TLB - Maslow, The Nursing Process, Collecting Data, NANDA, Care Plan,

Implementing activities

1. Carry out the care plan. 2. Continue data collection, and modify the care plan as needed. 3. Document care.

self-esteem

B

Implementing description

Carrying out the care plan

The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply. Preventing falls in the facility Changing a patient's oxygen tank Providing materials for a patient who likes to draw Helping a patient eat his dinner Facilitating a visit from a spouse Referring a patient to a cancer support group.

Changing a patient's oxygen tank Helping a patient eat his dinner

assessment description

Collection, validation, and communication of patient data is the first step in the nursing process Data can be obtained from the patient, family, or other sources as well as from the physical examination.

Environmental dimension

Safety and Security needs: housing community/neighborhood climate

Intellectual and spiritual Dimensions

Self-actualization needs: thinking learning decision making beliefs values fulfillment helping others

love and belonging

c

safety and security

d

unmet love and belonging needs signs

person withdrawal physically and emotionally person become overly demanding and critical

A nurse is reviewing a journal article about basic human needs and how they can be applied as a framework for prioritizing nursing care. Place the interventions listed below in order of priority, based on client needs. Use all options. 1. Encouraging the clients spiritual practices 2. Providing education focusing on the client's strengths to maximize potential 3. encouraging the client to set attainable goals 4. ensuring adequate fluid intake 5. referring the client to a support group

4. Ensuring adequate fluid intake 1. Encouraging the client's spiritual practices 5. Referring the client to a support group 3. Encouraging the client to set attainable goals 2. Providing education focusing on the client's strengths to maximize potential The nurse would prioritize the client's physiologic needs first (adequate fluid intake), then safety and security (spiritual practices), followed by love and belonging (support group), self-esteem (setting attainable goals), and finally self-actualization (strengths to maximize potential).

The nursing process provides a framework that enables the nurse, along with the patient, to accomplish the following:

Systematically collect patient data (assessing) Clearly identify patient strengths and actual and potential problems (diagnosing) Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning) Execute the care plan (implementing) Evaluate the effectiveness of the care plan in terms of patient goal achievement (evaluating)

Nursing process is systematic

The nursing process directs each step of nursing care in a sequential, ordered manner. Each activity depends on the accuracy of the activity that precedes it and influences the actions that follow it.

A nurse caring for patients in a long-term care facility uses available resources to help patients achieve Maslow's highest level of needs: self-actualization needs. Which statements accurately describe these needs? Select all that apply. Humans are born with a fully developed sense of self-actualization. Self-actualization needs are met by depending on others for help. The self-actualization process continues throughout life. Loneliness and isolation occur when self-actualization needs are unmet. A person achieves self-actualization by focusing on problems outside self. Self-actualization needs may be met by creatively solving problems.

The self-actualization process continues throughout life. A person achieves self-actualization by focusing on problems outside self. Self-actualization needs may be met by creatively solving problems.

love and belonging needs

understanding and acceptance of others in both giving and receiving love feeling of belonging to groups such as families, peers, friends, neighborhood, community lonely and isolated if needs are not met

evaluating patient's nutritional status

weight muscle mass strengh lab values

nurse activities to meet patients physical safety needs

* using proper hand hygiene and sterile techniques to prevent infection * using electrical equipment properly *administering medication knowledgeably *skillfully moving and ambulating patients *teaching parents about household chemicals that are dangerous to children

self-actualization

A

systematic person-centered observation:

H = Help: Observe the first signs patient may need help. Look for signs of distress (pallor, pain, labored breathing). E = Environmental equipment: Look for safety hazards; ensure that all equipment is working (IVs, oxygen, catheter). L = Look: Examine patient thoroughly. P = People: Who are the people in the room? What are they doing? Whichever approach you use for structuring your nursing assessment, always conclude by asking the patient if there is anything else he or she would like you to know so that you will be better able to provide care. This allows the patient to address anything critical that you may have missed.

Most essential of all needs

Oxygen

Human Dimensions

Physical, Environmental, Sociocultural, Emotional, Intellectual & Spiritual

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? Patient-centered care Evidence-based practice Quality improvement Informatics

Quality improvement Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs? Self-actualization Self-esteem Love and belonging Safety and security

Safety and security Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as moving and ambulating patients. Assisting the patient to ambulate ensures that the patient will not experience a fall. From the bottom of the hierarchy upwards, the needs are: physiological, safety, love and belonging, esteem and self-actualization. The third stage in Maslow's hierarchy of needs is the social stage (also known as the love and belonging stage), which includes interpersonal relationships. Human behavior is driven by needs, one of which is the need for a sense of personal importance, value or self-esteem. Self-actualization represents growth of an individual toward fulfillment of the highest needs; those for meaning in life, in particular.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? The nurse judges whether the patient database is adequate to address the problem. The nurse considers whether or not to suggest a counseling session for the patient. The nurse reassesses the patient and decides how best to intervene in her care. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

The nurse reassesses the patient and decides how best to intervene in her care. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

qualities that indicate self actualization

*acceptance of self and others as they are * focus of interest on problems outside oneself *ability to be objective *feeling of happiness and affection for others *respect for all people *ability to discriminate between good and evil *creativity as a guideline for solving problems and pursuing interests

what can negatively affect self esteem

*when a person's role changes: illness, death of a spouse *change in body image: mastectomy, injury, puberty

3 types of reflexion

1. Reflection in action happens in the here and now of the activity and is also known as "thinking on your feet." 2.Reflection on action occurs after the fact and involves thinking through a situation that has occurred in the past. It is used as a means of evaluating the experience and deciding what could have been done differently. 3. Reflection for action is the desired outcome of the first two types of reflection: it helps the person to think about how future actions might change as a result of the reflection.

medical model

A medical model often organizes data collection according to body systems. Although the medical model is helpful for formulating diagnoses related to physiologic problems, it neglects patient problems and strengths in psychosocial and spiritual dimensions of health and well-being.

Which client requires priority intervention by a nurse providing care on a medical-surgical unit? A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min An older adult client who is yelling and angry with family members A client with a blood pressure of 98/40 mm Hg who needs to ambulate to the bathroom A newly admitted client who is upset due to a new cancer diagnosis

A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min According to Maslow, the first-level physiologic needs are the most important. They are the activities necessary to sustain life, such as breathing, circulation, and eating. Using Maslow's theory and the ABCs (airway, breathing, circulation) to help prioritize care of clients, the nurse needs to see the client experiencing acute problems with circulation and a heart rate of 45 beats/min. All other client problems are not the priority at this time.

Nursing Process is Dynamic

Although the nursing process is presented as an orderly progression of steps, in reality, there is great interaction and overlapping among the five steps. No single step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

example of nursing process in action

Assessing You are checking on a patient who had abdominal surgery yesterday and hear that the patient has considerable pain: "It kept me up all night." The patient has been reluctant to ask for any pain medication, fearing effects of the drug. "I don't want to become a junkie." The patient's blood pressure and pulse rate are slightly elevated. Diagnosing You analyze the data just described and write the nursing diagnosis: Unrelieved pain related to a fear of taking pain-relieving medications. The patient agrees that this is becoming a problem. Outcome Identification and Planning You decide to work with the patient to achieve the outcome: By 1500, patient reports sufficient relief of pain to enable him to rest and to get out of bed to go to the bathroom. The patient wants to accomplish the outcome. You identify teaching as the primary nursing intervention. Implementing After asking the patient about his experiences with pain-relieving medications, you explain that although many of these drugs are addictive when abused, there is no harm if they are taken as prescribed postoperatively. You also explain that it is important for him to experience enough pain relief to be able to cough and deep breathe, ambulate, and do other things important to his recovery. You suggest that the medication will be most effective if taken before his pain peaks and becomes intense. You administer the prescribed medication for pain when the patient indicates that he is willing to give it a try. Evaluating After enough time has elapsed for the medication to take effect, you check back with the patient to evaluate whether he has obtained relief and met his outcome. If the patient is satisfied and you both feel that comfort is no longer a problem, you terminate the care plan for this diagnosis. If the patient still feels pain or is dissatisfied with the medication, each of the preceding steps of the nursing process is re-evaluated, and necessary changes are made in the care plan.

Gibbs Model of reflection

Description What happened? Don't make judgments yet or try to draw conclusions; simply describe. Feelings What were your reactions and feelings? Again, don't move to analyzing these yet. Evaluation What was bad or good about the experience? Make value judgments. Analysis What sense can you make of the situation? Bring in ideas from outside the experience to help you. What was really going on? Were different people's experiences similar or different in important ways? Conclusions (general) What can be concluded, in a general sense, from these experiences and the analyses you have undertaken? Conclusions (specific) What can be concluded about your own specific, unique, personal situation or way of working? Personal Action Plan What are you going to do differently in this type of situation next time? What steps are you going to take on the basis of what you have learned?

sociocultural dimension

Love and belonging needs: relationships communication support systems being a part of a community feeling loved and loving others

During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs? Self-esteem Physiologic Love and belonging Safety and security

Physiologic Rest is a basic physiologic need, because it allows time for the body to rejuvenate and be free of stress. Lack of sleep and rest may become a safety issue if not addressed. Love and belonging is related to acceptance in a group. Self-esteem is related to how one sees one's self.

physiologic

e

Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) focus and purposes

focus: Comprehensive clinical terminology purpose: Integrate, link, and map terms from various disciplines such as medicine, nursing, and occupational therapy. Website: https://www.nlm.nih.gov/healthit/snomedct/index.html

evaluating patient's oxygen needs

skin color vital signs anxiety levels response to activity restlessness mental responsiveness

self esteem needs

the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments

nurse activities to meet patients self actualization needs

the nurse focuses on the pts strengths and possibilities rather than on problems nurses interventions are aimed at providing a sense of direction and hope and providing teaching that is aimed at maximizing potentials

assessment checklist

❑ The initial database is obtained by means of a nursing history and nursing examination. ❑ Assessment data are documented: ❑ Accurately—Questionable data are validated. ❑ Completely—Use of a systematic guide ensures that recorded data describe (1) the patient's functional ability to meet each basic human need, and (2) responses to health and illness. ❑ Concisely—Irrelevant data and meaningless generalizations are avoided. ❑ Factually—Patient behaviors are recorded rather than the nurse's interpretation of these behaviors. ❑ Timely—Current data are recorded for the team. ❑ The initial database communicates a "real sense" of the patient that makes possible individualized care. ❑ Focused assessment data are recorded for each patient problem. ❑ Data collection and documentation are ongoing and responsive to changes in the patient's condition.

Implementing checklist

❑ The patient record contains daily documentation of the nursing measures used to (1) assist the patient to meet basic human needs, (2) resolve health problems, and (3) implement select aspects of the medical care plan. ❑ The care plan is implemented: ❑ Competently ❑ Confidently ❑ Caringly ❑ Creatively

Nursing is....

is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" (ANA, 2010, p. 6)

characteristics of the nursing process

systematic, dynamic, interpersonal, outcome oriented, and universally applicable

Assesment activities

1. Establish the database: • Nursing history • Physical assessment • Review of patient record and nursing literature • Consultation with the patient's support people and health care professionals 2. Continuously update the database. 3. Validate data. 4. Communicate data.

diagnosing activities

1. Interpret and analyze patient data. 2. Identify patient strengths and health problems. 3. Formulate and validate nursing diagnoses/problems. 4. Develop prioritized list of nursing diagnoses/problems.

Outcome identification and planning purpose

Develop an individualized plan of nursing care. Identify patient strengths that can be tapped to facilitate achievement of desired outcomes.

Assessment purpose

Make a judgment about the patient's health status, ability to manage his or her own health care, and need for nursing. Plan individualized holistic care that draws on patient strengths and is responsive to changes in the patient's conditions.

The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse? Physiologic Safety and security Self-esteem Love and belonging

Safety and security

nurse activities to meet patients love and belonging needs

*including family and friends in the care of the patient *establishing a nurse-patient relationship based on mutual understanding and trust (by demonstrating care, encouraging communication, and respecting privacy) * referring patients to specific supporting groups (cancer support, AA)

nurse activities to meet patients self esteem needs

*respecting patient values and beliefs *encouraging patients to set attainable goals *facilitating support from families or significant others these actions promote sense of worth and self-acceptance

Evaluation Purpose

Continue, modify, or terminate nursing care.

Objective data

Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient. Examples of objective data are an elevated temperature reading (e.g., 101°F), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or overt data.

nurse activities to meet patients emotional safety needs

encouraging spiritual practices that provide strength and support by allowing as much independent decision making and control as possible carefully explaining new and unfamiliar procedures and treatments

Higher level needs

love and belonging, self-esteem, self-actualization

evaluating patient's water balance

measuring intake and output testing the resilience of the skin checking the condition of the skin and mucous membrane weighing the patient

physiologic needs

need for: oxygen, water, food, elimination, temperature, sexuality, physical activity, rest; must be met at least minimally to maintain life, and therefore have the highest priority

Evaluating checklist

❑ Evaluative statements are recorded on the care plan to document the patient's level of outcome achievement at targeted times. ❑ Ongoing evaluation of the patient's responses to the care plan is used to make decisions about terminating, continuing, or modifying nursing care.

Read the following patient scenario and identify the step of the nursing process represented by each numbered and boldfaced nursing activity. Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape ("I don't want to think or talk about it"), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believes that Angela might be experiencing (2) rape-trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) to develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If she is not making progress, the care plan might need to be modified. (1) _____________________ (2) _____________________ (3) _____________________ (4) _____________________ (5) _____________________

(1) assessment (2) diagnoses (3) planning/outcome identification (4) implementing (5)evaluation/

Outcome identification and planning purpose activities

1. Establish priorities. 2. Write outcomes and develop an evaluative strategy. 3. Select nursing interventions. 4. Communicate plan of nursing care.

Something is a basic need if

1. Its lack of fulfillment results in illness 2. its fulfillment helps prevent illness or signal health 3. meeting it restores health 4. it takes priorities over other desires and needs when unmet 5. the person feels something is missing when the need is unmet 6. the person feels satisfaction when the need is met nursing interventions are aimed at meeting the patient's basic needs

Evaluation Activities

1. Measure how well the patient has achieved desired outcomes. 2. Identify factors that contribute to the patient's success or failure. 3. Modify the care plan (if indicated).

Diagnosing description

Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve

Implementing purpose

Assist patients to achieve desired outcomes—promote wellness, prevent disease and illness, restore health, and facilitate coping with altered functioning.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: Clinical judgment Clinical reasoning Critical thinking Blended competencies

Clinical Judgment Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients

According to Schmehl (2014), the basic steps in concept map care planning are as follows:

Collect patient problems and concerns on a list. Remember that this list can include a symptom, a lab value, a diagnostic test result, a treatment, or collaborative care concerns. These data can be obtained by you from the assessment, from the patient directly, from the medical record, and from interactions with the interprofessional team. Connect and analyze the relationships, differentiating between groupings of main and related problems. Take time to question, compare, contrast, and group your data. Create a diagram demonstrating problem recognition, critical thinking, and nursing actions. Use shapes, connecting lines, descriptive phrases, and learning styles to emphasize nursing actions related to the care plan. As your concept maps become more complex, use a key with your diagram to keep track of what each box, link, shape, or color represents. Keep in mind that creativity is encouraged; no two maps will look the same! Keep in mind key concepts: the nursing process, holism, safety, and advocacy.

Home Health Care Classification (HHCC) focus and purpose

focus: Diagnoses, interventions, and outcomes purpose: Provide a structure for documenting and classifying home health and ambulatory care. Consists of two interrelated taxonomies: HHCC of Nursing Diagnoses and HHCC of Nursing Interventions. Website: http://www.sabacare.com

nurses work to

to promote or restore health, prevent disease or illness, and facilitate coping with altered functioning.

Nursing process is interpersonal

The nursing process ensures that nurses are person centered rather than task centered Rather than simply approaching a patient to take vital signs, the nurse might ask, "How are you today, Mr. Byrd?

Nursing process is Outcome oriented

The nursing process offers a means for nurses and patients to work together to identify specific outcomes related to health promotion, disease and illness prevention, health restoration, and coping with altered functioning; to determine which outcomes are most important to the patient; and to match them with the appropriate nursing actions.

emotional safety and security

trusting others and being free of fear, anxiety, and apprehension patients entering the health care system often fear the unknown and may have significant emotional security needs

diagnosing purpose

Develop a prioritized list of nursing diagnoses/problems/issues

Evaluation description

During the evaluation phase, the nurse reviews the patient's outcome attainment and determines if outcomes have been met, partially met, or not met. Evidence interpretation is more associated with the diagnosing phase. Measuring the extent to which the patient has achieved the outcomes specified in the care plan; identifying factors that positively or negatively influenced outcome achievement; revising the care plan if necessary

A nurse uses Maslow's hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful? Making accurate nursing diagnoses Establishing priorities of care Communicating concerns more concisely Integrating science into nursing care

Establishing priorities of care

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? Systematic Interpersonal Dynamic Universally applicable in nursing situations

Interpersonal . Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. It functions independently of nursing standards, ethics, and state practice acts. It is based on the principles of the nursing process, problem solving, and the scientific method. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. It is not designed to compensate for problems created by human nature, such as medication errors. It is constantly re-evaluating, self-correcting, and striving for improvement. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

It is based on the principles of the nursing process, problem solving, and the scientific method. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care It is constantly re-evaluating, self-correcting, and striving for improvement. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve

Physical Dimension

Physiologic needs: breathing circulation temperature intake of food and fluids elimination of wastes movement

A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing? Safety and security Self-esteem Physiologic Love and belonging

Safety and security Safety and security needs have both physical and emotional components. Physical safety and security means being protected from potential or actual harm. Emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension. Physiologic needs are the most basic in the hierarchy and the most essential to life. They must be met at least minimally to maintain life. Love and belonging needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. Self-esteem needs include the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.

Emotional dimension

Self-esteem needs: fear sadness Loneliness Happiness accepting self

Outcome identification and planning description

Specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses; and (2) related nursing interventions

Subjective data

Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, or chilly, and experiencing pain. Subjective data also are called symptoms or covert data.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? Travelbee's Watson's Benner's Swanson's

Swanson Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. The nurse uses critical thinking skills to plan care for a patient. The nurse correctly administers IV saline to a patient who is dehydrated. The nurse assists a patient to fill out an informed consent form. The nurse learns the correct dosages for patient pain medications. The nurse comforts a mother whose baby was born with Down syndrome. The nurse uses the proper procedure to catheterize a female patient.

The nurse uses critical thinking skills to plan care for a patient. The nurse learns the correct dosages for patient pain medications. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

Universally applicable in nursing situations

When nurses have a working knowledge of the nursing process, they find that they can practice nursing with well or ill people, young or old, in any type of practice setting. Mastering the nursing process gives you a valuable tool you can use with ease in any nursing situation.

The nursing process is

a systematic method that directs the nurse, with the patient's participation, to accomplish the following: (1) assess the patient to determine the need for nursing care, (2) determine nursing diagnoses for actual and potential health problems, (3) identify expected outcomes and plan care, (4) implement the care, and (5) evaluate the results. each step depends on the accuracy of the steps preceding it.

five-step nursing process commonly used today:

assessment, diagnosis, outcome identification and planning, implementation, and evaluation. The nursing process encompasses all significant actions taken by registered nurses and forms the foundation of the nurse's decision making (ANA, 2015b). Although the ANA refers to a six-step nursing process, many practitioners still commonly refer to a five-step nursing process that combines outcome identification and planning into one step.

Yura and Walsh (1967) four steps in the nursing process:

assessment, planning, intervention, and evaluation. They viewed the nursing diagnosis as the logical conclusion of the assessment

International Classification for Nursing Practice (ICNP) focus and purposes

focus: Diagnoses, interventions, and outcomes purpose: Capture nursing's contributions to health and provide a framework into which existing vocabularies and classifications can be cross-mapped, enabling comparison of nursing data from various countries throughout the world. Website: http://www.icn.ch/what-we-do/ehealth

North American Nursing Diagnosis Association (NANDA) International focus and purpose

focus: diagnoses purpose: Increase the visibility of nursing's contribution to patient care by continuing to develop, refine, and classify phenomena of concern to nurses (see Nursing Diagnosis Quick Reference section). Website: www.nanda.org

Nursing Interventions Classification (NIC) focus and purpose

focus: interventions purpose: Identify, label, validate, and classify actions nurses perform, including direct and indirect care interventions (interventions done directly with patients, e.g., teaching; those done indirectly, e.g., obtaining laboratory studies). Website: https://nursing.uiowa.edu/cncce/nursing-interventions-classification-overview

Nursing-Sensitive Outcomes Classification (NOC) focus and purpose

focus: outcomes purpose: Identify, label, validate, and classify nursing-sensitive patient outcomes and indicators to evaluate the validity and usefulness of the classification, and define and test measurement procedures for the outcomes and indicators. Website: https://nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview

self actualization needs

highest level on the hierarchy of needs, which include the need for individuals to reach their full potential through development of their unique capabilities the process of self actualization continues throughout life

Safety and security needs

physical and emotional component physical: being protected from potential or actual harm

Lower levels needs

physiological safety and security

Maslow's basic human needs

physiological, safety and security love and belonging, self esteem, self-actualization

Outcome Identification and Planning checklist

❑ A comprehensive, individualized, and up-to-date care plan that specifies patient outcomes and nursing orders for each nursing diagnosis is developed with the assistance of the patient and family. ❑ Planning is comprehensive: ❑ Initial ❑ Ongoing ❑ Discharge ❑ Long-term goals alert the entire nursing team to realistic patient expectations after discharge. ❑ Short-term outcomes: ❑ When achieved, demonstrate a resolution of the problem specified in the nursing diagnosis ❑ Describe a single, observable, and measurable patient behavior ❑ Are valued by the patient and family ❑ Are realistic in terms of the resources of the patient and the nurse ❑ Nursing orders: ❑ Clearly and concisely describe the nursing intervention to be performed (ongoing assessment; nursing treatments and procedures; teaching, counseling, advocacy) ❑ Are individualized to the patient ❑ Are consistent with standards of care and supportive of other therapies ❑ Are effective in accomplishing the desired patient outcomes ❑ The care plan encourages patient and family participation

diagnosing checklist

❑ A prioritized list of nursing diagnoses/problems is in the care plan. ❑ Each nursing diagnosis describes an actual or potential patient health problem that independent nursing intervention can prevent or resolve. Each nursing diagnosis: ❑ Is derived from an accurate and validated interpretation of a cluster of significant patient data or "cues" ❑ Contains a precise problem statement describing what is unhealthy about the patient and what needs to change—suggests patient goals ❑ Identifies factors that contribute to the problem (etiology)—these suggest nursing interventions ❑ Uses nonjudgmental language and is written using legally advisable terms ❑ Old nursing diagnoses are deleted from the care plan once resolved, and new diagnoses are added as soon as identified.