This document outlines Maslow's Hierarchy of Needs as a framework for understanding human motivation, emphasizing the importance of meeting foundational needs such as physiological requirements, safety, and belonging before achieving self-esteem and self-actualization. It describes the nursing process as a systematic method for delivering patient-focused care, highlighting characteristics like patient-centeredness and the need for critical thinking. Additionally, it covers documentation approaches in nursing, such as focus charting and SOAPIE notes, for monitoring patient status and nursing interventions.

1. NURSING PRIORITIZATION

2. MASLOW’S HEIRARCHY OF NEEDS
• Abraham Maslow noted that humans are
motivated to meet certain needs before they
can achieve a higher level of needs. In other
words, some conditions are foundational and
must be met before seeking to have
additional needs met.
• Visualized as a pyramid. Needs at the bottom
of the pyramid are required as prerequisites
to meeting needs higher on the pyramid. The
categories of needs in Maslow’s theory are as
follows

4. PHYSIOLOGICAL
NEEDS
SAFETY AND
SECURITY
LOVE AND
BELONGING
SELF ESTEEM SELF –
ACTUALIZATION
are biological
requirements
for human
survival, e.g., air,
food, drink,
shelter, clothing,
warmth, sex,
and sleep.
Our most basic
need is for
physical survival,
and this will be
the first thing
that motivates
our behavior.
Once that level is
fulfilled, the next
level up is what
people want to
experience
order,
predictability,
and control in
their lives.
Safety needs can
be fulfilled by the
family and society
refers to a
human
emotional need
for
interpersonal
relationships,
affiliating,
connectedness,
and being part
of a group.
Examples of
belongingness
needs include
friendship,
intimacy, trust,
acceptance,
receiving and
giving affection,
and love.
are the fourth
level in Maslow’s
hierarchy and
include self-
worth,
accomplishment
, and respect.
Esteem is the
typical human
desire to be
accepted and
valued by others.
People often
engage in a
profession or
hobby to gain
recognition,
which gives them
are the highest level
in Maslow’s hierarchy,
and refer to the
realization of a
person’s potential,
self-fulfillment,
seeking personal
growth, and peak
experiences.
This level of need refers
to what a person’s full
potential is and the
realization of that
potential.

5. ABC’S NURSING PRIORITIZATION
• ABC stand for (Airway, Breathing and
Circulation)
• Life-threatening circumstances may exist when
these ABCs of nursing are involved. If the
patient’s airway is not open, they cannot
breathe. If the patient’s breathing is shallow,
labored or hindered, the lack of oxygen intake
may instantly become extremely serious. If the
patient is profusely bleeding or circulation is
otherwise blocked or impaired, the body tissues
may not have the blood flow required to sustain
vital organ function.

7. NURSING
PROCESS

8. NURSING PROCESS PURPOSE
• is defined as a systematic, rational
method of planning that guides all
nursing actions in delivering holistic
and patient-focused care. The
nursing process is a form of
scientific reasoning and requires
the nurse’s critical thinking to
provide the best care possible to the
client.
•To identify the client’s health status and actual
or potential health care problems or needs
(through assessment).
•To establish plans to meet the identified
needs.
•To deliver specific nursing interventions to
meet those needs.
•To help the nurse perform in a systematically
organized way their practice.
•To establish a database about the client’s
health status, health concerns, response to
illness, and the ability to manage health care
needs.

9. CHARACTERISTICS OFTHENURSINGPROCESS
• Patient-centered. The unique approach of the nursing process requires
care respectful of and responsive to the individual patient’s needs,
preferences, and values.
• Interpersonal. The nursing process provides the basis for the therapeutic
process in which the nurse and patient respect each other as individuals,
both of them learning and growing due to the interaction.
• Collaborative. The nursing process functions effectively in nursing and
inter-professional teams, promoting open communication, mutual
respect, and shared decision-making to achieve quality patient care.
• Dynamic and cyclical. The nursing process is a dynamic, cyclical process
in which each phase interacts with and is influenced by the other phases.
• Requires critical thinking. The use of the nursing process requires
critical thinking which is a vital skill required for nurses in identifying
client problems and implementing interventions to promote effective care
outcomes.

11. FOCUS CHARTING
PREPARED BY: DAWN C. DEGAN, RN

12. PURPOSE OF FOCUS CHARTING
IDENTIFICATION
COMMUNICATION
DOCUMENTATION
PROGRESS
FOCUS
CHARTING

13. FOCUS CHARTING
• is a method for organizing health
information in the individual's
record. It is a systematic
approach to documentation,
using nursing terminology to
describe individual's health status
and nursing action.

14. SOAPIE CHARTING
• is a mnemonic for a type of progress note that is
organized by six categories. SOAPIE progress
notes are written by nurses, as well as other
members of the health care team.
• categories:
Subjective, Objective, Assessment, Plan, Interventi
ons, and Evaluation.

17. FDAR
• The newest method that is being use in
charting in nurse’s note to evaluate
patient and guides further nursing
care plans and planning.
• It has 4 categories (Focus – Data –
Assessment – Response)

18. ACTUAL
VS
POTENTIAL PROBLEM
ACTUAL
• Patient issues or problems that
are present and observable
during the assessment phase.
They are based on the presence
of certain signs or symptoms.
Example:
• Acute/Chronic Pain
• Hyperthermia
• Ineffective airway clearance
POTENTIAL
• Indicates the patient may
potentially experience a problem
but they do not have current signs or
symptoms of the problem actively
occurring.
• Risk that may happen or develop.
Example:
• Risk for fall
• Risk for bleeding
• Risk for suicide

19. FOCUS
• a key word or diagnostic category from a
nursing diagnosis or collaborative
problem on the plan of care (action plan)
• a current individual concern or
behavior, i.e. nausea, chest pain, pre-op
teaching, hospital admission
• a sign or symptom of (possible
importance to the nursing and/or medical
diagnosis or treatment plan.

20. DATA
• Data is the information about the
patient's current status. This can include
the patient's vital signs or a noticeable
change in the patient's condition or
behavior.

21. TWOTYPES OF DATA
SUBJECTIVE
• a data that comes from feelings,
experiences, opinions, and thoughts
of a patient.
• For example:
“ masakit po yung tiyan ko”
“ nasusuka po ako”
OBJECTIVE
• A data that are observed through your senses of
hearing, sight, smell, and touch while assessing
the patient.
• For example:
• Vital signs
• Pain scale (Wong-baker or numeric scale)
• Laboratory findings
• Physical examination (characteristics or behavior)
• IPPA assessment

22. ACTION
• This is the action the nurse takes in
response to the data. For example,
the nurse might replace a bandage if
they noticed it needed to be changed.

23. COMPONENTS OF ACTION
DIAGNOSITC (DX) THERAPEUTIC (TX) EDUCATIVE (EDX)
Information gathering and
clinical reasoning to
determine a patient's
health problem.
A medical intervention
intended to remediate a
health problem.
Teaching-learning process
between the nurse and
patient.
Health teachings.
Example:
• Assessed current health
status.
• Determined presence of
pain
• Monitored Vital signs
accordingly.
• Assisted in high fowlers
position
• Promoted rest and
comfort
• Administered medication
as ordered.
• Provided conducive
sleeping environment
• Instructed to increase
OFI
• Encouraged to do deep
breathing exercise
• Reiterated importance of
hand hygiene.
• Advised to report any
untoward signs and
symptoms.

24. RESPONSE
• This is the response that the patient shows
after receiving any treatment. A response can
be either positive or negative. It can be
supported with have a subjective or objective
data/s
For example:
• “nabwasan naman po yung sakit” as verbalized
by the patient. Pain scale rated as 4/10.
• “marunong na po ako” as verbalized. Patient
acknowledge health teaching imparted.

25. HOWTO WRITE FOCUS OR PROBLEM
Problem – Focus Diagnosis Risk Diagnosis Health promotion
(Problem/Diagnostic label)
+ related to + as evidence
by
Example:
Impaired physical mobility
related to decrease muscle
control as evidence inability
to control lower extremities
Acute pain related to tissue
ischemia as evidence by
(Risk/potential problem) +
as evidence by (risk
factors)
Example:
Risk for fall as evidence by
improper use of crutches
Risk for suicide as evidence
by history of attempt
(Health promotion label) +
as evidence by (defining
characteristics)
Example:
Readiness for enhanced
nutrition as evidence by
patient’s verbalization of
desire to change diet
Readiness for enhanced
coping as evidence by
desire to enhance

26. NURSE’S NOTES
DATE AND TIME FOCUS DATA,ACTION AND RESPONSE
AUG. 22, 2024
7 am
Hyperthermia Received awake with ongoing IVF of PNSS 1L
x 8 hours.
D> “parang ang init po ng pakiramdam ko”
as verbalized. Febrile, flushed skin, irritable,
lethargic with initial vital signs of Temp: 38.8,
BP: 130/90, RR: 21, Spo2: 94% upon initial
assessment.
A> Assessed current health status, Identified
the triggering factors, Monitored Vital signs
and recorded according, Assisted in
removing excess clothing, Provided thin
linens, Administered antipyretic medication
as ordered. Demonstrated Tepid sponge
bath as alternative way to decrease high
temperature. Instructed to drink ample of

27. CASE SCENARIO: Actual
• A 31 year old female, G1P0 (0000) 39 weeks age of gestation, came in with a
chief complaint of hypogastric pain and cannot be relieved by walking.
“sobrang sakit po ng tiyan ko” as verbalized by the patient. Her
contractions lasting for 30-40 seconds with 3-5 minutes apart. Pain scale
rated as 7 out 10. Grimace noted. Patient was nauseated. Latest Internal
Examination (IE) of 7cm, Vital signs taken: BP: 130/80, PR: 101, RR:21, SPO2:
95% at room air upon initial assessment.

28. Case Scenario: Potential
• A 31 year old, female. G1P1(1001) was room in to OB Ward after delivering
her neonate via normal spontaneous delivery with right mediolateral
episiotomy. Patient has IV Therapy of PLRS 1L + 10 units oxytocin x 8
hours at level of 800cc. Pain rated as 4/10, with slightly boggy uterus,
Latest vital signs take: BP 100/70, RR: 21, T: 39.5 spo2: 95% PR; 110.

29. NURSING CARE PLAN

30. WHATIS NCP?
• A formal process that correctly identifies
existing needs and recognizes a client’s
potential needs or risks. Care plans
provide a way of communication among
nurses, their patients, and other
healthcare providers to achieve healthcare
outcomes. Without the nursing
care planning process, the quality and
consistency of patient care would be lost.

31. OBJECTIVES
• Promote evidence-based nursing care and
render pleasant and familiar conditions in
hospitals or health centers.
• Support holistic care, which involves the whole
person, including physical, psychological, social,
and spiritual, with the management and
prevention of the disease.
• Establish programs such as care pathways and
care bundles. Care pathways involve a team effort
to reach a consensus regarding standards of care
and expected outcomes. In contrast, care bundles
are related to best practices concerning care for a
specific disease.
• Identify and distinguish goals and expected
outcomes.
• Review communication and documentation of the
care plan.
• Measure nursing care.
PURPOSE
• Defines nurse’s role. Care plans help identify nurses’
unique and independent role in attending to clients’ overall
health and
• Provides direction for individualized care of the client. It
serves as a roadmap for the care that will be provided to the
patient and allows the nurse to think critically in developing
interventions directly tailored to the individual.
• Continuity of care. Nurses from different shifts or
departments can use the data to render the same quality
and type of interventions to care for clients
• Coordinate care. Ensures that all members of the
healthcare team are aware of the patient’s care needs
• Documentation. It should accurately outline which
observations to make, what nursing actions to carry out,
and what instructions the client or family members require.
• Serves as a guide for assigning a specific staff to a
specific client.
• Monitor progress. To help track the patient’s progress and
make necessary adjustments to the care plan
• Defines client’s goals. It benefits nurses and clients by
involving them in their treatment and care.

32. COMPONENTS OF NCP

33. DATA
• These are your gathered assessment
to your patient which include your:
Subjective data: verbalized by the
patient
Objectives: head to toe assessment,
physical examination and laboratories.
RN Diagnosis: with the use of NANDA
References: books or website. With
proper citations (APA)

34. PATHOPHYSIOLOGY
• The explanation of your nursing problem
or how you come up with the nursing
diagnosis using your assessments as
reference by showing it through diagram

35. GOALS
SHORT TERM GOALS
• This is your goal after a shift or 1-3
days of admission of your patient.
For example:
• After 6 hours of nursing intervention
patient’s fever decrease from 39.1 to
37.5 Degree Celsius.
• After 2 days, patient will be able to
ambulate with assist.
LONG TERM GOALS
• This is your goal to your patient
which can take a week , month/s or
year
For example:
• After 3 days, Patient displays
improvement in mood, coping.
• After 1 week, Patient demonstrates
the use of appropriate diversional
activities and relaxation skills.

36. NURSING INTERVENTION WITH RATIONALE
NURSING INTERVETION RATIONALE
• These are your nursing intervention (what you
did to your patient to solve nursing problems)
• This still follows your diagnostics, therapeutic
and educative.
For example:
Dx:
Monitor vital signs especially respiration.
Tx:
Assist patient to high fowler’s position to assume
comfort.
Edx:
Demonstrated effective coughing and DBE
• The reason behind the nursing intervention you
did to your patient
• Breathing pattern is vital for client’s survival
and may result to complications.
• It facilitates respiratory function of use of
gravity
• It helps maximize ventilation.

37. EVALUATION
• Evaluates the desired outcome/progress of
your short and long term goal.
• Not met: The goal was not achieved.
• Partially met: Some, but not all aspects of
the goals were achieved.
• Fully met: means there was complete
evidence that satisfied the entire best
practice.
For example:
After 1 day of nursing intervention, the goals
were fully met as evidence by able to do DBE

38. DATA PATHOPHYSIOLOGY OBJECTIVES NURSING
INTERVENTION
RATIONALE EVALUATION
Subjective:
“Nahihirapan ako
huminga”
Objective:
-use of accessory
muscle.
-dyspnea
Productive cough
noted.
-cyanotic lips
-vital signs:
RR: 26
SPO2: 93%
- Crackles noted
upon auscultation
Diagnostics:
Ineffective Airway
clearance related to
increased production
secretions.
References:
Ineffective Airway
Clearance Nursing
Care Plan |
Diagnosis &
Intervention. (2024,
July 15). Simple
Nursing.
https://simplenursin
g.com/nursing-care-
plan-ineffective-
airway-clearance/
Long term chain smoker for years
Exhibits more than 3 months of
productive cough
Diagnose with COPD
Airflow limitations
Exhibits difficulty of breathing due to
thick secretions
Short term:
1 day of nursing
intervention
patient will be
able to:
- Demonstrate
therapeutic
technique such
as DBE.
- Verbalize
comfort when
breathing.
Long term:
After 3 days of
nursing
intervention
patient will be
able to:
-can cough
effectively and
expectorate
secretion
-maintain patent
airway
- Difficulty of
breathing will be
lessen
Dx:
Assess and monitor vital
signs especially respiratory
rate
Assess breath sounds using
auscultation technique
Tx:
Assist patient in high fowlers
position
Promoted rest and comfort
Edx:
Demonstrate abdominal and
purse lip breathing
Instruct back tapping when
coughing or after
nebulization
Breathing pattern is
vital for patient’s
survival.
For further
assessment for
obstructions of airway
To facilitates
respiratory function
Decrease fear for
current situation
Provide some means
to cope with/control
dyspnea
To prevent possible
aspiration/s.
Short term:
After 1 day of nursing
intervention, goal met as
evidence by demonstrated
proper therapeutic
technique and verbalized
comfort when breathing.
Long term:
After 3 days of nursing
intervention, goal met as
evidence by patient can
cough effectively and
expectorate secretion,
maintain airway and
difficulty of breathing was
lessen.

40. THE END