The Human Needs Approach

Data gathering Assessment

tool
With possible nursing
diagnoses

Compiled by

Ecaroh Smailliw RN
Introduction/foreword

It is with the challenges that I had has a student nurse and

the current challenges student nurses are experiencing,
that I have decided to compile this assessment booklet
under the various needs.
This booklet was compiled with the intention of assisting
student nurses to assess their patients under the various
needs as adopted from psychologist Abraham Maslows
(1908-1970) theory of hierarchy of needs. It is hoped that
student nurses will use this guideline to not only carefully
assess their patients under the respective need, but that it
will also greatly assist them to formulate the correct
diagnoses based on their data collection.
It is anticipated that with correct assessment and nursing
diagnoses, that improved/optimal patient care will follow.
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Please be reminded that this is just a basic guideline to

assessing client under the various needs and is not a
textbook or the bible to nursing assessment.

Objectives
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At the end of this session students will be able to:

1. Describe the Methods of data gathering
2. Explain The human Need Approach under
a. Physical Needs
b. Psychosocial Needs
Methods of data gathering
Assessment involves the gathering of all possible data
regarding patients, to identify problems. The data
gathering methods include: 1. Interviews, 2. Observation,
3. Physical assessment, 4. Consultation with other
members of the health care team through records/reports
related to the patient as well as through verbal interaction
and 5. Review of literature.
Data are gathered essentially through five sources: (1)
The patient; (2) Family members, friends and associates;
(3) other members of the health care team; (4) Records of
the patients present and past health status; and (5)
Written information regarding the problem or problems
and treatment facing the patient.
The Human Needs Approach in gathering data
This system for data gathering is based on organizing data
around human needs. It is used most often by those who
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approach nursing with the objective of meeting human

needs or preventing interference with the meeting of those
needs. The physical needs are identified separately and
the psychosocial are grouped together.
Physical Needs
1. Activity: This aspect of data gathering looks at the
patients ability to move and exercise for optimal
functioning. You look at the patients usual exercise
pattern at home, Diversional choices and the effects
of exercise. Any recent variation from the norm,
such as joint or muscle pain or disability, is of
importance. The individuals posture and
positioning and the level of activity prescribed by
the physician are other items of concern. Note the
pathophysiology of bones, joints and muscles, as
well as the use of tractions, bedboards or assistive
devices. Assess extremities for movement,
sensation, colour and warmth. Note also any
medication given that has a relation to this area.
Possible Nursing Diagnoses
Activity Intolerance related to an imbalance between
oxygen supply and demand
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 Impaired physical mobility related to use of

traction/muscle atrophy/muscle
degeneration/fracture/pain/immobilization/prolonged
bed rest/muscle stiffness/loss of limb (s)/impaired
circulation.
Impaired walking related to (see above)
Fatigue related to an imbalance between oxygen
supply and demand
Impaired bed mobility see related factor for impaired
physical mobility
Impaired wheelchair mobility see related factor for
impaired physical mobility
2. Circulation: Collection of data under this category
looks at the delivery of nutrients and oxygen to the
cells and the removal of waste from those cells.
Objective data includes pulse, blood pressure,
colour and warmth of the skin. Medication taken
for heart, blood pressure or other cardiovascular
situations. Any other signs and symptoms relating
to cardiovascular problems, including lab and
diagnostic tests, for example, haemoglobin,
haematocrit and blood chemistry levels.

During your interview, you should try and

ascertain from patient or significant other any
history or perception of any cardiovascular
problems and the medications that were ordered.
Identification of possible cardiovascular risk
factors should also be noted, such as smoking,
hypertension, diabetes mellitus, obesity and
lack/inadequate exercise.
Possible Nursing Diagnoses
Ineffective Peripheral Tissue Perfusion related to
decreased oxygen carrying capacity/high-low blood
pressure
Risk for Decreased Cardiac Tissue Perfusion related
to decreased cardiac output
Risk for Ineffective Cerebral Tissue Perfusion related
neurological impairment/unconsciousness/increased
intracranial pressure
Risk for Ineffective Gastrointestinal Tissue Perfusion
Risk for Ineffective Renal Perfusion
Decreased Cardiac Output
Risk for Impaired Perfusion
Risk for Bleeding
Risk for Shock
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Please note that nursing diagnoses such as Ineffective

Breathing Pattern, Impaired Gaseous Exchange and
Ineffective Airway Clearance may be used here depending
on your assessment findings. Especially if there is an
impairment in gas exchange, ability to breathe and to
mobilize secretions (which may be excess in some cases)
3. Elimination: This section looks at the excretion of
wastes from the large intestines and the urinary
system. You should observe the patients bowel
habits and the type and frequency of stools. You
should also listen for bowel tones/sounds, normal
pattern of bowel movements and characteristics of
the stool, noting those that are unusual. Any history
of constipation or diarrhea is also important along
with medication history.
The urinary system deals with the excretion of
waste products by the kidneys through the urethra
and bladder. It is important for you to note normal
patterns of urination, colour and odour of the urine.
Kindly note the presence of a urinary catheter or
any other urinary output device. Urinary output
should be measured and compared to fluid intake.
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Note pH and specific gravity of urine as well as

urinary pathophysiology and any medication taken
for urinary problems, noting any problems with
incontinence.

Possible Nursing Diagnoses

Diarrhoea related to increased gastrointestinal
motility
Constipation related decreased peristaltic action
Bowel Incontinence
Perceived constipation
Dysfunctional Gastrointestinal Motility
Impaired urinary Elimination
Urinary Retention
4. Fluid and Electrolytes Balance/Hydration: This
aspect of data gathering deals with keeping proper
fluid and electrolyte composition within the body.
You should observe fluid intake and output,
including the type and amount of intravenous fluids
being given. Note changes in alertness or mentation
and muscle tone. Observe for changes in
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respiration that are not related to exertion and also

for changes in cardiac rate and rhythm that are not
due to heart disease. An alteration in the amount of
fluid present in the tissues maybe demonstrated by
poor skin turgor or oedema as well an observation
of daily weight. Note serum electrolyte levels and
any medication given that could affect fluid and
electrolyte balance.

Possible Nursing Diagnoses

Deficient Fluid Volume related to insufficient
intake/excessive loss
Excess Fluid Volume related to antidiuretic
therapy/accumulation/stasis within tissues
Risk for electrolyte imbalance related to diuretic
therapy/excessive losses/medication therapy
Risk for Imbalanced Fluid Volume
5. Nutrition: This aspect of data gathering looks at
getting nutrients into the body. You should observe
the patients eating habits (the amount of food
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taken and the kinds of food preferred). Ask about

food likes and dislikes and the amount of fiber as
well as any dietary modifications in regard to food
intake. Consider the patients knowledge of proper
nutrition and understanding of any special dietary
restrictions. Consider as well what are the clients
ideal body weight, as well as weight gain and
weight loss that may be significant to nutritional
data. Assess for presence of NPO status, clients
ability to swallow, impaired respirations, ability to
feed self, disease states that increase or decrease
metabolic needs, any medication that may alter or
increase appetite.

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Possible Nursing Diagnoses

Imbalanced Nutrition: Less than body requirement

Imbalanced Nutrition: More than body requirement
Impaired Swallowing
Ineffective Infant Feeding Pattern
6. Oxygenation: This need looks at all data concerned
with getting oxygen into the lungs and carbon
dioxide out of the lungs. You need to gather
information on breathing patterns and changes in
breathing patterns. These include observation of
chest symmetry and of rate, depth and rhythm of
respiration. You should ascultate lungs for
abnormal/normal sounds, check breath sounds, and
look for indications of impaired airway and for
signs and symptoms or difficulty in respirations.
Note patients need for oxygen. You should also
note whether the patient coughs, type of cough,
whether it is productive or non productive.
Whether suctioning is being applied and the type of
medication the patient is on as well as noting any
disease states, e.g. Heart disease.
Risk factors such as smoking should also be noted.
It has been proven that smoking is a risk factor
along with exposure to pollutants in the air. Some
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work settings predispose the person to an increased

risk for respiratory problems. A history of frequent
colds or upper respiratory infections should also be
listed as a risk factor.
Possible Nursing Diagnoses

Impaired Gaseous Exchange

Ineffective Breathing Pattern
Ineffective Airway Clearance
Risk for Shock
Risk for Bleeding
Decreased Cardiac Output
Ineffective Tissue Perfusion
7. Protection from Infection/Safety: These data looks
at the effect of the total environment on the patient.
You need to consider the environment both in terms
of the patients ability to respond to it and in terms
of safety from microbes for the patient and others.
Data that should be included are the care of
equipment, the positioning of bed rails, procedures
for hand washing and the provision of isolation.
Other factors that you need to consider are room
temperature, cleanliness, drafts, lighting and noise.
You should note if the client can reach bell, the
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impact of patient on other patient, the location of

the patient in relation to the nurses station.
The ability to communicate is also another
important factor in terms of patient safety.
Possible Nursing Diagnoses

Risk for Infection

Risk for Injury
Impaired Verbal Communication
Risk for Falls
Risk for Imbalanced Body Temperature
Ineffective Thermoregulation
Hypothermia
Hyperthermia
Impaired Skin Integrity
8. Regulation and Sensation /Comfort: This section
of the data collection looks at all the characteristics
associated with both the central nervous system
and the autonomic nervous system, including the
special senses and pain. It also looks at levels or
states of consciousness. Special senses include
visual and auditory acuity or lack of it. The pain
component includes the nature of the pain and its
location, duration, the patients perception of its
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intensity, the pathophysiology, the length of time

pain has been present and all the medication used
to control same. Sometimes it is more useful to list
pain under another assessment area-when it is
known to relate to a specific problem. Be sure
pathophysiology, and any related observations
made are in included.
The patient could be asked to read a book, a name
tag/identification bracelet, you can also enquire
about the wearing of glasses. The clients hearing
may be checked by noting his/her response to your
question and comments; this can be best tested by
standing beside or behind the client.
Possible Nursing Diagnoses

Impaired Comfort
Acute Pain
Chronic Pain
Nausea
Disturbed Sensory Perception (This can also be used
as a safety and security diagnosis)
9. Rest and Sleep: This aspect of data collection
looks at the patients normal sleep and rest patterns
and how hospitalization or illness may have
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affected them. You will need to look at the patients

appearance, does he/she appears to be tired/rested,
what amount of sleep is normal for that patient,
what is the usual bedtime, does he/she use sleep
aids or any other equipment? The patients physical
and psychological status is important; identify
factors that might be interfering with the amount
and/or quality of sleep. Identify factors such as
pain, equipment (noise, interference with comfort
or positioning), you should also consider the
clients diagnosis and its relationship in terms of
extra sleep and rest periods.
Possible Nursing Diagnoses
Insomnia
Disturbed Sleep Pattern
Sleep Deprivation
10. Skin Integrity (Safety)/Hygiene: This section
looks at the condition of the skin, its turgor,
hydration, colour, lesions, wounds, rashes, scars,
tattoos, injection scars; they should be noted, is the
skin outside of its normal continuity, is it raised, are
there breakages?, these are some of the questions
that should be asked. You should also list any
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sensitivity to soaps or lotions. Lastly, you should

include, hygienic needs, such as the hair, mouth
and nails.
Possible Nursing Diagnoses
Impaired Skin integrity
Impaired Integrity if breakage is beyond the
epidermis
Self Care Deficit (both activity and safety)
Psychosocial Needs
This aspect of data gathering can be very complex and has
several parts, such as growth and development, mental
health, sexuality, values and beliefs and Sociocultural
beliefs.
1. Growth and Development: Each individuals life
stage reflects that individuals stage of
development. To understand this stage you should
look at the persons age, gender, occupation, and
role in the family. A very good example is a 30year
old man who has a full time job, woman and at
least two children, his response to hospitalization
will be in contrast to a 65year old retired woman
who lives alone, and their adaption to illness will
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be different. It is important that you note peoples

perception related to their stage in life.
2. Self-Esteem/Love and Belonging: You should look
for behaviour and record any statements that may
indicate how the patients feel about themselves and
their own life situations. What kind of family
support does the patient have, is it accessible, is it
available at home, will the patient have visitors?
Does the patient make statements about significant
others, their feelings about them and the type of
support they offer? How does the client and
significant others interact? You should also note,
eye contact, tone of voice, affect and level of
anxiety.
3. Sexuality: You need to gather information about
sexual difficulties, menstruation and menopause.
You should also make a note of all the medications
that are being used or any diseased state that could
have an effect on the clients sexuality.
It is of paramount importance to gather all
information about sexuality when the person has
had an illness or surgery that affects the
reproductive or gynaecology, breast, or urinary
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systems. The patient may indicate to you that there

are problems with sexual performance. Sexuality is
a very sensitive area for most people, so you need
to be careful how you go about asking questions as
they relate to this area, because you may come
across as prying.
4. Sociocultural: Each person should be assessed
within the context of their ethnic/cultural
framework and the impact it may have on illness
and hospitalization. Other questions that you will
need to ask your self are: is the patient able to
speak or understand English language, will the
general care customs, dietary
preferences/restrictions and/or religious practices
affect the care of the client. What are the
expectations of the family in the care of their
significant others, can they take food, can they visit
in large numbers, can they assist in taking care of
the patients, how will this affect the patients status,
job, role in the family?
5. Values and Beliefs: These may be based on an
organized religion or on a general philosophical
system. Kindly note any religious affiliation noted
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on the patients admission form. You could ask the

patient if he/she want a religious advisor, pastor or
church to be notified. Observe all
religious/philosophical reading materials and
conversations. Consult with the hospitals chaplain
if there is one, about any written or any other
religious material with which you are not familiar,
or you could simply ask the patent if you could
help.
Possible Nursing Diagnoses

Sexual Dysfunction
Ineffective Sexuality Pattern
Anxiety
Fear
Body Image Disturbance
Ineffective Coping
Compromised Family Coping
Grieving
Care Giver Role Strain
Chronic Low Self Esteem
Situational Low Self Esteem
Hopelessness
Adult Failure to thrive
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Powerlessness
Ineffective Denial
Interrupted Family Process
Moral Distress
Impaired Religiosity
Spiritual Distress

References
Ellis, J., Nowliss, E.,& Bentz, M. P. Modules for basic
nursing skills. (2000). Washington:
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Lippincott Williams & Wilkins

Gulanick, M., & Myers, J. Nursing care plans, diagnoses,
interventions and outcomes. (2011).
St. Louis, Missouri: Elsevier Mosby

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