Question

How can you make Maslow's Hierarchy of needs for hypotension care plan

Answer 1

Maslow's heirarchy of needs is an interdisciplinary theory that is useful for designationg prioroites of nursing care. The heirarchy of human needs include 5 levels of priorities:

1. The most basic or first level includes air, water and food
2. The second level includes Physical and Psychological security
3. The third level contains love and belonging needs, including freindships, social relationships and sexual love
4. The fourth level emcompassess esteem and self esteem needs which involves self confidence, usefulness, acheivement and self worth
5. The final level is the need for the self-actualization, the state of fully acheiving potential and having the ability to solve problems and cope realistically with situations of life

When using this heirarchy, basic physiological and safety needs are usually  given the first priority especially when a patient is severely dependent physically. Patients entering the health care system generally have unmet needs. In this scenario, patient entering the emergency room with hypotension has an unmet need for fluids (water), the most basic physiologic need

Nursing diagnoses	goal	Intervention	Rationale
Deficient fluid volume related to active loss reated to active fluid loss(burns, diarrhea, vomiting,ascites) , failure of regulatory mechanisms as evidenced by decreased blood pressure, tachycardia	client will maintain fluid volume at functional level as evidenced by individually adequate urinary output with normal specific gravity,BP within normal limits, stable vital signs, moist mucus membranes, good skin turgor and prompt capillary refil	Monitor vital signs and CVP. Note presence and degree of postural BP changes. Observe for temperature elevations or fever Palpate peripheral pulses; note capillary refil and skin color, turgor and temperature. Assess mentation Monitor urine output. Measure or estimate fluid losses from all sources such as gastric losses, wound drainage and diaphoresis Encourage foods with high fluid content and increase fluid intake according to client's beverage preferences Investigate reports of sudden or sharp chest pain, dyspnea, cyanosis, increased anxiety and restlesness Monitor for sudden or marked elevation of BP, restlessness, moist cough, dyspnea, basilar crackles and frothy sputum	Tachycardia is present along with a varying degree of hypotension depending on degree of fluid deficit Conditions that contribute to extracellular fluid deficit can result in inadequate organ perfusion to all areas and may cause circulatory collapse and shock Fluid replacement needs are based on correction of current deficits and ongoing losses. A decreased urine output may indicate insuffcient renal perfusion or hypovolemia, requiring more aggresive fluid replacement Relieves thirst and discomfort of dry mucus membranes and augments parentral replacement Hemoconcentration and increased platelet aggregation cna cause sytemic emboli formation Too rapid correction of fluid deficit the cardiopulmonary system , especially colloids are used in fluid replacement system