Maslow’s Theory of Human Needs: Nursing Case Study

Nurse Note

Your physical assessment narrative note should be documented in the head-to-toe sequence.

Date/ Time



Dry skin to her scalps

No neck complications

Pupils are 5mm and react to light 3mm

Conjunctiva is red complains of getting winded sometimes

Ears without drainage but have to repeat some words because she cannot hear well

Nose stuffy at times

Dry skin to her scalp

Mouth without any sores and still has teeth. The patient was seeing a dentist twice a year.

Hand grasp very weak on the left than the right one

Capillary refill fast to the hands and slow to the feet

Radial pulse strong on both hands

Heart sounds not regular and fast

Lungs sound with a wheezing sound when she breaths out to upper lungs from the backside only

Other lung diminished

Occasional congested morning cough and never spits anything

Abdomen soft with tenderness

4inch scar to her right abdomen

The last BM was 3days formed stool. Large amounts of urine yellow no odor

Achy pain to the lower back

She has a small healed scar to her lower back 2inch long

5inch long scar to her right knee

Pedal pulse is strong in the right foot but weak on the left foot

Left push /pull is absent, right foot push/pull pulses are strong

She is cooperative; speech is clear slight hesitations when asked questions

She knows who she is, where she is, and what day it is.




Laboratory Profile


Reason for the Abnormality and

Reason to be Assessing this Lab




Cholesterol levels

4500 to 5700ml


Reason for abnormality- mutations in particular genes and easily passed down a generation.

Some medication, medical conditions, and lifestyle factors, a blood disorder, affect a specific part of the blood or more parts, making an individual function abnormally.

Reason To Be Assessing This Lab

Cases of high cholesterol levels within the family

Cases of heart attacks in the family.

To complete blood count and check ten levels of blood components of every significant cell in the body, such as white blood cells, red blood cells, and platelets (Serraino & Murphy, 2017). The significance of blood count helps a doctor determine any disorders in the patient’s blood; however, the patient has to wait for the doctor’s advice before fasting before the test.

To conduct a metabolic test to determine why the patient has yellow, odorless urine. It also helps determine various components in blood plasma (Serraino & Murphy, 2017). A metabolic blood test also essential information about a person’s bones, organs, and muscles. We let the patient whether she must fast before the test.

High-density lipoprotein, a good level or low-density lipoprotein, is bad to check cholesterol levels. High-density lipoprotein levels are important because they help eliminate harmful substances for the blood and enable the liver to reduce them into waste (Serraino & Murphy, 2017). It is necessary for the patient to first at least eight hours before this test. Test enzyme makers because the patient has poor eating habits; these enzymes are CPK-2(CK-MB). These enzymes are in the heart and increase a person’s blood levels after having a heart attack.CPK-3 is found in the heart, resulting from muscle inflammation caused by intense exercise or injuries. CPK-1 exists in the brain, and their high levels indicate brain or lung injury.

Furthermore, when tropin links into the blood can cause heart injury. Enzyme tests help doctors identify particular conditions such as heart attacks. In case they suspect a heart attack condition, they quickly check the cardiac tropin enzyme.

We can also conduct coagulation tests to determine the blood’s clotting rate and how well it clots.  The importance of clotting helps stop bleeding in would or cuts (Serraino & Murphy, 2017). However, clots in arteries or veins can be dangerous because they block blood flow to the heart, brain, or lungs, causing strokes or heart attacks. These tests get determined by personal health conditions or any other health condition that may affect clotting. The coagulation test results can help determine whether the patient has thrombosis, liver conditions, acute leukemia, and vitamin K deficiency.

The main purpose of conducting a cholesterol test is to determine whether the levels are high and the underlying risks of developing a heart attack (Serraino & Murphy, 2017). A complete calculation of different types of fats is what gets referred to as a total cholesterol test. Since the initial cholesterol tests of the patient were abnormal, conducting a cholesterol test is important. Additionally, her family has a history of having high cholesterol levels. Hence a regular cholesterol test is important to monitor whether the medications are effective.




Pulmonary function test 95% confidence interval Reason for abnormality

Some of the reasons why a person may develop abnormal pulmonary function are asthma, foreign bodies obstructing the airway, emphysema, lungs’ inflammation, loss of lung tissues, challenges from arterial blood flow.

Reasons for assessing this lab

The main reason for conducting a pulmonary function test is to determine how well the lungs are working. These tests measure gas exchange rates and flow capacity, and lung volumes (Sapey, Patel, Greenwood, Walton, Hazeldine, Sadhra & Thickett, 2017).  Information obtaining after conducting these tests helps decide the best treatment for a specific lung disorder. However, there are two main causes of challenges of air moving in and out of the lungs. The first challenge is obstructive that happens when it becomes difficult for air to freely flow out of the lungs due to resistance in the airway. Reduced airflow is the primary cause of this challenge.

Restrictive challenges take place when the lungs are unable to expand. Due to this, airflow becomes a challenge due to low lungs (Sapey et al., 2017). Pulmonary function tests help diagnose allergies troubles in breathing due to lung injuries, respiratory infections, lung conditions, lung diseases, scleroderma, and sarcoidosis.

Additionally, there are risks associated with pulmonary tests depending on the age of an individual. These include dizziness, asthma, feeling short of breath, and coughing (Sapey et al., 2017). At the same time, there are reasons why an individual should not undergo pulmonary tests. First, if the person had belly surgery recently, recent eye surgery resulted from increased pressure in the eye. Notably, before the pulmonary test, the patient should avoid taking some medicines, stop smoking, avoid taking heavy meals, and adhere to any other doctor’s instructions.

17/03/2021 abdomen No tenderness  

Reasons For Abnormality

Abnormal tenderness can result from gallstones, endometriosis, celiac disease, gastritis, inguinal hernia, and hiatal hernia.

Reason to be Assessing this Lab

Abdomen tenderness indicates inflammation as an acute process in one or many organs in the body. Blocked or twisted organs can cause inflammation. Some common causes of abdomen tenderness are swelling of the appendix, which is a small pouch attached to the large intestines. Swelling on the appendix happens when it gets blocked by substances such as feaces passing through it. An abdominal abscess can also cause abdominal inflammation, a pocket filled with pus, and infected fluid inside the belly. The fluids come from a busted appendix, ovary, or intestine. The common cause of this inflammation in women is an inguinal hernia. It is a condition that occurs when there is a burst in the membrane lining the abdominal cavity or when the intestines burst. A twisted fallopian tube which in most cases it is a rare issue or a ruptured ovarian cyst.

Furthermore, ectopic pregnancy can cause abdominal tenderness. It is a life-threatening condition where the fetus starts to form outside the uterus, bursting the suck of fluid holding the fetus. Pelvic pulmonary infection is also another challenge. It is an inflammation of the female reproductive system that could result from infections from different STIs. All these infections get linked to some inflammation that causes tenderness on the abdomen.



Maslow’s Theory of Human Needs

I.     Needs Assessment/Analysis/Problem Identification




·         Give Data to support that the need has been met


·         Give data that indicates that there is a possible problem

List actual and potential diagnosis based on data from the abnormal column.








Apical 108 irregular



Asthmatic attacks



Arthritis on the lower spine






Heart sound not regular



Ineffective breathing patterns



The patient cannot move the left leg

Mild swelling on both ankles





Low fat/1500cal diabetic diet Stomach ache


3 cups of coffee in the morning The patient wets the bed





Duodenal ulcers



Urinal incontinent

last bowel movement three days ago

a large amount of brown stool


involuntary leakage of urine






Self –care


Pain 5/10



Arthritis on the lower spine




The patient is dirty

The patient has arthritis and right knee replacement


The patient is in a wheelchair, can turn a little in bed but cannot get out by herself.


The patient cannot bath



Lower back pain 4/10 The patient is sleep-deprived



Diabetes Mellitus type 2 The patient has a high body temperature


Low sex drive Arthritis in the lower spine

(physical & emotional)






Health Management




she depends on the husband to make decisions


taking naps while in a wheelchair


cholesterol level high

She seeks assistance from her daughter


The patient has suicidal thoughts


The Patients does not sleep


High blood pressure



Sense of hatred towards her family Husband is unable to take care of her




Suicidal thoughts Low self-esteem


Loss of employment The patient dismissed before retirement age


Nursing Priority

Using your filled-out Maslow’s form, identify the patient’s priority nursing diagnoses according to importance: #1 being the top priority or most important, #3 being the least priority or least important. Diagnoses 1 and 2 will be used as the two nursing diagnoses in the patient’s subsequent concept maps.

Priority Nursing Diagnosis
#1 Atherosclerotic cardiovascular disease
#2 High blood pressure
#3 pneumonia


Concept Map

Bp 138/78

Apical 108 and irregular

Respiration 20 regular and unlabored at rest

Temperature 97.8

Oxygen saturation 90% F orally


Pulmonary infection


Cardiovascular disease

Cardiovascular disease

High blood pressure




Nursing Intervention – Assess Nursing Intervention – Do Nursing Intervention – Teach
Cardiovascular disease Simvastatin 40mg PO daily  

Prevent coronary events.

Primary and secondary prevention o atherosclerotic cardiovascular disease.

Rationale Rationale Rationale
Heart attacks cases in the family To prevent the infection Stabilize the patient
Nursing Intervention – Assess Nursing Intervention – Do Nursing Intervention – Teach




Increase oxygen saturation


Prevent pneumonia

Rationale Rationale Rationale

Breathing rate normal



To improve breathing rate

Avoid damaging the lungs


Nursing Intervention – Assess Nursing Intervention – Do Nursing Intervention – Teach

High blood pressure





Control blood sugar

Rationale Rationale Rationale

Blood pressure above the normal



Reduce blood pressure to normal

Prescribe high blood pressure medication



Medication Intervention (list med name here)

Nursing Intervention – Assess Nursing Intervention – Do Nursing Intervention – Teach

Pulmonary infection




Give inhaler


Treat the chronic obstructive pulmonary disease

Rationale Rationale Rationale

Prevent damaging the lungs



Help in breathing


Repair damaged lungs