8/30/2011                                                                    Deficit Needs                                ...
8/30/2011Maslow’’s Characteristics of                                                                               Maslow...
8/30/2011Maslow’’s Basic Hierarchy               Maslow’’s Basic Hierarchy  Bathing/hygiene self-care deficit     Love and...
8/30/2011   Nursing Health    Assessment            Nurse as DetectiveDefinition                Job: Nurse                ...
8/30/2011          Health Assessment                         Symptom Analysis            Components                       ...
8/30/2011             The Interview                 Physical Assessment   TYPES                                 Head to To...
8/30/2011     Framework of Nursing                                             Framework of Nursing           Process     ...
8/30/2011Health-Illness Continuum         Wellness and Well-Being What is Health?                  Well-being             ...
8/30/2011Health Illness Continuum                 Internal Variables                    :                                 ...
8/30/2011                                        Factors that Influence    External Variables                             ...
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basic needs & health:illness continuum

  1. 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. 2. 8/30/2011Maslow’’s Characteristics of Maslow’’s Basic Hierarchythe 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 lungsFigure 11-2 The five overlapping phases of the nursing process. Each phasedepends on the accuracy of the other phases. Each phase involves criticalthinking. Berman, pg. 180Maslow’’s Basic Hierarchy Maslow’’s Basic HierarchyBasic 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. 3. 8/30/2011Maslow’’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 dietMaslow’’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-complianceMaslow’’s Basic Hierarchy Maslow’’s Basic HierarchySafety and Security: Self Actualization A being need trusting nurse client relationship Grows out of motivation to be all you can be 3
  4. 4. 8/30/2011 Nursing Health Assessment Nurse as DetectiveDefinition 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. 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 OLDCARTSOnset Active listening + processingLocationDurationCharacteristics ObservingAggravating or Alleviating FactorsRelated SymptomsTreatment InterviewingSeverity 5
  6. 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 CultureReview Functional Health PatternsHealth Perception - Health Maintenance PatternNutritional-Metabolic PatternElimination PatternActivity- Rest PatternSleep-Rest PatternCognitive - Perceptual Pattern 6
  7. 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 neededProblem 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. 8/30/2011Health-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 healthWellness 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 EnvironmentalDimensions 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. 9. 8/30/2011Health 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 BeliefsVariables Influencing HealthBeliefs, 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. 10. 8/30/2011 Factors that Influence External Variables Behavior Change Culture and WorldviewBehaviors: 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 IllnessPublic Policy: PrimaryHealth Promotion and DiseasePrevention- for individual and thecommunity SecondaryEquitable Access to Health Care Tertiary External VariablesThe Environment: Work Life Safety and Security Environmental Ecosystem 10