When prioritizing a clients plan of care based on Maslows hierarchy of needs the nurses first priority would be?

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In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of establishing priorities in order to:

• Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients
• Prioritize the delivery of client care
• Evaluate the plan of care for multiple clients and revise plan of care as needed

Actual needs and problems take priority over wellness, possible risk and health promotion problems and short term acute patient care needs and problems typically take priority over longer term chronic needs.

Applying a Knowledge of Pathophysiology When Establishing Priorities for Interventions with Multiple Clients

As previously mentioned with the “Integrated Process related to the Nursing Process“, priorities are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method. Knowledge of these frameworks and an in-depth knowledge about pathophysiology facilitate the proper establishment of priorities relating to the interventions that are then provided to individual clients and groups of clients with diverse needs of varying acuity and differing priorities.

The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.

Some examples of each of these needs according to Abraham Maslow's Hierarchy of Needs are:

Physical and Biological Needs

• Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.

Safety and Psychological Needs

• The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security.

Love and Belonging

• The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of others including a group.

Self Esteem and Esteem by Others

• All people have a need to be recognized and respected as a valued person by themselves and by others. People have a need self-worth and self-esteem and they need the esteem of others.

Self Actualization

• Self-actualization needs motivate the person to reach their highest level of ability and potential.

The ABCs / MAAUAR method, which was previously detailed, places the ABCs as the highest and greatest priorities which are then followed with the 2nd and 3rd priority level needs.

The 2nd priority needs include MAAUAR which is mental status, acute pain, acute impaired urinary elimination, unresolved and unaddressed needs, abnormal diagnostic test results, and risks. The 3rd level priorities include all concerns and problems addressed with the 2nd level priority needs.

Prioritizing the Delivery of Client Care

The delivery of client care is prioritized as just discussed above.

In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to effectively manage their time; they should avoid unnecessary interruptions, time wasters and helping others when this helping others could potentially jeopardize their own priorities of care.

Evaluating the Plans of Care for Multiple Clients and Revising the Plan of Care as Needed

In addition to providing guidance and direction in terms of nursing care delivery, plans of care, including nursing care plans and other systems like a critical pathway, provide the mechanism with which the outcomes of the care can be measured and evaluated.

Appropriate and effective client care is dependent on the accuracy and appropriateness of the client's plan of care. For this reason, reasessments and updating and revising a plan of care as based on the client's current status is necessary.

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

SEE – Management of Care Practice Test Questions

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

Latest posts by Alene Burke, RN, MSN (see all)

In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.[1][2][3]

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

Assessment

Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.

Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment.

Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes.

Diagnosis

The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.

The North American Nursing Diagnosis Association (NANDA) provides nurses with an up-to-date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.  

A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for physical and emotional health.[4][5]

Maslow's Hierarchy of Needs

• Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise.

• Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease).

• Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, and sexual intimacy.

• Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one's physical appearance or body habitus.

• Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one's maximum potential.

Planning

The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Goals should be:

1. Specific

2. Measurable or Meaningful

3. Attainable or Action-Oriented

4. Realistic or Results-Oriented

5. Timely or Time-Oriented

Implementation

Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.

Evaluation

This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

According to a 2011 study conducted in Mekelle Zone hospitals, nurses lack the knowledge to implement the nursing process into practice and factors such as nurse-patient ratios inhibit them from doing so. Ninety percent of study participants lacked sufficient experience to apply the nursing process to standard practice. The study also concluded that a shortage of available resources, coupled with increased workloads due to high patient-nurse ratios, contributed to the lack of the nursing process implementation in the delivery of patient care.[6][7][8]

The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future.[9][10]

Critical thinking skills will play a vital role as we develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us in the navigation of these uncharted waters. 

Concept-Based Curriculum

Baron further explores this need for a concept-based curriculum as opposed to the traditional educational model and the challenges faced with its implementation. A direct impact on quality patient care and positive outcomes. Nursing practice and educational environments form a bond with clinical knowledge and expertise, and that bond facilitates the transition into the current workforce as an indispensable team player and leader in this new wave of healthcare. 

Learning should be the focus and the integration into current practice. Learning is a dynamic process, propelled by a force that must coexist within the same learning milieu between educator and student, preceptor and novice, mentor, and trainee. 

IN the future, nurses must be able to problem-solve in a multitude of situations and conditions to meet these new adversities: challenging nurse-patient ratios, multifaceted approaches to prioritization of care, fewer resources, navigation of the electronic health record as well as functionality within the team dynamic and leadership style.

Review Questions

Maslow's Hierarchy of Needs for Nursing. Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN

1.

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Shih CY, Huang CY, Huang ML, Chen CM, Lin CC, Tang FI. The association of sociodemographic factors and needs of haemodialysis patients according to Maslow's hierarchy of needs. J Clin Nurs. 2019 Jan;28(1-2):270-278. [PubMed: 29777561]

Maslow K, Mezey M. Recognition of dementia in hospitalized older adults. Am J Nurs. 2008 Jan;108(1):40-9; quiz, 50. [PubMed: 18156858]

Raso A, Ligozzi L, Garrino L, Dimonte V. Nursing profession and nurses' contribution to nursing education as seen through students' eyes: A qualitative study. Nurs Forum. 2019 Jul;54(3):414-424. [PubMed: 31056754]

Hu J, Yang Y, Fallacaro MD, Wands B, Wright S, Zhou Y, Ruan H. Building an International Partnership to Develop Advanced Practice Nurses in Anesthesia Settings: Using a Theory-Driven Approach. J Transcult Nurs. 2019 Sep;30(5):521-529. [PubMed: 31060444]

Bird M, Tolan J, Carter N. Baccalaureate Nursing Students' Perceptions of Learning in Mentored and Simulated Research Practica. J Nurs Educ. 2019 May 01;58(5):290-293. [PubMed: 31039263]

Salmond SW, Echevarria M, Allread V. Care Bundles: Increasing Consistency of Care. Orthop Nurs. 2017 Jan/Feb;36(1):45-48. [PubMed: 28107300]

Rigolosi R, Salmond S. The journey to independent nurse practitioner practice. J Am Assoc Nurse Pract. 2014 Dec;26(12):649-57. [PubMed: 24824941]