of large amount of fluid in alveoli

Depressed bone marrow function

Damage to lung parenchyma

Massive multiplication of infectious organisms (pneumococci)

Troublesome cough, purulent sputum, chest pain, fever, chills

Inflammation responseIncrease in neutrophils (phagocytosis)

Stimulation and release of inflammatory mediators

Dullness on percussion, rales and crackles on auscultation

Unresolved condition

Prolonged illness—immobility—risk for major complications of many body systems

Multiplicationof leucocytes(neutrophils andmacrophages)

Red hepatizationCapillaries dilateorganisms multiplyExudation of WBCfibrin and neutrophils

Possible complicationsPleurisy• Pleural effusion

Atelectasis• Delayed resolution

(elderly and undernourished)• Emphysema• Pericarditis• Arthritis• Endocarditis

Gray hepatizationAccumulationof leucocytesand fibrin decreasesblood flow in damagedlung parenchyma

Resolutionof infectious conditionIngestion of degeneratedneutrophils, fribrin, and deador attenuated bacteria

FIGURE B4–1 Generic pathoflow sheet for pheumonia. 53

Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2000). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: C.V. Mosby, p. 615.

54 Appendix B4

stool and urine on his bedclothes and on his skin. He was rushed to the hos-pital where he was diagnosed with pneumococcal pneumonia.

ASSESSMENT OF MR. KING USING HUMANNEEDS APPROACH—MASLOW’S HIERARCHY

I. Physiological: Comfort and warmth, food and fluids, elimination, oxy-genation, adequacy of pain management, adequacy of diet.A. Comfort/Warmth and Adequacy of Pain Management

Temperature 102�F, pulse 100, respirations 36, Blood pressure140/100, skin very warm to touch, shivering at times; complained ofchest pain, stated, “I am so uncomfortable.” Complains of pain inchest aggravated by breathing and coughing. Ordered analgesia every4 hours as needed and respiratory treatments twice a day as needed.

B. Food and Fluids, Adequacy of DietHas not eaten for several days, skin dry, skin turgor poor (skin whenlifted over clavicle returns to normal in more than 3 seconds),hyperactive bowel sounds. Ordered soft diet. Ate only 25 percentat breakfast. Drank 100 cc of orange juice, refused other fluids.Hemoglobin 9.0 g/dl. Hematocrit 32.0 percent. States, “I am nothungry.” Having intravenous fluid (5 percent dextrose water at 42 drops per minute), absorbing without problems.No order for special diet on first admission. Obvious weight loss.Current weight 130 lbs., height 5 feet 8 inches, body frame medium.Ideal body weight 169 lbs. States he “has no appetite and no one tocook for him.” Blood profile: Hemoglobin 9.0 g/dl. Hematocrit 32 percent. Red blood cell content 3.2 � 106/UL.White blood cell count 12.0 � 103/UL.Segmented neutrophils 75–80.Band neutrophils 0–9 percent.Generalized weakness, conjunctiva pale.

C. EliminationConstipation. Dry stool on bedclothes, in client’s groin, and on buttocks.Sheets and undergarment wet with recently voided urine. Bladdernot palpable.

D. OxygenationColor pale, respirations 36, using assessory muscles (substernalretraction) mildly diaphoretic. Crackles in both lower lung bases

on auscultation, rhonchi heard throughout lung fields. Dullnesspercussed above the diaphragm. Receiving oxygen by nasal canulaof 3 liters per minute. Pulse oximeter readings at 85 to 90 percentwith pulse rate between 100 and 120 beats per minute. Capillaryrefill more than 2 seconds. Nursed in semi-Fowler’s position.

E. Safety and Security (Physical and Psychological safety—UnsafeEnvironment, Need for Emotional Support)Physical Environment—Physical SafetyLives in a three-bedroom house, has bars on all windows anddoors, all bedrooms upstairs. Kitchen and dining areas downstairs.There are eight steps leading from downstairs to the bedrooms.There is central heating in the house and ceiling and floor fans.There is a shower and one bathtub upstairs. Unable to ambulate.Psychological SafetyAge 68, had a stroke, lives alone, neighbor has a key, visits occasion-ally. Distant relative lives out of town. Has not eaten for several days,lying in feces and urine.

II. Love and Belonging: Family and significant others (adequacy of sup-port system) Wife died 6 months ago, had no children, one distantrelative lives out of town. Neighbor visits periodically.

III. Self-esteem: Pride and worthiness (need for building self-worth)Recounts how he worked two jobs to buy his house. Has lived in itfor 20 years and as soon as it was paid for he began to take things easy,he developed a “stroke.” States his wife also died from a stroke (6 months ago). Talked of the “wonderful care she gave him.” Stated,“I want to follow her, there is nothing to live for.” Tears in eyes.

IV. Self-actualization: Goal realization, self-fulfillment (identification oflife accomplishments). States, “Just as I am ready to enjoy life, my wifedied of a stroke and now I am dying of a stroke. Life has dealt me araw deal. I did pay for my house, however, now what!”

Appendix B4 55

Subjective data: Breathing patterns, Short term: Short-term goal met:Client stated: “I am so ineffective, related to Client will admit and Client’s respirations wereshort of breath.” the collection of mucus demonstrate easier 28 about 20 minutes after

in respiratory tract; breathing. Respirations administration of painObjective data: evidenced by will be between 28 and medication, water, andColor pale, temperature respirations of 36 and 30 within 30 minutes coughing and expectoration101�F, respirations 36, client statement of “I after intervention. exercises (oxygen,using assessory muscles am so short of breath.” Fowler’s position,of respiration (substernal Long term: intravenous therapy,retraction mildly Ineffective airway Use of assessory medication given asdiaphoretic). clearance related to muscles will be less ordered). Client statedCrackles in both lower lung consolidation of lung marked. “My breathing is so muchbases on auscultation, tissue (pneumonia) Crackles and ronchi better, thank you.”ronchi heard throughout evidenced by crackles will be less evident.lung fields. Dullness and ronchi. Pulse oximeter Long-term goals met:percussed above the Defining characteristics: reading will be By the end of the shiftdiaphragm. Receiving Breathing pattern between 90–100 by (1500) the client wasoxygen by nasal canula altered the end of the sleeping, respirations wereat 3 liters per minute, pulse Increased respirations shift (1500). markedly reduced, pulseoximeter readings 85–90%, (dyspnea) oximeter readings were betweenpulse rate between 100 Troublesome cough 90 and 100, crackles andand 120 beats per (ineffective) ronchi less marked onminute, capillary refill more Diminished breath auscultation. Clientthan 2 seconds. Nursed in sounds expectorating mucus (lesssemi-Fowler’s positions; Adventitious breath tenacious and rusty),reluctant to cough, brings sounds (crackles,up rusty tenacious purulent ronchi wheezes) continues

CLIENT: Mr. George King Individualized Care PlanAGE: 68 Using Human Needs Approach—Maslow’s Hierarchy

Physiological Needs—Priority I. Oxygenation

Ordered & Nursing Selected Data Diagnosis Goals Interventions Rationale Evaluation

• Continue to nurse insemi-Fowlers position.

• Keep nasal canulaproperly positioned inanterior nares at alltimes to facilitateadequate delivery ofoxygen.

• Offer 100 to 120 cc offluids every hour(increase as clienttolerates or is willingto take).

• Teach deep breathing,coughing andexpectoration (haveclient support rib cagewith palms of hands,breathe in deeply andcough on exhalation—repeat every 1 to 2 hours).

• Promotes lung expansion.

• Supplemental oxygenreplaces depleted cellularoxygen; promotes easierbreathing and increasesoxygen saturation inarterior blood.

• Water liquefiessecretions (decreasestenacity) bathes tissue,provides comfort, andenables sputumproduction andliquefaction.

• Promotes more effectivecough and the removal ofmucus from the lungs.

sputum. Chest X-ray Restlessness temperature 99.6�F,results. Consolidation of Cyanosis pulse 86 to 90.lung parenchyma.


Physiological Needs—Priority I. Oxygenation


• Teach proper use ofincentive inspirometerif ordered (place mouthtightly around mouthpiece, inhale slowly,raise piston to desiredlevel, exhale slowly,only partially removemouth piece andcomplete exhalation,repeat between 5 and6 times and continueevery hour.

• Feed well-balanceddiet.

Dependent• Administer IV fluids as

ordered, ambulate asordered. Administer allordered medications(expectorants,antibiotics, andantipyretics).

• Aids lung expansion andhelps to determineadequate inspiration.

• Balanced diet providesenergy and healingproperties, andstrengthens the immunesystem.

• IV fluids prevent/correctdehydration and aidelectrolyte balance.Ambulation, a form ofexercise, preventsimmobility thuspreventing manycomplications.Expectorants aid theexpulsion of mucus fromthe respiratory tree.Antibiotics destroydestructive organisms.

Reference: Smith, S., Duell, D., & Martin, C. (2000). Clinical nursing skills: Basic to advanced skills. Stamford, CT: Appleton & Lange.

Subjective data:Client complained ofchest pain, stated“I am so uncomfortable.”

Objective data:Lying in semi-Fowler’sposition, guardingchest with hand.Skin warm to touch,shivering at times.Temperature 102˚F.Pulse 100.Respirations 36.Blood pressure140/100.Grimacing whenattempting to cough.

Pain, acute relatedto damaged lungparenchymaevidenced byverbal complaintsand grimacingwhen attemptingto cough, elevatedpulse, respirations,and bloodpressure.

Defining characteristics:Acute painClient reports painFacial expressionof pain (grimacing)Guarding behaviorIncreased bloodpressureIncreased pulserate in morningChange in eatinghabits

Short term:Client will verbalizereduction in painfrom 10 (on a scale of0–10) within 30 minutes ofadministration ofanalgesia (dependentintervention) andother nursinginterventions(independent).

Long term:Client will rate painnot above 2 (scale0–10) throughout theday.Client will engage inactivities of dailyliving (eating).Client will demon-strate comfort(absence ofgrimacing andprotective behavior).Skin will be cool totouch with anabsence of shivering.Client will admitcomfort.

Independent• Have client rate pain on scale

of 0–10.

• Inform client of nonpharmacolicmethods to relieve pain:—Adjust to position of comfort.—Breathe easily and slowly

(in through nose, outthrough pursed lips).

—Splint chest when coughing.—Take small amounts of fluid

at least every hour.—Maintain oxygen in place

(nasal canula).—Expectorate after each

coughing spell.—Use distraction to prevent

focusing on pain—television, music (radio inroom), guided imagery.

Dependent• Pharmacological

—Inform client of availableanalgesic and frequency ofadministration.

—Instruct client to ask for painmedication before painbecomes severe

—Administer analgesic aroundthe clock (every 4 hours as ordered).

—Cold compress on forehead.

• Provides understanding ofthe client’s perception ofthe severity of the pain(pain is subjective).

• Understanding of the planof care and involvement inthe therapeutic regimenwill foster acceptance,eliminate or decrease thefeeling of powerlessness,and foster recovery.

• Analgesic when given on aregular basis will keeppain controlled.

Short-term goal met:Client listenedattentively to theteaching session.Demonstratedtechniques taughtand stated pain wasless about 20 minutesafter the interven-tions (nonpharmaco-logic and pharmaco-logic).

Long-term goals met:Client ate poorly atbreakfast, but drank100 to 120 cc of fluidsevery hour.Ate 50% of diet atlunch and 75% ofevening meal.Temperature 100.8˚FRespirations 28Pulse 88Blood pressure130/88Admitted feelingcomfortable, nofurther grimacing.

CLIENT: Mr. King Individualized Care PlanAGE: 68 Using Human Needs Approach—Maslow’s Hierarchy

Physiological Needs—Priority II Comfort and Warmth and Adequacy of Pain Management


Reference: Cox, H.C., Hinz, M., Lubno, M., Scott-Tilley, D., Newfield, S., Slater, M., & Sridaromont, K. (2002). Clinical applications of nursing diagnosis. Philadelphia: F.A. Davis.

Subjective data:Client states:“I have not eaten forseveral days” and“I am not hungry.”

Objective data:Poor skin turgor.Anorectic(ate 25 percent ofbreakfast, drank100cc orange juice,refused other fluids).Hemoglobin 9.0(normal 13.5–18 g/dl).Hematocrit 32.0normal (40–54%)Receiving intravenousfluids (5% dextrosewater at 42cc perhour).

Nutrition,imbalanced,less than bodyrequirementrelated toinfectious state(temperature 102˚F)evidenced by:anorexia,poor skin turgor,Hemoglobin of 9.0,Hematocrit of 32.0,and hyperactivebowel sounds.

Defining characteristics:Hyperactive bowelsoundsWeight loss morethan 20% belowideal body weightAnorexiaPoor muscle tonePale conjunctivaAlopecia

Short term:Client will verbalizethe importance thatfood and fluids playin loweringtemperature andimproving health.Client will drink100–120 cc of fluidevery hour.Client will identifyfood likes anddislikes.

Long term:Client will eat atleast 50% of allmeals by second dayand 75% by day 3.Client will demon-strate steady weightgain beginning onday 3.Client will showincrease inhemogloblin andhematocrit by day 3and bowel soundswill be normal.Client will voiceinterest in food.

• Inform client that:—Fluids will liquefy mucous in

lungs, aiding congestion—Proper nutrition will

strengthen immune systemand aid in fighting infection.

• Offer frequent small amountsof fluid (about 100–120cc every hour).Encourage client to feed self—provide straw.

• Help client choose foodsinclusive of his idiosyncrasies.

• Serve foods attractively,provide enough time for eating,assist client as necessary.

• Serve small meals. Providemouth rinses before meals(lemon/lime).

• Include iron-rich foods.

• Record intake.• Weigh daily as ordered.

• Having adequateinformation about thetherapeutic regime andbecoming involved in theplan of care will create afeeling of ownership anddecrease powerlessness.

• Frequent small amounts offluids will conserve clientenergy, yet provide therequired volume over timeand produce the therapeu-tic effect.

• Eating patterns are learnedover time (cultivatespecific patterns). Peoplegenerally eat more of whatthey are familiar with andof what they like.

• Proper mastication willfacilitate gastric emptyingand aid digestion.

• Mouth rinses such aslemon and lime stimulatethe salivary glands, makechewing easier. Smallmeals prevent gastricoverload.

• Iron-rich foods willincrease oxygen carryingcomponent of red bloodcells, add vitality.

• Weight gain showstherapeutic results.

Short-term goal met:Client demonstratedreadiness to learnand activelyparticipated in theplan (frequentdrinking, sharing offeelings, and eating).

Long-term goal met:Client ate approxi-mately 80% of mealby second day.Blood profile showedpositive changes by3rd day.

Client gained about ahalf pound a day.Fluid intake equaledoutput by day 3.

CLIENT: Mr. King Individualized Care PlanAGE: 68 Using Human Needs Approach—Maslow’s Hierarchy

Physiological Needs—Priority III Foods and Fluids: Adequacy of Diet



Subjective data:Client states“Please excuse me forthe state I am in Icannot help myself.”

Objective data:Dry stool in groin onbedclothes and onbuttocks. Sheet andundergarment wet withrecently voided urine.

Skin integrityimpaired, risk forrelated to immobilityand incontinence ofurine.

Defining characteristics:Break in epidermisand/or dermisMarked erythema ofskinIncreased warmth toareaSerosanguineousbloody discharge orpus

Short term:Client will discuss ways to prevent skinbreakdown.

Long term:Client will maintainintact skin (free ofexcessive redness ordecubitus ulcers).

• Inform client that:—Lying in one position for a

prolonged period of time cancreate trauma to the area (initialredness and later skin break).

—These ulcers can becomesevere, infectious, and difficultto heal.

Client will discuss ways of preventingdecubitus ulcers:• Turn every 2 hours.• Take daily baths.

• Cleanse perineal area thoroughlyafter each voiding or defecation.

• Sit in chair for meals whenallowed.

• Take walks in hall at least 2 times aday as allowed.

• Drink at least 3 liters of fluids a day.

• Eat foods high in protein,carbohydrates, minerals, andvitamins.

• Report wetness or discomfort atpressure sites (bony prominences).

• Teach kegel exercises. Instructclient to perform these every hour.

• Assist client with all aspects of care.

• The informed client is morelikely to cooperate with theplan of care.

• Turning increases circulation,helping to maintain skinintegrity.

• Cleansing removes bodywaste, preventing tissueerosion by bacteria.

• Movement increases tissueintegrity, improves musclestrength and circulation.

• Drinking prevents dryness andremoves tissue waste.

• Eating provides energy, buildsmuscle mass, increasesmuscle integrity, andstrengthens immune system.

• Change areas immediately.Immediate attention preventsinvasion of bacteria.

• Exercises strengthen perinealmuscles and correctincontinence.

• Assist client with all aspectsof care. Client should have alldependency needs met by thenurse.

Short-term goal met:Client verbalized intentto cooperate with allaspects of care.

Long-term goal met:Ambulated in hallwayusing wheelchair.Marked improvement inappetite, drinking fluidslavishly. Voices need tovoid, uses urinalefficiently. No furthersign of urinaryincontinence.Skin remained intact.No skin breakdown.


Physiological Needs—Priority IV Elimination—Urination


Subjective data:Client states“Please excuse mefor the state I am in: I cannot help myself.”

Objective data:Dry stool onbedclothes, in groin,and on buttocks.Stool moderatelyhard, small tomoderate amount.

Contipation, riskfor alteredelimination relatedto immobility.

Defining characteristics:Decrease infrequency ofdefecationHard consistencyof stool, difficult topass (stays inrectum)AbdominaldistensionIncreasedflatulenceHeadachePalpable mass

Short term:Client will state theimportance of havinga regular bowelmovement.Client will identifyways of promotingeasy passage of stool.

Long term:Client will have onebowel movementdaily or at least onein 3 days (soft intexture and moderateto large in size).

• Tell client that regular bowelmovements are necessary toprevent stool becoming hardand dry, straining and bleeding,abdominal pain, and excessgas formation.

• Inform client of the interven-tions that will enable him todefecate regularly:—Exercise—Adequate fluid

intake.—Eating foods that contain

bulk.—Defecate on urge—Use laxatives and enemas

only when ordered.• Turn client at least every 2 hours.• Sit in chair for meals as ordered.• Assist client to walk as ordered.

• Provide 100–120cc of fluidevery hour, increase amount as tolerated to total of 3 litersper day.

• Feed foods high in fiber.

• Assist client to have a bowelmovement during urge(approximately the same timeevery day).

• Record frequency of stool andconsistency.

• Insight into healthprinciple will createpositive outlook.

• Understanding of thetherapeutic regimen andinvolvement in the plan ofcare will enhancecommitment, strengthenmotivation, and decreaseor eliminate the feeling ofpowerlessness.

• Exercise strengthensabdominal muscles andaids in the pushing of stoolthrough the intestines.

• Fluids softens stoolenabling easy passage.

• Fiber softens stool, createsbulk and easy passage.

• Stool is easier to push outwith urge. Delay causesabsorption of water andhardens stool.

• A record determinesefficacy of nursinginterventions.

Short-term goal met:Client demonstratedreadiness to learnand stated “I neverknew the passing ofstool had so muchrelated to it.”

Long-term goal met:Client cooperatedwith all nursingprocedures,demonstratedsatisfaction. Had onebowel movementevery day startingwith the second day.Expressed joy overthe care he received.Stated, “I willcontinue all this whenI go home.”Ambulates withwalker alone.


Physiological Needs—Priority V Elimination—Constipation


Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2000). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: C.V. Mosby, pp. 1141–1145.

Subjective data:Client states“Wife died 6 monthsago. Had no children.One distant relativelives out of town.Neighbor visitsperiodically. Pleaseforgive me, I cannothelp myself.”

Objective data:Lying in stool andurine.

Social isolationevidenced byverbalization ofloss and power-lessness.

Defining characteristics:Absence ofsignificant others(wife and distantrelative)Expresses feelingsof being aloneVoices death wishApologetic ofpresent conditionExpresseshopelessness andpowerlessness

Short term:Client will identifythe social benefits ofliving in theNorthside NursingHome.

Long term:Client will identifyhobbies and skillsthat can be practicedand later shared withnursing homeresidents.

• Share information about theresidents and the activities inthe Northside Nursing Home;age group, daily activities,extracurricular and individual-ized activities. Observe client’sreaction, confront negativebehaviors, comment onpositive ones.

• Have client keep a log ofhobbies (able to use upperextremities) and other skills inwhich he engaged through theyears. Review log and givepositive feedback every day.

• Previous knowledge ofactivities and environmen-tal conditions will createreadiness (for admission toNorthside Nursing Home)and decrease anxiety.

• Recalling of previousstrengths and accomplish-ments will createsatisfaction and accept-ance of self and conveythe desire to again be acontributing member ofsociety (among NorthsideNursing Home residents)and enhance self-esteem.

Short-term goal met:Client listenedattentively to theinformation sharedabout the NorthsideNursing Home.Pamphlet withinformation provided.Looked at physicalstructure and stated“This is a good-looking home”(began to identify).No high anxietybehavior manifested.

Long-term goal met:Kept red notebook onbedside stand,documentation madedaily; reminded nurseto read log. Nurseand client usedproject as favorablepast time each day.


Love and Belonging Needs



Subjective data:Client states“I live alone, myneighbor has a keyand visits occasionally.One distant relativelives out of town. Ihave not eaten forseveral days, forgiveme for the state I amin, I cannot helpmyself.”

Objective data:Age, 68Stool and urine ingroin and onbuttocks. Lives inthree bedroom house,has bars on allwindows and doors,all bedroomsupstairs. Eight stepsto climb fromdownstairs toupstairs, kitchen isdownstairs.Unable to ambulate.

Injury, risk for:Psychological(depression)Physiological(trauma) related topreoccupation withloneliness (socialisolation), fallsattempting to crawlupstairs, andaccessibility ofhealth care and firepersonnel to reachhim on time if anemergency develops.

Defining characteristics:Anticipation ofhelplessnessInability to summonhelp after a fall orother emergencyLower extremitydysfunctionSelf-care deficit:bathing/hygiene,dressing/grooming,feeding, toileting.

Short term:Psychological:Client will verbalizehis feelings aboutbeing alone.Client will explorethe possibility of thedistant relativecoming to live with him.Client will explorethe possibility of acaretaker living withhim.Client will explorethe need for movingto another livingfacility such as anursing home.

Long term:Physiological:Client will be free ofphysical injury.Psychological:Client will expresssatisfaction with hisliving arrangements.

• Provide atmosphere foropen communication:quiet room, comfortabletemperature, cleanclothes and bed,adequate food intake,unhurried demeanor. Helpclient share his deep-seated feelings about hiscurrent living situation.Use empathy, effectivelistening, clarification,restatement, simplequestions, and tactilecommunication.

• Ask probing questionsabout others living withhim—distant relative,homemaker.

• Discuss potential safetyproblems of living incurrent home.

• Ask about any desire tosee social worker toexplain possiblealternatives and availablehelp.

• Provides for sharingof information(intimate thoughts).Develops trustrelationship.

• Provides database forfurther nursingaction.

• Provides collabora-tion with experts inthe health carearena. Facilitatesspecialized andcomprehensive clientcare.

Short-term goal met:Psychological:Client talked about his fear ofbeing alone and how helpless hefelt. Discussed his inability to callthe neighbor especially at night.Stated he thought “death wasbetter than this.”

Long-term goal met:Physical and Psychological: Social worker visited. Discussedhis Medicare coverage and hispension; informed client thatthere were adequate funds to pay for his living expenses inNorthside Nursing Home. Clientcomplied. Sustained no physicaltrauma.

Physiological:Satisfied with new livingarrangements.


Safety and Security Needs


Reference: Kozier, B., Erb, E., Berman, A., & Burke, K. (2000). Fundamentals of nursing: Concepts, process, and practice. Upper Saddle River, NJ: Prentice Hall Health. Cox.(2002). Clinical applications of nursing diagnosis. Philadelphia: F.A. Davis.

Subjective data:Client states“As soon as my housewas paid for and Ithought of taking thingseasy, I developed astroke. My wife alsodied from a stroke 6months ago. She gaveme such wonderful care.I want to follow her.”

Objective data:Tears in eyes.

Self-esteemdisturbance—situational—low.

Defining characteristics:Voices self-failureSelf-negatingPassivityExpression ofpowerlessnessVoices desire to die.Emotional distur-bances (crying)

Short term:Client will voice atleast three wishesabout self.

Long term:Client will identify atleast one enablingintervention for realizingeach wish.

• Provide atmosphereconducive to verbalization:—Unhurried demeanor—Tactile communication—Empathy—Expectancy—Humor (remember to use

appropriately, assess thesituation before you smileor laugh)

• Ask client: “If you had onewish what would it be?”(allow time for response).Then say, “and two?” (allowtime for response). Then say“and three?” (allow time forresponse).

• Reread wishes to client andhave him prioritize (urgentdesire, second, and third).

• Develop a plan of care(collaborate) for theaccomplishment of eachwish.

Provides data forintervention.

—Humor can expressidentification with theverbalized report andaids relaxation(decreases anxiety,builds trust). Humor canbe detrimental, usewith caution.

• Identification of a directwish encouragesexploration of thoughtand generates self-assurance, acceptance,and the thought ofworthiness amongothers, in this case thenurse.

• Writing each wishconnotes empathy,interest, andunderstanding in theclient’s affairs.

• Rereading, prioritizing,and planningencourages partnershipand confidence.

Short-term goal met:Client willing to talk.

Long-term goal met:Identified first wish as “desire to walk again.”Client reminded that he was only 68years old, that the weakness in his legs(stroke) had improved enough for himto be discharged home, and that thelack of assistance and the pneumoniahad compounded his problem. Nurseinformed client that physiotherapywould begin in this hospital andcontinue in the Northside NursingHome and that his legs would likelygrow stronger and stronger.Identified second wish as a desire to goto work again, even part time. Mobiletransportation discussed and thepossibility of Medicare equipping himwith an electric chair. Also discussedhis finding a job at Northside.Identified visitation to his wife’s graveas his third wish. Informed that thesocial worker would include thisrequirement as part of his extracurric-ular activities while in NorthsideNursing Home. The client voicedsatisfaction in the future plan; bothclient and nurse had a fourth wishthat he would walk again unaided.


Self-Esteem Needs



Client states “Just as I am ready to enjoy lifemy wife died of a strokeand now I am dying of astroke. Life has dealt mea raw deal; I did pay formy house, however, nowwhat?”

Self-mutilation—risk for.

Defining characteristics:Loss of significantother (wife)Inability to expressgriefAlterations in sexuality(loss of sexual partner)Persistent low self-esteemAltered body imageInability to plan long-term goalsDepressionUnrealistic goalplanningFear of the unknown

Short term:Client will identify selfas middle adult age(40–68).Client will identifynumber of productiveyears that are stillpossible.Client will rehearse thethings he would havedone if his wife had notdied and he had not hada stroke.

Long term:Client will identify thefactors he believedcaused the stroke.Client will discusschange in lifestylehabits.Client will discussaccomplishments, andhis previously desiredgoals beyond 68 years.

• Explore client’s previouslifestyle, diet, work, rest,sleep, and spirituality.

• Teach moderation andappropriate diet with 6–8glasses of water daily and aplanned exercise regimenwhen he begins to walk again.

• Encourage planningpositively and realistically.

• Encourage client to havehope for the future and writedown the things he wants toaccomplish until he becomesan older adult.

• Encourage the followingafter he leaves NorthsideNursing home:—Testicular exam every

month.—Complete physical exam

at least every 3 years.—Vision and hearing

screenings.—BP, EKG, cholesterol

screenings.—TB tests every 2 years.—Interaction with

community group whofosters positive lifestyle.

—Keep focused on initial lifegoals and work towardthese until totally unable.

• Exploration providesbaseline data fornursing intervention.

• Information contributesto knowledge base andchange in behavior.

• Encouragement buildsself-esteem.

• Writing aids in thesetting of goals.

• These steps teachhealth promotion, fostera healthy lifestyle,prolong longevity,generate hope and faith,encourage interactionand sharing, and fosterself-actualization.

Short-term goal met:Client expressed interest in the agedimension—thought 68 years wasvery old.Client stated he believed he could stillbe active at 80 years old.

Stated he wanted to travel to Europe,Australia, and probably theCaribbean, said the travel club was agood idea. Stated, “I am sorry I gotsick, but I believe I can turn my lifearound from here. Thank you, I mightbe able to marry again, someday. Iwish my wife knew all these things,she might not have died.”

Long-term goals met:Stated his diet consisted mainly ofhamburgers, pizzas, and soft drinks.Admitted drinking “a lot of beer, somealcohol, and smoked about a pack ofcigarettes a week.” 24-hour recalldone; rehearsed with client; low-fat,balanced diet with minimum salt and6 to 8 glasses of water discussed.

Admitted sleeping only 4 hours a day,since he worked 2 jobs. Deniedexercising on a regular basis.Verbalized desire to comply.


Self Actualization Needs


Documents

Assessment B4 According to Human Needs · PDF fileAssessment According to Human Needs Approach 51 Refer to Chapter 2 “Assessment,” p. 65: Care Plans Developed Using