53 a focus 2 basic needs & health:illness continuum

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Nursing Fundamentals Focus II Mrs. Judy Ontiveros, RN, MSN

Fall 2010

• Identify the basic human needs and explain the hierarchy of according to Maslow�’s view

• Explain how nurses use the hierarchy of basic needs taking into consideration human diversity in carrying out the nursing process.

• Define �“health�” and �“illness�”. Explain why the concept of the health illness continuum is useful in the nursing practice.

Objectives

Maslow�’s Pyramid

Physiological

Safety

Love and belonging

Self esteem

Deficit Needs

Realistic, sees life clearly, and is objectiveJudges people correctlyHas superior perception, is more decisiveHas clear notion of right and wrongIs usually accurate in predicting future eventsUnderstands art, music, politics, and philosophy

Maslow�’s Characteristics of the Self-actualized Person

Possesses humility, listens to others carefullyIs highly creative, flexible, spontaneous, courageous, and willing to make mistakesIs open to new ideasIs self-confident and has self respectHas low degree of self-conflict; personality is integratedRespects self, does not need fame, possesses a feeling of self controlIs highly independent, desires privacy


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Can appear remote and detachedIs friendly, loving, and governed more by inner directives than by societyCan make decisions contrary to popular opinionIs problem-centered rather than self-centeredAccepts the world for what it is


Nursing Process

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

Basic Physiologic Needs:

Mrs. C came in with advanced lung cancerStruggling to breatheNauseated from chemotherapyToo weak to get up aloneKnows she will die soon

Maslow�’s Basic Hierarchy

Basic Physiologic Needs

Nurses Priority


Ineffective breathing pattern related to obstructed airway

Ca of lungFluid build up in lungs


Imbalanced nutrition: less than body requirements, related to nausea and vomiting

Chemo therapyCoughing from cancer


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Bathing/hygiene self-care deficit related to generalized weakness

Advanced disease stateNausea and vomiting Lack of nutritious diet


Hopelessness related to coping with the diagnosis of a terminal illness


Safety and Security:

trusting nurse client relationship


Love and BelongingClient is important part of health care teamFamily members important


Self EsteemDevelops out of

relationships with othersDepression

Non-compliance


Self ActualizationA being need

Grows out of motivation to be all you can be


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Definition

Essential part of the nursing process

Nursing Health Assessment

Job: NurseTools: SensesClues:Modus Operandi:Mission:

Determine overall health statusHomeostasis vs. Disease

Nurse as Detective

Identify Priority AreasDetermine dataEstablish a data baseAnalyze the dataFollow up

Assessment Process

1. Subjective data collection2. Objective data collection 3. Validation of data4. Documentation of data

4 Major Steps in Nursing Assessment

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Subjective DataHistory

SymptomsObjective Data

Physical ExaminationSigns

Health Assessment Components

Critical Thinking

OLDCARTSOnset LocationDurationCharacteristicsAggravating or Alleviating FactorsRelated SymptomsTreatmentSeverity

Symptom Analysis

C haracteristics, S/S, look/feelO nsetL ocatitionD urationS everityP atternA ssociated factors

Symptom AnalysisCOLDSPA

Initial

Focus

Emergency

Ongoing

Types of Assessment

Active listening + processing

Observing

Interviewing

Data Collection Methods

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TYPESDirectedNon Directed

Stages of InterviewOpening BodyClosing

The Interview

Health History- Demographic data- Expectations and goals- Reason for visit

- Medical history- Family history- Functional health patterns

Organizing Data

Health Perception - Health Maintenance Pattern

Nutritional-Metabolic PatternElimination PatternActivity- Rest PatternSleep-Rest PatternCognitive - Perceptual Pattern

Review Functional Health Patterns

Physical Assessment

Head to Toe AssessmentVS, (Pain) AllergiesSymptom Analysis-

Presence of Pain (COLDSPA mnemonic)

NeuroSkin

CirculatoryMusculoskeletalGIGUEnergy levelUse of Assistive devices,

Psychosocial Assessment Interview: Observing behaviorsHealth Functional PatternsSelf conceptRoleCoping Value beliefsCulture

Assessment Basic Needs

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AssessmentObjective data:

Awake, anxious, Agitated. Skin warm, moist, color pale. VS: SPO2 93%, T101F, BP �– 118/70, P-100, R-30. Diminished breath sounds bil lungs. Dyspnea results on activity.

Subjective data:

c/of pain in lower left chest with inspirationStates she is very frightened.

Framework of Nursing Process

Diagnosis:

analysis of dataidentification of the problem to determine dx.A problem statement derived from assessment

data

Problem Statement

+ related to assessment data (NANDA)


Impaired Gas Exchange related factor excess secretions, weakness, pain 2nd to pneumonia

Example Nursing Diagnosis

Goal setting:Example Expected Outcomes:

Increased gas exchange as Evidenced by:Ease of breathingDyspnea at rest not present

Cyanosis not presentO2 sat WNL (98-100)%


Planning/Intervention:

Example Nursing Interventions:

Clear oral, nasal and tracheal secretions asneeded

Set up O2 equipment and administer through a heated humidified system

Administer 4L or O2 via NC


Evaluation/modification:

Example Evaluation Data:O2% sat 97%Sat in chair 20 minutes respirations 16, p 88, 130/90Temp 99.6FCough non - productive and tiring, antitussive given


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What is Health?

TraditionalFlorence NightengaleWHOSick Role1953 President�’s CommissionPersonal Definition

Health-Illness Continuum

Wellness Seven components of wellness

PhysicalSocialEmotionalIntellectualSpiritualOccupationalEnvironmental

Wellness and Well-Being

Dimensions of Wellness

Well-beingSubjective perception of vitality and feeling wellDescribed objectively, experienced, measuredPlotted on a continuum

A component of health

Wellness and Well-Being

What is Illness?Highly personal stateSeven areas of well being diminished. Not synonymous with diseaseMay or may not be related to a disease

Health Illness Continuum

DiseaseAlteration in body functions

Results in reduction of capacitiesResults in shortened life span

EtiologyCausation of disease

Health Illness Continuum

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:Health Illness Continuum

Internal BiologicPsychologicalCognitive Dimensions

Non ModifiableRegular Health ExamsAppropriate Screening

Variables Influencing Health Beliefs, Practices, Promotion of

Health

External VariablesEnvironmentStandards of LivingFamily and Cultural BeliefsSocial Support Networks

Variables Influencing Health Beliefs, Practices, Promotion

of Health

Biology:

Genetic makeup Family historyPast Medical History

Internal Variables

LifestyleOvereatingNo exerciseToo much saltOverweightSmokingReligious Beliefs

Risk Factors of Illness

Social Environment:

Social InteractionSocial InstitutionsIntellectual FactorsSocial Networks

External Variables

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Behaviors:Personal Choices Lifestyle FactorsFamily Health PracticesCultural Factors

External Variables

Public Policy:

Health Promotion and Disease Prevention- for individual and the communityEquitable Access to Health Care

External Variables

The Environment:

Work LifeSafety and SecurityEnvironmental Ecosystem

External Variables

Culture and Worldview

CommunicationCognition and PerceptionAge and Development LevelLifestyle and HabitsEconomic ResourcesRoles and RelationshipsCoping Stress ToleranceWorkplace and Environmental Conditions

Factors that Influence Behavior Change

Primary

Secondary

Tertiary

Prevention of Illness

53 a focus 2 basic needs & health:illness continuum

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