P Need:
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Psychosocial
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E Need:
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Elimination
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History – demographic information – ethnicity,
religion, age sex, marital status.
View of self – self-esteem, internal vs. external
locus of control
Sexuality
Perception of stress and ways of coping
Beliefs and attitudes about illness
Family assessment – support systems
Home and community assessment (The data will
be used to help the patient cope with
illness/hospitalization, find effective teaching
methods, and plan for discharge.)
Current Status – includes a mental status exam
(part of which will be learned this semester)
Degree of reality orientation – orientation to time,
place, and person; memory – remote and recent
General observations of intelligence, behavior,
speech, mood or affect, ability to understand and
follow directions, attention span, etc.
P-Need Medications – ie. Psychotropic,
Tranquilizers, etc.
History of urinary, renal, or bowel problems.
Patterns of elimination, e.g., has daily BM, wakes
up several times a night to urinate, has difficulty
starting stream. Past illness or surgery. Use of
laxatives or other aids to elimination.
Current Status – pattern, method (bedpan, toilet),
difficulty with urination, number of days since last
BM. Use of foley catheter. Description of urine or
BM.
Physical assessment of abdomen
Relevant laboratory tests – BUN, Creatinine, Xrays, CT scan
E-Need Medications ie., Laxatives, Urinary
antispasmodics
Diagnostic test – Colonscopy, Barium enema,
Cystoscopy
Therapeutic interventions
Fluid intake and output for a 24 hour period
R Need:
Rest,
Regulatory,
Reproductive
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S Need:
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Safety
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Rest, sleep, activity, comfort
Description of rest/restful activity
Normal sleep pattern
Changes in sleep pattern
Aids used in sleep
Usual pattern of daily activity
Exercise, types, amount, frequency
Aids in ambulation
Medications associated with activity
Pain – onset, progression, duration, character,
location, course, aggravating or relieving factors
Treatment to relieve pain (history or current)
NOTE: this area also includes regulatory
mechanisms, i.e., the neurological and endocrine
systems
Neurological exam:
level of consciousness
speech problems
perceptual problems
emotional problems
PERLA
motor deficits – movement of extremities
sensory deficits – vision, hearing, smell, taste,
touch
Endocrine system – evaluation for the function of
pituitary, thyroid, parathyroid, thymus, pancreas,
and adrenals
NOTE: is the patient diabetic?
Current status – see preceding list
Diagnostics
Therapeutic interventions
Assessment of reproductive function
Usual physical environment-stairs, equipment,
pollution (the elderly sometimes function well in
familiar environment and appear disoriented in
the hospital)
Hygiene
Skin – usual care, condition
Medications (not included elsewhere); over-thecounter; allergies; immunizations; antibiotics
Emotional environment
prior hospital experience
present attitude toward hospital
need for privacy
strength of nurse patient relationship
Physical environment in hospital
Risk factors for infection
Risk for fall
O Need:
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Oxygenation
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N Need:
Nutrition
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History of cardiac or respiratory problems
Occupational or environmental hazards (other risk
factors)
Physical assessment of chest, skin, pulses, blood
pressure, breathing patterns, temperature,
exercise tolerance
Diagnostic tests – EKG, electrolytes, CPK, LDH,
SGOT, Hg, Hct
Therapeutic interventions
O-Need Medications – Cardiac glycosides, Calcium
channel blockers, Beta blockers, Antihistamines,
Antitussives
Family history of ulcers, Ca, colitis, diabetes
Patient, history – GI diseases, diabetes, “gas,”
belching, nausea, vomiting, heartburn, pain,
difficulty eating, swallowing, or digesting food,
weight gain or loss
Height / Weight
General appearance
Diet patterns
Food restrictions; allergies; tolerances; special
diet
Food preferences
Fluid intake
Care and condition of teeth
N-Need Medications
Nutritional and abdominal assessment
Laboratory and diagnostic tests
Therapeutic interventions