Nursing Process, Maslow, Assessment, and Patient Care (Vocabulary flashcards)
Maslow, Assessment, and the Nursing Process: Comprehensive Exam Notes
Are we assessing before action? The emphasis is on assessment first, especially in acute scenarios. Example: when a patient is in pain, you ask clarifying questions to quantify and understand the problem before calling a doctor. Use a pain scale from 1–10; determine onset, qualities, triggers, and related factors.
Question sequence: What’s your pain level? How are you feeling? What can I do for you? When did it start? Can you describe it? Did you eat something? Gather complete information before involving the physician.
Very rare to call the doctor as the first action; the nurse must assess first.
Maslow’s hierarchy in clinical practice
Maslow’s framework guides nursing assessment and the order of addressing needs: physiological needs prioritized first, then safety, love/belonging, self-esteem, and self-actualization.
In mental health or acute distress (e.g., shortness of breath or high anxiety), you must address physiological needs first (oxygen, breathing) before addressing higher-order needs.
The eight psychological/physiological needs (from the transcript): ext{Oxygen}, ext{Water}, ext{Food}, ext{Elimination}, ext{Temperature}, ext{Sexuality}, ext{Physical activity}, ext{Rest}
Most common focus is on the physiological needs with the mental health needs embedded; the hierarchy is a ladder you climb, not a flat checklist.
Example emphasis: if a patient is short of breath or anxious, treat breathing and safety first before addressing psychological comfort.
Prioritizing safety and security (physical and emotional)
Physical safety components: hand hygiene, proper use of PPE, rail up when leaving the room, call bell within reach, bed in lowest position when not in use, table within reach.
Hand hygiene and infection control (C. diff context): sanitize hands before and after entering/exiting rooms; gloves as needed; wash hands between patients.
Emotional/psychological safety: communicate what you’re going to do, explain procedures, provide reassurance, and build trust through empathetic communication.
Discomfort and anxiety: avoid increasing patient anxiety (e.g., telling a patient you’ll be back in five minutes); instead, use non-promising language like “I’ll be back shortly.”
In practice, safety and security also include addressing environmental changes (e.g., Alzheimer’s patients or unfamiliar rooms) and ensuring supports are in place.
Love and belonging in care
Concept: patients need to feel understood, accepted, and that they belong and are cared for.
Trust-building through consistent presence, empathy, and therapeutic communication.
Practical tips: avoid making patients feel neglected; acknowledge anxiety; explain actions; involve family and caregiver when appropriate; maintain consistent, transparent communication.
Respect and independence: empower patients to do as much as they can (do not enable passivity); solicit and respect patient preferences and capabilities.
Family dynamics: families are anxious and want information; clinicians should address families with empathy and clear information.
Self-esteem and self-actualization in nursing care
Self-esteem: respect and dignity for every patient; even if a patient is challenging, start from a calm, respectful approach.
Self-actualization: helping patients reach their maximal potential; in nursing practice, this is less of a daily target but appears in helping patients improve and regain autonomy and meaning.
The Nursing Process: APIE/APPIE
Acronym variants and evolution:
ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation)
APPIE or AAPIE (with the “D” for Diagnosis replaced by “P” for Plan in some variants; still covers the same five steps)
Core idea: nursing diagnoses (not medical diagnoses) identify patient problems and guide care planning.
Key steps:
Assessment: systematic data collection (head-to-toe initial assessment; ongoing focused assessments; crisis/emergency assessments; quick priority assessments).
Diagnosis: identify patient problems (NANDA diagnoses: problem-focused, risk, health-promotion).
Planning: set patient-centered goals (short-term per shift; long-term by discharge) and outline interventions.
Implementation: execute the plan with evidence-based interventions; ensure actions have verbs (e.g., assess, monitor, reposition).
Evaluation: determine whether goals were met, partially met, or not met; if needed, revise the plan.
Important distinction: nursing diagnoses are separate from medical diagnoses; use nursing-focused language to guide care.
Advised resources: Lipincott Advisor (or Lipincott) for care plans; tools used in clinical practice to guide interventions and documentation.
Practical notes:
Use two identifiers to verify patient identity (e.g., name and date of birth); verify by wristband and, if needed, a patient photo.
If a patient cannot speak, use caregiver information and translators to gather data; be mindful of cultural considerations (e.g., in some cultures, men may not be allowed in the room).
Data types: subjective vs objective
Subjective data: what the patient says (e.g., pain level, dizziness, fatigue, headaches).
Objective data: measurable signs (e.g., vital signs, SpO2, exam findings).
When inconsistent data exist, you collect your own vital signs to verify home/previous data.
Example: a patient might report fever 104°F; you verify with your own measurement and corroborate with labs.
Data collection and documentation practices
Head-to-toe assessment: complete, system-by-system evaluation for new admissions.
Focused assessments: targeted assessment for a specific problem (e.g., respiratory assessment for dyspnea).
Emergency/crisis assessment: rapid evaluation in life-threatening situations; immediate actions and call for rapid response.
Ongoing assessment: compare current data to earlier data to detect changes and adjust care.
Documentation: document everything; if you forget to document, you still must record what occurred—careful, precise, timely notes.
In many facilities, student documentation policies vary; always adhere to unit policies and practice with your clinical instructor.
The patient care plan framework (NANDA diagnoses and planning examples)
Types of nursing diagnoses:
Problem-focused: a clinical judgment concerning an undesirable human response (e.g., Activity intolerance related to fatigue, as evidenced by AEB).
Risk nursing diagnosis: clinical judgment concerning vulnerability (e.g., Risk for electrolyte imbalance related to diarrhea, AEB dry mucous membranes, sunken eyes).
Health promotion diagnosis: nursing judgment about motivation/desire to improve well-being.
Examples and phrasing:
Problem-focused: "Activity intolerance related to fatigue as evidenced by… (AEB)".
Risk: "Risk for electrolyte imbalance related to diarrhea as evidenced by dry mucous membranes…".
Health promotion: "Readiness for enhanced nutrition" or similar language addressing motivation and desire to improve well-being.
Goals and outcomes:
Short-term goals: by the end of the shift; e.g., "Patient will eat 25% of breakfast by the end of the shift."
Long-term goals: at discharge or follow-up; e.g., "Patient will follow up with PCP/ pulmonologist."
Interventions (implementation): start with action verbs; e.g., "Oxygen therapy titrated to maintain SpO2 92–100%"; "Ambulate 50 feet with assistance"; "Reposition patient every 2 hours (q2h)"; "Provide emotional support and information to reduce anxiety"; "Consult PT/OT; consult dietitian; involve social work as needed.".
Oxygenation and respiratory care in plan
Oxygen therapy is ordered by physicians; oxygen is titrated to target SpO2 between 92 ext{–}100 ext{ extyen} depending on patient condition (e.g., COPD may have different targets).
Common targets: SpO_2 ext{ normal range}
ightarrow 95 ext{ extyen}100 ext{ extyen}; if COPD, goals may be individualized.Interventions: raise the head of the bed; reassess SpO2 after oxygen changes; administer breathing treatments as prescribed; notify respiratory therapy if needed.
Practical notes: when documenting interventions, you can list the action performed (e.g., "Administered oxygen per physician order"), but ensure you capture the rationale in the plan for why that intervention was chosen.
Mobility and safety: turning and preventing deconditioning
Turn immobile or frail patients every q2h (every 2 hours) or more often if needed; use pillows/boots to reduce pressure on bony prominences; ensure heels are off the bed if possible.
Deconditioning risk: immobility increases risk of blood clots, pneumonia, muscle wasting; keep ambulation and activity levels appropriate to patient condition; coordinate with PT/OT.
Ensure joint safety: proper alignment of limbs, avoid overstretching, and ensure proper support with pillows.
Pain management and patient communication
Pain assessment: use 0–10 scale; reassess after analgesia, typically within 1 hour.
Goal: reduce pain to an acceptable level (often 3 or lower, depending on clinical context).
If pain persists (e.g., 8/10 after analgesia), reassess cause, modify plan, and communicate with the physician for possible adjustments.
Therapeutic communication: maintain calm demeanor; explain procedures; avoid triggering anxiety; teach breathing and relaxation techniques when appropriate.
Team-based care and interdisciplinary collaboration
Involve social workers for transportation, financial barriers, and support services; involve dietitians for nutrition; involve PT/OT for mobility; involve respiratory therapists for breathing care.
Family involvement is important, but balance with patient autonomy; ensure family understands goals and plans; reduce caregiver stress by clear communication.
Testing strategies and NCLEX-style tips emphasized in the session
Read the entire question; avoid overinterpreting a single sentence.
Time management: allocate roughly 1.5 minutes per question; do not overthink.
Expect rationale in answer explanations; read them to learn the concept behind the correct option.
Practice with APPIE/NANDA-based questions; know that some terms like “implementation” and “interventions” are often used interchangeably on exams.
Practical test question: Maslow level for poison-control information
Question: A nurse provides poison-control-number information to a parent. Which Maslow level is addressed?
Answer: Safety and security needs (not physiological need like oxygen, etc.).
Rationale: The information reduces danger and enhances caregiver safety, consistent with the safety/security tier of Maslow.
When to escalate and safety considerations in practice
In emergencies, do not hesitate to call for rapid response or code when patient status deteriorates (e.g., severe dyspnea, impending respiratory failure).
If you do not know how to operate a device or med, seek help from the charge nurse or supervisor and follow hospital policy; do not risk patient safety.
Always document thoroughly; include the exact actions taken, times, and patient responses; keep a spare sheet for quick notes if needed.
The NCLEX/clinical practice cycle: ongoing improvement
The nursing process is dynamic and patient-specific; plans are revised as patient conditions change.
Reassess and tweak the plan if goals are not met; continue to evaluate until goals are achieved or are meaningfully adjusted.
The process supports health promotion and patient-centered care; involve patient and family in goal setting where possible.
Quick reference concepts and formulas for study
SpO2 normal range: 95\%\le SpO_2 \le 100\% (with some COPD exceptions may be lower).
Oxygen titration: target range around 92\%–100\%.
Short-term goals examples: 25\% of breakfast by end of shift; ambulate 50\text{ ft} with PT guidance; vital sign targets as prescribed by protocol.
Repositioning interval: q\,2\,h (or sooner if skin integrity or edema risk demands).
Hematology reference: a patient with dehydration may have Hb = 7\,\text{g/dL} or low Hct; assess with CBC.
The AAPI/APDIE (nursing process) steps: Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation. The D in ADPIE is sometimes replaced by P in APPIE to emphasize nursing-focused problems rather than medical diagnoses.
Practical takeaways for exam success
Always separate subjective data (patient’s report) from objective data (vital signs, labs, exam findings).
When writing nursing diagnoses, use concise statements with a problem and related factors (e.g., "Ineffective breathing pattern related to airway obstruction as evidenced by tachypnea and diminished breath sounds (AEB)"), using AEB where appropriate.
Ground all interventions in a measurable plan with a clear rationale; link interventions to the goals and to patient/problem data.
Use the Lipincott Advisor and clinical instructor guidance to tailor care plans to individual patient needs; avoid copying generic plans without personalization.
Final reminders for practical care in clinicals
Expect to perform head-to-toe assessments, focused assessments, and emergency assessments; documentation follows unit policy.
Be mindful of patient comfort, dignity, and safety at all times; maintain a calm demeanor for anxious patients and their families.
Coordinate with the healthcare team to tailor rehabilitation and nutrition plans; remember that every patient is unique and plans must be individualized.
Summary
The session emphasizes a holistic, patient-centered approach based on Maslow’s hierarchy, a structured nursing process (APIE/APDIE), thorough assessment (subjective and objective data), appropriate nursing diagnoses (NANDA), collaborative planning/interventions/evaluation, and professional practice standards (documentation, safety, ethical behavior, and teamwork).