Prioritized based on Maslow’s Hierarchy of Needs

1. Decreased Cardiac Output (Hypertension)

In Maslow’s Hierarchy of Needs, physiological needs are the first prioritized level.
This means that in order for one to achieve the four remaining levels, one must fulfill
his/her physiological needs which include maintaining his/her body in the best
condition. Decreased cardiac output is a diagnosis that concerns the physical health
of a person which means it is important that one must take necessary precautions
and medications to maintain this in a healthy level.
a. Subjective Cues
 Client states that she is diagnosed with hypertension due to coronary disease.
 Client states “Madalas akong nahihilo”.
 Client states “Minsan nga nahimatay ako”.
 Client states “Madalas naninikip dibdib ko”.

b. Objective Cues
 Smokes
 Takes antihypertensive medication (losartan 25 mg/day)
 Blood Pressure 140/90 mm Hg
 Radial Pulse 82 beats/min
 Respiration Rate 19 breaths/min
c. Goal
 To normalize or near normal blood pressure
 To normalize or near normal pulse rate
 To lessen or show no signs of dizziness and syncope
 To experience lesser on no chest pains
 To teach client the importance of diet, medication regimen, and prescribed
activity level.
d. Expected Outcome
 Pulse rate remains within set limits
 Blood pressure remains within set limits
 Diminish to no dizziness and syncope
 Diminish to no chest pains
 Cardiac output remains adequate
 Follows diet
 Takes medication regime

2. Disturbed Sensory Perception (Visual)

a. Subjective Cues
 Client states “Nag-laser surgery ako dati dahil sa cataract ko”.
 Client states “Yung dalawa kong kapatid nagpasurgery rin dati sa mata.”
b. Objective Cues
 Uses eye glasses for reading
 Pupils are equal and responsive to light
 History of eye surgery
c. Goal
  To help client regain vision to extent possible
 To teach client about normal age-related eye changes
d. Expected Outcome
 Regains vision to extent possible
 Describes effects of vision loss on lifestyle

3. Disturbed Sensory Perception (Auditory)

a. Subjective Cues
 Client states “Minsan mahina ang pandinig ko”.
 Client states “Madalas akong nahihilo”.
b. Objective Cues
 Unable to hear normal voice tones
 Unable to hear ticking in both ears (watch tick test)
c. Goal
 To help client regain hearing to extent possible
 To help client demonstrate correct use of hearing aids
d. Expected Outcome
 Regains hearing to extent possible
 Uses and demonstrates correct use of hearing aids

4. Impaired Memory
a. Subjective Cues
 Client states “Nakakalimutan ko minsan yung dapat kong gawin. Minsan hindi ko
alam kung bakit ako pumasok ng kwarto o lumabas ng bahay.”
b. Objective Cues
 Blood Pressure 140/90 mm Hg
 Radial Pulse 82 beats/min
 Respiration Rate 19 breaths/min
 Responsive to questions
c. Goal
 To help lessen to no memory distortions
 To help express feelings about memory impairment
 To develop measures to cope with memory impairment
d. Expected Outcome
 Able to recall events more often
 Expresses feelings about memory impairment
 Acknowledges the need to take measures to cope up with memory impairment

5. Risk for Falls

Keeping oneself one step away from accidents means he/she values his/her safety
and security needs. These needs are considered as secondary level. After one has
fulfilled his/her physiological needs the next thing he/she would have to do is
maintain these. And to achieve these, one must protect his/herself from any forms
 of risk. Risk for falls is commonly experienced by most people and being exposed to
this would only cause harm and one might sustain injuries which then affects
his/her safety and security needs.
a. Subjective Cues
 Client states “Minsan mahina ang pandinig ko”.
 Client states “Malabo na pandinig ko eh”.
 Client had a recent episode of syncope.
b. Objective Cues
 Uses eye glasses
 Unable to hear ticking in both ears (watch tick test)
 History of eye surgery
 Blood Pressure 140/90 mm Hg
 Radial Pulse 82 beats/min
 Respiration Rate 19 breaths/min
c. Goal
 To be free from falls
 To develop strategy to maintain safety and prevent falls
d. Expected Outcome
 Client will be free from falls
 Client will not sustain injuries

6. Risk for Injury

e. Subjective Cues
 Client states “Minsan mahina ang pandinig ko”.
 Client states “Malabo na pandinig ko eh”.
 Client had a recent episode of syncope.
f. Objective Cues
 Uses eye glasses
 Unable to hear ticking in both ears (watch tick test)
 History of eye surgery
 Blood Pressure 140/90 mm Hg
 Radial Pulse 82 beats/min
 Respiration Rate 19 breaths/min
g. Goal
 To reduce and prevent injuries
 To identify factors that increase potential for injury

 To develop strategy to maintain safety

h. Expected Outcome
 Applies safety measures
 Lesser to no injury
7. Situational low Self-Esteem
There are those times that one may feel lonely and not confident with oneself. This
may hinder him/her from achieving self-actualization which according to Maslow is
the highest and ultimate goal of every person. But before one may achieve this
he/she must gain confidence and love for him/herself. The fourth stage comprises all
of the things that one gains self-esteem – confidence, respect, achievements and
etc. Questioning your worth as a person means you’re having a hard time knowing
what you can do and what you love. Situational low self-esteem affects the person
as a whole and losing his/her confidence affects the things he/she can do.
a. Subjective Cues
 Client states “Minsan ramdam ko wala na akong silbi sa pamilya ko”.
 Client states “Dahil matanda na ako wala na ako masyadong nagagawa para sa
mga pamilya ko”.
b. Objective Cues
 Tone of voice sounded “sad”
c. Goal
 To encourage client to voice feelings
 To lessen the “worry”
 To let the family know about the client’s thoughts
 To create ways to help the client together with the family
d. Expected Outcome
 Able to voice out feelings about self and events
 Lessened worry
 Client’s family creates different ways to make the client feel important