Introduction to Nursing Theories

Introduction to Nursing TheoriesThis page was last updated on January 31, 2012

I N T R O D U C T I O N

Nursing theory is the term given to the body of knowledge that is used to support nursing practice. Nursing theory is a framework designed to organize knowledge and explain phenomena in nursing, at a

more concrete and specific level.

A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing.

Each discipline has a unique focus for knowledge development that directs its inquiry and distinguishes it from other fields of study.(Smith & Liehr, 2008).

Theory-guided, evidence-based practice is the hallmark of any professional discipline.

Nursing is a professional discipline (Donaldson & Crowley, 1978).

Almost 90% of all Nursing theories are generated in the last 20 years.

Nursing models are conceptual models, constructed of theories and concepts

A paradigm is a model that explains the linkages of science, philosophy, and theory accepted and applied by the discipline.

M E T A P A R A D I G M S I N N U R S I N G

Person

Recipient of care, including physical, spiritual, psychological, and sociocultural components. Individual, family, or community

Environment

All internal and external conditions, circumstances, and influences affecting the person

Health

Degree of wellness or illness experienced by the person

Nursing

Actions, characteristics and attributes of person giving care.

C O M P O N E N T S O F A T H E O R Y

D E F I N I T I O N S

Theory

a set of related statements that describes or explains phenomena in a systematic way. the doctrine or the principles underlying an art as distinguished from the practice of that particular art.

a formulated hypothesis or, loosely speaking, any hypothesis or opinion not based upon actual knowledge.

a provisional statement or set of explanatory propositions that purports to account for or characterize some phenomenon.

Concept

a mental idea of a phenomenon Concepts are the building blocks (the primary elements) of a theory.

Construct

a phenomena that cannot be observed and must be inferred Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given

theory are its constructs.

Proposition

a statement of relationship between concepts

Conceptual model

made up of concepts and propositions They epresent ways of thinking about a problem or ways of representing how complex things work the

way that they do.

Different Frameworks will emphasize different variables and outcomes and their interrelatedness.( Bordage, 2009)

Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory.

Variables

Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation.

Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program.

Middle range theory

a testable theory that contains a limited number of variables, and is limited in scope as well, yet is of sufficient generality to be useful with a variety of clinical research questions.

N U R S I N G P H I L O S O P H I E STheory Key PointsFlorence Nightingale’s Legacy of caring

Focuses on nursing and the patient environment relationship.

Ernestine Wiedenbach: The helping art of clinical nursing

Helping process meets needs through the art of individualizing care.

Nurses should identify patients ‘need-for –help’ by:

o Observation

o Understanding client behaviour

o Identifying cause of discomfort

o Determining if clients can resolve problems or have a need for help

Virginia Henderson’s Definition of Nursing

Patients require help towards achieving independence.

Derived a definition of nursing

Identified 14 basic human needs on which nursing care is based. Faye G.Abedellah’s Typology of twenty one Nursing problems

Patient’s problems determine nursing care

Lydia E. Hall :Care, Cure, Core model

Nursing care is person directed towards self love.

Jean Watson’s Philosophy and Science of caring

Caring is a universal, social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring.

Caring is central to the essence of nursing.Patricia Benner’s Novice to Expert Described systematically five stages of skill acquisition in nursing

practice – novice, advanced beginner, competent, proficient and expert.

C O N C E P T U A L M O D E L S A N D G R A N D T H E O R I E SDorothea E. Orem’s Self care deficit theory in nursing

Self–care maintains wholeness.

Three Theories:

o Theory of Self-Care

o Theory of Self-Care Deficit

o Theory of Nursing Systems

Nursing Care:

o Wholly compensatory (doing for the patient)

o Partly compensatory (helping the patient do for himself or

herself)

o Supportive- educative (Helping patient to learn self care and emphasizing on the importance of nurses’ role

Myra Estrin Levine’s: The conservation model

Proposed that the nurses use the principles of conservation of:

o Client Energy

o Personal integrity

o Structural integrity

o Social integrity

A conceptual model with three nursing theories –

o Conservation

o Redundancy

o Therapeutic intention

Martha E.Roger’s: Science of unitary human beings

Person and environment are energy fields that evolve negentropically

Nursing is a basic scientific discipline

Nursing is using knowledge for human betterment.

The unique focus of nursing is on the unitary or irreducible human being and the environment (both are energy fields) rather than health and illness

Dorothy E.Johnson’s Behavioural system model

Individuals maintain stability and balance through adjustments and adaptation to the forces that impinges them.

Individual as a behavioural system is composed of seven subsystems: the subsystems of attachment, or the affiliative, dependency, achievement, aggressive, ingestive-eliminative and sexual.

Disturbances in these causes nursing problems. Sister Callista: Roy‘s Adaptation model

Stimuli disrupt an adaptive system

The individual is a biopsychosocial adaptive system within an environment.

The individual and the environment provide three classes of stimuli-the focal, residual and contextual.

Through two adaptive mechanisms, regulator and cognator, an individual demonstrates adaptive responses or ineffective responses requiring nursing interventions

Betty Neuman’s : Health care systems model

Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors.

Nursing is concerned with the whole person.

Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client’s response to stressors.

Imogene King’s Goal attainment theory

Transactions provide a frame of reference toward goal setting.

Major concepts (interaction, perception, communication, transaction,

role, stress, growth and development)

Perceptions, Judgments and actions of the patient and the nurse lead to reaction, interaction, and transaction (process of nursing).

Nancy Roper, WW.Logan and A.J.Tierney A model for nursing based on a model of living

Individuality in living.

A conceptual model of nursing from which theory of goal attainment is derived.

Living is an amalgam of activities of living (ALs).

Most individuals experience significant life events which can affect ALs causing actual and potential problems.

This affects dependence – independence continuum which is bi-directional.

Nursing helps to maintain the individuality of person by preventing potential problems, solving actual problems and helping to cope.

Hildegard E. Peplau: Psychodynamic Nursing Theory

Interpersonal process is maturing force for personality.

Stressed the importance of nurses’ ability to understand own behaviour to help others identify perceived difficulties.

The four phases of nurse-patient relationships are:

o 1. Orientation

o 2. Identification

o 3. Exploitations

o 4. Resolution

The six nursing roles are:

o 1. Stranger

o 2. Resource person

o 3. Teacher

o 4. Leader

o 5. Surrogate

o 6. Counselor

Interpersonal process alleviates distress.Ida Jean Orlando’s Nursing Process Theory

Nurses must stay connected to patients and assure that patients get what they need, focused on patient’s verbal and non verbal expressions of need and nurse’s reactions to patient’s behaviour to alleviate distress.

Elements of nursing situation:

1. Patient

2. Nurse reactions

3. Nursing actionsJoyce Travelbee’s Human To Human Relationship Model

Therapeutic human relationships.

Nursing is accomplished through human to human relationships that

began with the original encounter and then progressed through stages of emerging identities.

Kathryn E. Barnard’s Parent Child Interaction Model

Growth and development of children and mother–infant relationships

Individual characteristics of each member influence the parent–infant system and adaptive behaviour modifies those characteristics to meet the needs of the system.

Ramona T.Mercer’s :Maternal Role Attainment

A complex theory to explain the factors impacting the development of maternal role over time.

Katharine Kolcaba’s Theory of comfort

Comfort is desirable holistic outcome of care.

Health care needs are needs (physical, psycho spiritual, social and environmental needs) for comfort, arising from stressful health care situations that cannot be met by recipients’ traditional support system.

Comfort measures include those nursing interventions designed to address the specific comfort needs.

Madeleine Leininger’s Transcultural nursing, culture-care theory

Caring is universal and varies transculturally.

Major concepts include care, caring, culture, cultural values and cultural variations

Caring serves to ameliorate or improve human conditions and life base.

Care is the essence and the dominant, distinctive and unifying feature of nursing

Rosemarie Rizzo Parse’s :Theory of human becoming

Indivisible beings and environment co-create health.

A theory of nursing derived from Roger’s conceptual model.

Clients are open, mutual and in constant interaction with environment.

The nurse assists the client in interaction with the environment and co creating health

Nola J.Pender’s :The Health promotion; model

Promoting optimum health supersedes disease prevention.

Identifies cognitive, perceptual factors in clients which are modified by demographical and biological characteristics, interpersonal influences, situational and behavioural factors that help predict in health promoting behaviour

C O N C L U S I O N

The conceptual and theoretical nursing models help to provide knowledge to improve practice, guide research and curriculum and identify the goals of nursing practice.

Nursing knowledge is the inclusive total of the philosophies, theories, research, and practice wisdom of the discipline.As a professional discipline this knowledge is important for guiding practice.(Smith & Liehr, 2008).

R E F E R E N C E S

1. Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113–120.2. Smith, M. J., & Liehr, P. R. (2008). Middle range theory for nursing. New York: Springer Publishing.

3. George B. Julia , Nursing Theories- The base for professional Nursing Practice, 3rd ed. Norwalk, Appleton & Lange.

4. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams&

wilkins.

5. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

6. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

7. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

8. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002

9. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.

A p p l i c a t i o n o f T h e o r y i n N u r s i n g P r o c e s sThis page was last updated on January 28, 2012

I n t r o d u c t i o n

Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable

fact or event) that is explanatory & predictive in nature.

Theories are composed of concepts, definitions, models, propositions & are based on assumptions.

They are derived through two principal methods; deductive reasoning and inductive reasoning.

O b j e c t i v e s

to assess the patient condition by the various methods explained by the nursing theory

to identify the needs of the patient

to demonstrate an effective communication and interaction with the patient.

to select a theory for the application according to the need of the patient

to apply the theory to solve the identified problems of the patient

to evaluate the extent to which the process was fruitful.

D e f i n i t i o n

Nursing theory is an organized and systematic articulation of a set of statements related to questions in

the discipline of nursing.

"A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived

from nursing models or from other disciplines and project a purposive, systematic view of phenomena by

designing specific inter-relationships among concepts for the purposes of describing, explaining,

predicting, and /or prescribing."

C h a r a c t e r i s t i c s o f a U s e f u l T h e o r y [Robert T. Croyle (2005)]

A useful theory makes assumptions about a behavior, health problem, target population, or environment that are:

Logical

Consistent with everyday observations

Similar to those used in previous successful programs and

Supported by past research in the same area or related ideas.

I m p o r t a n c e o f n u r s i n g t h e o r i e s

Nursing theory aims to describe, predict and explain the phenomenon of nursing

It should provide the foundations of nursing practice, help to generate further knowledge and indicate in

which direction nursing should develop in the future. Theory is important because it helps us to decide

what we know and what we need to know

It helps to distinguish what should form the basis of practice by explicitly describing nursing. The benefits

of having a defined body of theory in nursing include better patient care, enhanced professional status for

nurses, improved communication between nurses, and guidance for research and education

The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and

explain what nurses do

As medicine tries to make a move towards adopting a more multidisciplinary approach to health care,

nursing continues to strive to establish a unique body of knowledge

This can be seen as an attempt by the nursing profession to maintain its professional boundaries

E v o l u t i o n o f N u r s i n g T h e o r i e s & A p p l i c a t i o n

The history of professional nursing begins with Florence nightingale.

Later in last century nursing began with a strong emphasis on practice.

Following that came the curriculum era which addressed the questions about what the nursing students

should study in order to achieve the required standard of nursing.

As more and more nurses began to pursue higher degrees in nursing, there emerged the research era.

Later graduate education and masters education was given much importance.

The development of the theory era was a natural outgrowth of the research era.

With an increased number of researches it became obvious that the research without theory produced

isolated information; however research and theory produced the nursing sciences.

Within the contemporary phase there is an emphasis on theory use and theory based nursing practice

and lead to the continued development of the theories.

C h a r a c t e r i s t i c s o f t h e o r i e s

Theories are

Interrelating concepts in such a way as to create a different way of looking at a particular phenomenon.

Logical in nature.

Generalizable.

Bases for hypotheses that can be tested.

Increasing the general body of knowledge within the discipline through the research implemented to

validate them.

Used by the practitioners to guide and improve their practice.

Consistent with other validated theories, laws, and principles but will leave open unanswered questions

that need to be investigated.

P u r p o s e s o f t h e o r y i n p r a c t i c e

Assist nurses to describe, explain, and predict everyday experiences.

Serve to guide assessment, intervention, and evaluation of nursing care.

Provide a rationale for collecting reliable and valid data about the health status of clients, which are

essential for effective decision making and implementation.

Help to establish criteria to measure the quality of nursing care

Help build a common nursing terminology to use in communicating with other health professionals. Ideas

are developed and words defined.

Enhance autonomy (independence and self-governance) of nursing by defining its own independent

functions.

PURPOSES OF NURSING THEORIES

In Practice:


Serve to guide assessment, interventions, and evaluation of nursing care.

Provide a rationale for collecting reliable and valid data about the health status of clients, which are

essential for effective decision making and implementation.

Help to describe criteria to measure the quality of nursing care.

Help build a common nursing terminology to use in communicating with other health professionals.

Ideas are developed and words are defined.

Enhance autonomy (independence and self-governance) of nursing through defining its own independent

functions.

In Education:

Provide a general focus for curriculum design

Guide curricular decision making.

In Research:

Offer a framework for generating knowledge and new ideas.

Assist in discovering knowledge gaps in the specific field of study.

Offer a systematic approach to identify questions for study; select variables, interpret findings, and

validate nursing interventions.

Approaches to developing nursing theory

Borrowing conceptual frameworks from other disciplines.

Inductively looking at nursing practice to discover theories/concepts to explain phenomena.

Deductively looking for the compatibility of a general nursing theory with nursing practice.

Questions from practicing Nurse about using Nursing theory

Practice

Does this theory reflect nursing practice as I know it?

Will it support what I believe to be excellent nursing practice?

Can this theory be considered in relation to a wide range of nursing situation?

Personal Interests, Abilities and Experiences

What will it be like to think about nursing theory in nursing practice?

Will my work with nursing theory be worth the effort?

C o n c l u s i o n

If theory is expected to benefit practice, it must be developed co- operatively with people who practice

nursing.

People who do research and develop theories think differently about theory when they perceive the

reality of practice.

Theories do not provide the same type of procedural guidelines for practice as do situation- specific

principles and procedures or rules.

Procedural rules or principles help to standardize nursing practice and can also be useful in achieving

minimum goals of quality of care.

Theory is ought to improve the nursing practice.

One of the most common ways theory has been organized in practice is in the nursing process of

analyzing assessment data.

R e f e r e n c e s

1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby

Publications; 2002.


3. George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed. New Jersey :Prentice

Hall;2002.

4. Croyle RT. Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition).

U.S. Department of Health and Human Services, National Institutes of Health, 2005. Available at

www.thecommunityguide.org.

U n d e r t a n d i n g t h e W o r k s o f N u r s i n g T h e o r i s t sThis page was last updated on January 26, 2012

T h e o r i e s o f N u r s i n g

Theory is "an internally consistent group of relational statements (concepts, definitions and propositions)

that present a systematic view about a phenomenon and which is useful for description, explanation,

prediction and control".

Theories provide a framework for selecting and organizing information:

o What to ask

o What to observe

o What to focus on

o What to think about

Nursing theory is an organized and systematic articulation of a set of statements related to questions in

the discipline of nursing.

U s e s o f N u r s i n g T h e o r y

Define relationships among the variables of a given field of inquiry

Guide research, practice and communication

Allow the prediction of the consequences of care

Allow the prediction of a range of patient responses

L e v e l s o f T h e o r y

There are four levels of theory

Metatheory

Grand Theory

Middle Range Theory

Practice Theory

T y p e s o f T h e o r y

In nursing there are four types of theories:

Needs

Interaction

Outcome

Humanistic

V a l u e o f t h e o r y

Enhances understanding and explanation for events

Influence our behavior.

Makes to think differently about a problem or a situation

Helps to try new approaches or altering behavior.

We can gain a new perspective of events

Basis for challenge of its speculative tenets or propositions

Challenges subsequent discovery of new ideas or knowledge that might explain and predict events not

yet understood

In practice


Serve to guide assessment, intervention, and evaluation of nursing care.

Provide a rationale for collecting reliable and valid data about the health status of clients.

Help to establish criteria to measure the quality of nursing care

Help build a common nursing terminology.

Enhance autonomy of nursing by defining its own independent functions.

In education

Provide a general focus for curriculum design.

Guide curricular decision making

In research

Offer a framework for generating knowledge and new ideas.

Assist in discovering knowledge gaps in specific field of study.

Offer a systematic approach to identify questions for study, select variables, interpret findings, and

validate nursing interventions.

T h e o r y d e v e l o p m e n t

Theory development within nursing occurs in the context of practice.

Two activities contribute significantly to the overall process of developing theory in nursing.

o Concept analysis and

o Practical validation of theory.

Concept analysis

Identify and verify abstract concepts

"what events in practice can be linked with abstract concept x"

Application of theory in practice

Nursing process operation of analysis of assessment data.

Used as scientific rationale supporting judgments in nursing care plans.

C o n c e p t s

Concepts may be

1. readily observable, or concrete - thermometer, rash, and lesion;

2. indirectly observable, or inferential - pain and temperature; or

3. non-observable, or abstract - equilibrium, adaptation, stress, and powerlessness

nursing theories address and specify relationships among four major abstract concepts referred to as the

metaparadigm of nursing.

Four concepts are considered to be central to nursing:

o Person or client, the recipient of nursing care (includes individuals, families, groups, and

communities).

o Environment, the internal and external surroundings that affect the client. This includes people

in the physical environment, such as families, friends, and significant others.

o Health, the degree of wellness or well-being that the client experiences.

o Nursing, the attributes, characteristics, and actions of the nurse providing care on behalf of, or

in conjunction with, the client.

R e f e r e n c e s

1. Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical practice.6th edition.

Philadelphia. Mosby publications. 1996.

2. Black M. Joice, Hawks hokanson Jane. Medical Surgical Nursing: Clinical Management for positive

outcomes. St Lois, Missouri. 2005.


4. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia,

2002.

Application of Theory of Goal AttainmentThis page was last updated on January 31, 2012

O B J E C T I V E S

to assess the patient condition by the various methods explained by the nursing theory

to identify the needs of the patient

to demonstrate an effective communication and interaction with the patient.

to select a theory for the application according to the need of the patient

to apply the theory to solve the identified problems of the patient

to evaluate the extent to which the process was fruitful


King’s theory offers insight into nurses’ interactions with individuals and groups within the environment.

It highlights the importance of client’s participation in decision that influences care and focuses on both

the process of nurse-client interaction and the outcomes of care.

Mr.Sy (74 years) was admitted in L3 ward of ...Hospital, for a herniorrhaphy on ... for his left indirect

inguinal hernia and was expecting discharge from hospital... the theory of goal attainment was used in his

nursing process.

N U R S I N G P R O C E S S

A s s e s s m e n t

King indicates that assessment occur during interaction. The nurse brings special knowledge and skills

whereas client brings knowledge of self and perception of problems of concern, to this interaction.

During assessment nurse collects data regarding client (his/her growth & development, perception of self

and current health status, roles etc.)

·Perception is the base for collection and interpretation of data.

·Communication is required to verify accuracy of perception, for interaction and transaction.

The first process in nursing process is nurse meets the patient and communicates and interacts with him. Assessment is conducted by gathering data about the

patient based on relevant concepts.Mr. Sy is 74yrs married, got admitted in L3 ward of ...Hospital on 27/03/08 with a diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh

done on 30/03/08. The following areas were addressed to for gathering data.

What is the patient’s perception of the situation?

Patient says ” I have undergone surgery for hernia”. “ The wound is getting healed, I have no other problem” “I have pain in the area of surgery when moving” “I’m taking medicines for hypertension for the last 7 years

from here” “I have vision problem to my left eye. I had undergone a surgery for my right eye about 10 years

back”.

What are my perceptions of the situation?

Patient underwent herniorahaphy operation on 30th March for indirect inguinal hernia which he kept

untreated for 35 years. Patient has health maintenance related problems. Patient is at risk of developing

infection. Patient has pain related to surgical incision. Patient may develop hypertension related complications

in future.

What other information do I need to assist this patient to achieve health?

HISTORY

Identification details

Mr. Sy is 74yrs married, male, studied up to 7th Std is doing Business, a practicing Muslim, got admitted in L3

ward of ...Hospital on 27/03/08 with a diagnosis of indirect inguinal hernia underwent herniorraphy with

prolene mesh done on 30/03/08.

Present History of Illness Abdominal swelling for 35 years with difficulty in activities and occasional

abdominal pain. He has hypertension for seven years. The swelling remained stable with uncomplicated

progress, getting increasing size when standing for long and reducible on applying pressure No h/o severe pain but increasing size for the last few years Relived after

pressing the swelling back to position and on taking rest and applying pressure.

Past health history Patient underwent cataract surgery about 10 years back On treatment for hypertension No

other significant illness

Family History Patient’s next elder brother and next younger brother had inguinal hernia and were operated

Elder brother underwent 3 surgeries for hernia

Socioeconomic Status High economic status >Rs.20000/- per month.

Life Style Non vegetarian No habit of smoking or alcoholism. Aware about health care facilities

Physical examination Alert, conscious and oriented Moderately built, adequate nourishment, with BMI of

22 Vital signs – normal except BP 140/90 mmHg General head-to-foot examination reveals normal

finding except for the vision difficulty of the right eye and healing surgical wound on the left inguinal region. Subjective problems Pain at the surgical wound site

Lack of bowel movement for 2 days Review of relevant systems

GI system Inspection: Healing wound, No infection, No redness, No swelling.

Auscultation: Normal bowel sounds Palpation No pain at the site, Normal abdominal

organs

Percussion: No dull sound suggesting fluid

A p p l i c a t i o n o f O r e m ' s S e l f - C a r e D e f i c i t t h e o r y

T h i s p a g e w a s l a s t u p d a t e d o n O c t o b e r 1 7 , 2 0 1 1

O B J E C T I V E S

t o a s s e s s t h e p a t i e n t c o n d i t i o n b y t h e v a r i o u s m e t h o d s

e x p l a i n e d b y t h e n u r s i n g t h e o r y t o i d e n t i f y t h e n e e d s o f t h e p a t i e n t

t o d e m o n s t r a t e a n e f f e c t i v e c o m m u n i c a t i o n a n d i n t e r a c t i o n

w i t h t h e p a t i e n t .

t o s e l e c t a t h e o r y f o r t h e a p p l i c a t i o n a c c o r d i n g t o t h e n e e d o f

t h e p a t i e n t

t o a p p l y t h e t h e o r y t o s o l v e t h e i d e n t i f i e d p r o b l e m s o f t h e

p a t i e n t

t o e v a l u a t e t h e e x t e n t t o w h i c h t h e p r o c e s s w a s f r u i t f u l .

PATIENT PROFILE

Areas Patient detailsName Age Sex Education Occupation Marital status Religion Diagnosis Theory applied

Mrs. X 56 years Female No formal education House hold Married Hindu Rheumatoid arthritis Orem’s theory of self care deficit.

O R E M ’ S T H E O R Y O F S E L F C A R E D E F I C I T

T h e s e l f c a r e d e f i c i t t h e o r y p r o p o s e d b y O r e m i s a

c o m b i n a t i o n o f t h r e e t h e o r i e s , i . e . t h e o r y o f s e l f c a r e , t h e o r y

o f s e l f c a r e d e f i c i t a n d t h e t h e o r y o f n u r s i n g s y s t e m s . I n t h e t h e o r y o f s e l f c a r e , s h e e x p l a i n s s e l f c a r e a s t h e

a c t i v i t i e s c a r r i e d o u t b y t h e i n d i v i d u a l t o m a i n t a i n t h e i r o w n

h e a l t h .

T h e s e l f c a r e a g e n c y i s t h e a c q u i r e d a b i l i t y t o p e r f o r m t h e

s e l f c a r e a n d t h i s w i l l b e a f f e c t e d b y t h e b a s i c c o n d i t i o n i n g

f a c t o r s s u c h a s a g e , g e n d e r , h e a l t h c a r e s y s t e m , f a m i l y

s y s t e m e t c .

T h e r a p e u t i c s e l f - c a r e d e m a n d i s t h e t o t a l i t y o f t h e s e l f c a r e

m e a s u r e s r e q u i r e d .

T h e s e l f c a r e i s c a r r i e d o u t t o f u l f i l l t h e s e l f - c a r e r e q u i s i t e s .

T h e r e a r e m a i n l y 3 t y p e s o f s e l f c a r e r e q u i s i t e s s u c h a s

u n i v e r s a l , d e v e l o p m e n t a l a n d h e a l t h d e v i a t i o n s e l f c a r e

r e q u i s i t e s .

W h e n e v e r t h e r e i s a n i n a d e q u a c y o f a n y o f t h e s e s e l f c a r e

r e q u i s i t e , t h e p e r s o n w i l l b e i n n e e d o f s e l f c a r e o r w i l l h a v e

a d e f i c i t i n s e l f c a r e .

T h e d e f i c i t i s i d e n t i f i e d b y t h e n u r s e t h r o u g h t h e t h o r o u g h

a s s e s s m e n t o f t h e p a t i e n t .

O n c e t h e n e e d i s i d e n t i f i e d , t h e n u r s e h a s t o s e l e c t r e q u i r e d

n u r s i n g s y s t e m s t o p r o v i d e c a r e : w h o l l y c o m p e n s a t o r y , p a r t l y

c o m p e n s a t o r y o r s u p p o r t i v e a n d e d u c a t i v e s y s t e m .

T h e c a r e w i l l b e p r o v i d e d a c c o r d i n g t o t h e d e g r e e o f d e f i c i t

t h e p a t i e n t i s p r e s e n t i n g w i t h .

O n c e t h e c a r e i s p r o v i d e d , t h e n u r s i n g a c t i v i t i e s a n d t h e u s e

o f t h e n u r s i n g s y s t e m s a r e t o b e e v a l u a t e d t o g e t a n i d e a

a b o u t w h e t h e r t h e m u t u a l l y p l a n n e d g o a l s a r e m e t o r n o t .

T h u s t h e t h e o r y c o u l d b e s u c c e s s f u l l y a p p l i e d i n t o t h e

n u r s i n g p r a c t i c e .

F o r M r s . X … .

S h e c a m e t o t h e h o s p i t a l w i t h c o m p l a i n t s o f p a i n o v e r a l l t h e

j o i n t s , s t i f f n e s s w h i c h i s m o r e i n t h e m o r n i n g a n d r e d u c e s b y

t h e a c t i v i t i e s .

S h e h a s t h e s e c o m p l a i n t s s i n c e 5 y e a r s a n d h a s t a k e n

t r e a t m e n t f r o m l o c a l h o s p i t a l .

T h e s y m p t o m s w e r e n o t r e d u c i n g a n d c a m e t o - - M C , H o s p i t a l

f o r f u r t h e r m a n a g e m e n t .

P a t i e n t w a s a b l e t o d o t h e A D L b y h e r s e l f b u t t h e w a y s h e

p e r f o r m e d a n d t h e p o s t u r e s h e u s e d w a s m a k i n g h e r p r o n e t o

d e v e l o p t h e c o m p l i c a t i o n s o f t h e d i s e a s e .

S h e a l s o w a s m a l n o u r i s h e d a n d w a s n o t h a v i n g a w a r e n e s s

a b o u t t h e d e f i c i e n c i e s a n d e f f e c t s .

D A T A C O L L E C T I O N A C C O R D I N G T O O R E M ’ S T H E O R Y O F S E L F C A R E

D E F I C I T

1. BASIC CONDITIONING FACTORS

Age 56 yearGender FemaleHealth state Disability due to health condition,

therapeutic self care demandDevelopment state Ego integrity vs despairSociocultural orientation No formal education, Indian, HinduHealth care system Institutional health careFamily system Married, husband workingPatterns of living At home with partnerEnvironment Rural area, items for ADL not in easy

reach, no special precautions to prevent injuries

resources Husband, daughter, sister’s son

2. UNIVERSAL SELF-CARE REQUISITES

AirBreaths without difficulty, no pallor cyanosis

Water Fluid intake is sufficient. Edema present over ankles. Turgor normal for the age

Food Hb – 9.6gm%, BMI = 14.Food intake is not adequate or the diet is not nutritious.

Elimination Voids and eliminates bowel without difficulty.Activity/ rest Frequent rest is required due to pain.

Pain not completely relieved, Activity level ha s come down.Deformity of the joint secondary to the disease process and use of the joints.

Social interaction Communicates well with neighbors and calls the daughter by phone Need for medical care is communicated to the daughter.

Prevention of hazards Need instruction on care of joints and prevention of falls. Need instruction on improvement of nutritional status. Prefer to walk bare foot.

Promotion of normalcy Has good relation with daughter

3. DEVELOPMENTAL SELF-CARE REQUISITES

Maintenance of developmental environment

Able to feed self , Difficult to perform the dressing, toileting etc

Prevention/ management of the conditions threatening the normal development

Feels that the problems are due to her own behaviours and discusses the problems with husband and daughter.

4. HEALTH DEVIATION SELF CARE REQUISITES

Adherence to medical regimen

Reports the problems to the physician when in the hospital. Cooperates with the

medication, Not much aware about the use and side effects of medicines

Awareness of potential problem associated with the regimen

Not aware about the actual disease process.

Not compliant with the diet and prevention of hazards. Not aware about the side effects of the medications

Modification of self image to incorporates changes in health status

Has adapted to limitation in mobility.

The adoption of new ways for activities leads to deformities and progression of the disease.

Adjustment of lifestyle to accommodate changes in the health status and medical regimen.

Adjusted with the deformities. Pain tolerance not achieved

5 . M E D I C A L P R O B L E M A N D P L A N

P h y s i c i a n ’ s p e r s p e c t i v e o f t h e c o n d i t i o n : D i a g n o s e d w i t h

r h e u m a t o i d a r t h r i t i s a n d i s o n t h e f o l l o w i n g m e d i c a t i o n s :

T . V a l u s S R O D

T . P a n 4 0 m g O D

T . T r a m a z a c 5 0 m g O D

T . R e c o f i x F o r t e B D

T . S h e l c a l B D

S y p . H e a m u p 2 t s p T I D

M e d i c a l D i a g n o s i s : R h e u m a t o i d a r t h r i t i s

M e d i c a l T r e a t m e n t : M e d i c a t i o n a n d p h y s i c a l t h e r a p y .

A R E A S A N D P R I O R I T Y A C C O R D I N G T O O R E M ’ S T H E O R Y O F S E L F -

C A R E D E F I C I T : I M P O R T A N T F O R P R I O R I T I Z I N G T H E N U R S I N G

D I A G N O S I S .

A i r

W a t e r

F o o d

E l i m i n a t i o n

A c t i v i t y / R e s t

S o l i t u d e / I n t e r a c t i o n

P r e v e n t i o n o f h a z a r d s

P r o m o t i o n o f n o r m a l c y

M a i n t a i n a d e v e l o p m e n t a l e n v i r o n m e n t .

P r e v e n t o r m a n a g e t h e d e v e l o p m e n t a l t h r e a t s

M a i n t e n a n c e o f h e a l t h s t a t u s

A w a r e n e s s a n d m a n a g e m e n t o f t h e d i s e a s e p r o c e s s .

A d h e r e n c e t o t h e m e d i c a l r e g i m e n

A w a r e n e s s o f p o t e n t i a l p r o b l e m .

m o d i f y s e l f i m a g e

A d j u s t l i f e s t y l e t o a c c o m m o d a t e h e a l t h s t a t u s c h a n g e s a n d

M R

NURSING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT

Nursing diagnosis (diagnostic operations)

Outcome and plan (Prescriptive operations)

Implementation (control operations)

Evaluation (regulatory operations)

Based on self care deficits

Outcome Nursing goal and objectives Design of nursing system Appropriate method of helping

Nurse- patient actions to - Promote patient as self care agent - Meet self care needs - Decrease the self care deficit.

1. Effectiveness of the nurse patient action to -Promote patient as self care agent - Meet self care needs - Decrease the self care deficit. 2. Effectiveness of the selected nursing system to meet the needs.

T h u s i n t h e p a t i e n t M r s . X t h e a r e a s t h a t n e e d a s s i s t a n c e w e r e …

A i r

W a t e r

F o o d

E l i m i n a t i o n

A c t i v i t y / R e s t ( 2 )

S o l i t u d e / I n t e r a c t i o n

P r e v e n t i o n o f h a z a r d s ( 2 )

P r o m o t i o n o f n o r m a l c y

M a i n t a i n a d e v e l o p m e n t a l e n v i r o n m e n t .

P r e v e n t o r m a n a g e t h e d e v e l o p m e n t a l t h r e a t s

M a i n t e n a n c e o f h e a l t h s t a t u s

A w a r e n e s s a n d m a n a g e m e n t o f t h e d i s e a s e p r o c e s s .

A d h e r e n c e t o t h e m e d i c a l r e g i m e n

A w a r e n e s s o f p o t e n t i a l p r o b l e m .

m o d i f y s e l f i m a g e

A d j u s t l i f e s t y l e t o a c c o m m o d a t e h e a l t h s t a t u s c h a n g e s a n d

m e d i c a l r e g i m e n

A P P L Y I N G T H E O R E M ’ S T H E O R Y O F S E L F - C A R E D E F I C I T , A N U R S I N G

C A R E P L A N F O R M R S . X C O U L D B E P R E P A R E D A S F O L L O W S …

A . T H E R A P E U T I C S E L F C A R E D E M A N D : D E F I C I E N T A R E A : F O O D

A D E Q U A C Y O F S E L F C A R E A G E N C Y : I N A D E Q U A T E

N U R S I N G D I A G N O S I S

I n a b i l i t y t o m a i n t a i n t h e i d e a l n u t r i t i o n r e l a t e d t o i n a d e q u a t e

i n t a k e a n d k n o w l e d g e d e f i c i t

O U T C O M E S A N D P L A N

a . O u t c o m e :

I m p r o v e d n u t r i t i o n

M a i n t e n a n c e o f a b a l a n c e d d i e t w i t h a d e q u a t e i r o n

s u p p l e m e n t a t i o n .

b . N u r s i n g G o a l s a n d o b j e c t i v e s

G o a l : t o a c h i e v e o p t i m a l l e v e l s o f n u t r i t i o n .

O b j e c t i v e s : M r s . X w i l l :

s t a t e t h e i m p o r t a n c e o f m a i n t a i n i n g a b a l a n c e d d i e t .

L i s t t h e f o o d i t e m s r i c h i n i r o n , t h a t a r e a v a i l a b l e i n t h e

l o c a l i t y .

c . D e s i g n o f t h e n u r s i n g s y s t e m :

s u p p o r t i v e e d u c a t i v e

d . M e t h o d o f h e l p i n g :

g u i d a n c e

s u p p o r t

T e a c h i n g

P r o v i d i n g d e v e l o p m e n t a l e n v i r o n m e n t

I M P L E M E N T A T I O N

M u t u a l l y p l a n n e d a n d i d e n t i f i e d t h e o b j e c t i v e s a n d t h e p a t i e n t

w e r e m a d e t o u n d e r s t a n d a b o u t t h e r e q u i r e d c h a n g e s i n t h e

b e h a v i o u r t o h a v e t h e r e q u i s i t e s m e t .

E V A L U A T I O N

M r s . X u n d e r s t o o d t h e i m p o r t a n c e o f m a i n t a i n i n g a n o p t i m u m

n u t r i t i o n . S h e t o l d t h a t s h e w i l l s e l e c t t h e i r o n r i c h d i e t f o r h e r f o o d .

S h e l i s t e d t h e f o o d s t h a t a r e r i c h i n i r o n a n d t h a t a r e l o c a l l y

a v a i l a b l e .

T h e s e l f c a r e d e f i c i t i n t e r m s o f f o o d w i l l b e d e c r e a s e d w i t h

t h e i n i t i a t i o n o f t h e n u t r i t i o n a l i n t a k e .

T h e s u p p o r t i v e e d u c a t i v e s y s t e m w a s u s e f u l f o r M r s . X

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

B . T H E R A P E U T I C S E L F C A R E D E M A N D : D E F I C I E N T A R E A : A C T I V I T Y



S e l f - c a r e d e f i c i t : d r e s s i n g , t o i l e t i n g r e l a t e d t o r e s t r i c t e d

j o i n t m o v e m e n t , s e c o n d a r y t o t h e i n f l a m m a t o r y p r o c e s s i n t h e

j o i n t s .


a . O u t c o m e :

i m p r o v e d s e l f - c a r e

m a i n t a i n t h e a b i l i t y t o p e r f o r m t h e t o i l e t i n g a n d d r e s s i n g w i t h

m o d i f i c a t i o n a s r e q u i r e d .


G o a l : t o a c h i e v e o p t i m a l l e v e l s o f a b i l i t y f o r s e l f c a r e .


p e r f o r m t h e d r e s s i n g a c t i v i t i e s w i t h i n l i m i t a t i o n s

u t i l i z e t h e a l t e r n a t i v e m e a s u r e s a v a i l a b l e f o r i m p r o v i n g t h e

t o i l e t i n g

p e r f o r m t h e o t h e r a c t i v i t i e s o f d a i l y l i v i n g w i t h m i n i m a l

a s s i s t a n c e .

c . D e s i g n o f t h e n u r s i n g s y s t e m : P a r t l y c o m p e n s a t o r y

d . M e t h o d o f h e l p i n g :

1 . G u i d a n c e :

A s s e s s t h e v a r i o u s h i n d e r i n g f a c t o r s f o r s e l f c a r e a n d h o w t o

t a c k l e t h e m .

2 . S u p p o r t :

P r o v i d e a l l t h e a r t i c l e s n e e d e d f o r s e l f c a r e , n e a r t o t h e

p a t i e n t a n d a s k t h e f a m i l y m e m b e r s a l s o t o g i v e t h e a r t i c l e s

n e a r t o h e r . P r o v i d e p a s s i v e e x e r c i s e s a n d m a k e t o p e r f o r m a c t i v e

e x e r c i s e s s o a s t o p r o m o t e t h e m o b i l i t y o f t h e j o i n t .

M a k e t h e p a t i e n t u s e c o m m o d e s o r s t o o l s t o p e r f o r m t o i l e t i n g

a n d i n s i s t o n a v o i d a n c e o f s q u a t t i n g p o s i t i o n

P r o v i d e a s s i s t a n c e w h e n e v e r n e e d e d f o r t h e s e l f c a r e

a c t i v i t i e s

P r o v i d e e n c o u r a g e m e n t a n d p o s i t i v e r e i n f o r c e m e n t f o r m i n o r

i m p r o v e m e n t i n t h e a c t i v i t y l e v e l .

I n i t i a t e t h e p a i n r e l i e v i n g m e a s u r e s a l w a y s b e f o r e t h e p a t i e n t

g o f o r a n y o f t h e a c t i v i t i e s o f d a i l y l i v i n g

M a k e t h e p a t i e n t t o u s e l o o s e f i t t i n g c l o t h e s w h i c h w i l l b e

e a s y t o w e a r a n d r e m o v e .

3 . T e a c h i n g :

T e a c h t h e f a m i l y m e m b e r s t h e l i m i t a t i o n i n t h e a c t i v i t y l e v e l

t h e p a t i e n t h a s a n d t h e c o o p e r a t i o n r e q u i r e d

4 . P r o m o t i n g a d e v e l o p m e n t a l e n v i r o n m e n t :

T e a c h t h e f a m i l y a n d h e l p t h e m t o p r a c t i c e h o w t o h e l p t h e

p a t i e n t a c c o r d i n g t o h e r n e e d s


M u t u a l l y p l a n n e d a n d i d e n t i f i e d t h e o b j e c t i v e s a n d t h e p a t i e n t

w a s m a d e t o u n d e r s t a n d a b o u t t h e r e q u i r e d c h a n g e s i n t h e

b e h a v i o u r t o h a v e t h e r e q u i s i t e s m e t .

E V A L U A T I O N

P a t i e n t w a s p e r f o r m i n g s o m e o f t h e a c t i v i t i e s a n d s h e

p r a c t i c e d t o i l e t i n g u s i n g a c o m m o d e i n t h e h o s p i t a l . S h e v e r b a l i z e d a n i m p r o v e d c o m f o r t a n d s e l f c a r e a b i l i t y .

S h e p e r f o r m e d t h e d r e s s i n g a c t i v i t i e s w i t h m i n i m a l a s s i s t a n c e

P a t i e n t v e r b a l i z e d t h a t s h e w i l l p e r f o r m t h e a c t i v i t i e s a s

i n s t r u c t e d t o g e t h e r A D L d o n e .

T h e p a r t l y c o m p e n s a t o r y s y s t e m w a s u s e f u l f o r M r s . X

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

C . T H E R A P E U T I C S E L F C A R E D E M A N D : D E F I C I E N T A R E A : P A I N

C O N T R O L



I n e f f e c t i v e p a i n c o n t r o l r e l a t e d t o l a c k o f u t i l i z a t i o n o f p a i n

r e l i e f m e a s u r e s


a . O u t c o m e :

i m p r o v e d p a i n s e l f c o n t r o l

a c h i e v e a n d m a i n t a i n a r e d u c t i o n i n t h e p a i n .


G o a l : t o a c h i e v e r e d u c t i o n i n t h e p a i n .


d e s c r i b e t h e t o t a l p l a n o f p h a r m a c o l o g i c a l a n d n o n

p h a r m a c o l o g i c a l p a i n r e l i e f d e m o n s t r a t e a r e d u c t i o n i n t h e p a i n b e h a v i o u r s

v e r b a l i z e a r e d u c t i o n i n t h e p a i n s c a l e s c o r e f r o m 7 – 4

c . D e s i g n o f t h e n u r s i n g s y s t e m : s u p p o r t i v e e d u c a t i v e

d . m e t h o d o f h e l p i n g :

G u i d a n c e :

E x p l o r e t h e p a s t e x p e r i e n c e o f p a i n a n d m e t h o d s u s e d t o

m a n a g e t h e m . A s k t h e c l i e n t t o r e p o r t t h e i n t e n s i t y , l o c a t i o n , s e v e r i t y ,

a s s o c i a t e d a n d a g g r a v a t i n g f a c t o r s .

S u p p o r t :

P r o v i d e r e s t t o t h e j o i n t s a n d a v o i d e x c e s s i v e m a n i p u l a t i o n s

p r o v i d e h o t a n d c o l d a p p l i c a t i o n t o h a v e b e t t e r m o b i l i t y .

E n c o u r a g e e x e r c i s e s t o t h e j o i n t s b y i m m e r s i n g i n t h e w a r m

w a t e r .

A d m i n i s t e r T . U l t r a c e t a n d T a b D i c l o f e c a c a s p r e s c r i b e d .

P r o v i d e d i v e r s i o n a n d p s y c h o l o g i c a l s u p p o r t t o t h e p a t i e n t

T e a c h i n g :

T e a c h t h e n o n – p h a r m a c o l o g i c a l m e t h o d t o t h e p a t i e n t o n c e

t h e p a i n i s a l i t t l e r e d u c e d .

P r o v i d i n g t h e d e v e l o p m e n t a l e n v i r o n m e n t :

D i s c u s s w i t h t h e p a t i e n t t h e n e c e s s i t y t o m a i n t a i n a p a i n

d i a r y w i t h a l l i n f o r m a t i o n r e g a r d i n g e p i s o d e s o f p a i n a n d

r e f e r t o t h a t p e r i o d i c a l l y

E n q u i r e f r o m t h e h e a l t h t e a m , t h e n e e d f o r o p i o i d a n a l g e s i c s

o r o t h e r a n a l g e s i c s a n d g e t a p r e s c r i p t i o n f o r t h e p a t i e n t .


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

E V A L U A T I O N

P a t i e n t s t i l l h a s p a i n o v e r t h e j o i n t s a n d s h e a g r e e d t h a t s h e

w i l l u s e t h e m e a s u r e s f o r p a i n r e l i e f t h a t i s t o l d t o h e r . T h e p a i n s c a l e s c o r e w a s 6 a f t e r t h e m e a s u r e s w e r e p r o v i d e d

t o t h e p a t i e n t .

S h e d e m o n s t r a t e d s l i g h t r e d u c t i o n i n t h e p a i n b e h a v i o u r s .


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

D . T H E R A P E U T I C S E L F C A R E D E M A N D : D E F I C I E N T A R E A :

P R E V E N T I O N O F H A Z A R D S .



P o t e n t i a l f o r f a l l a n d f r a c t u r e s r e l a t e d t o r h e u m a t o i d

a r t h r i t i s .


a . O u t c o m e :

A b s e n c e o f f a l l s a n d i n j u r y t o t h e p a t i e n t


G o a l : p r e v e n t t h e f a l l s a n d i n j u r y a n d t o m a i n t a i n a g o o d b o d y

m e c h a n i c s .


r e m a i n f r e e f r o m i n j u r y a s e v i d e n c e d b y :

a b s e n c e o f s i g n s a n d s y m p t o m s o f f a l l o r i n j u r y

E x p l a i n i n g t h e m e t h o d s t o p r e v e n t t h e i n j u r y .



S u p p o r t

N e v e r l e a v e t h e c l i e n t a l o n e i n t h e u n i t

A s s e s s t h e p a t i e n t s g a i t , a c t i v i t i e s a n d t h e m e n t a l s t a t u s f o r

a n y c o n f u s i o n o r d i s o r i e n t a t i o n

E n c o u r a g e t h e p a t i e n t t o u s e s u p p o r t i v e d e v i c e s a s r e q u i r e d .

P r o v i d e a s a f e e n v i r o n m e n t i n t h e h o s p i t a l b y a v o i d i n g s h a r p

o b j e c t s o r w o o d e n o b j e c t s o n t h e w a y a n d s l i p p e r y f l o o r .

I n v o l v e t h e f a m i l y m e m b e r s i n p r o v i d i n g a n d m a i n t a i n i n g a

s a f e e n v i r o n m e n t i n t h e h o m e

I n v o l v e t h e f a m i l y m e m b e r s t o p r o v i d e s u p p o r t t o t h e p a t i e n t

w h e n e v e r n e c e s s a r y

P l a n a b a l a n c e d d i e t f o r t h e p a t i e n t w i t h a m u t u a l i n t e r a c t i o n


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

E V A L U A T I O N

P a t i e n t r e m a i n e d f r e e f r o m i n j u r y a s e v i d e n c e d b y a b s e n c e o f

s i g n s a n d s y m p t o m s . P a t i e n t e x p l a i n e d t h e v a r i o u s m e a s u r e s t h a t t h e y w i l l t a k e t o

p r e v e n t t h e i n j u r y .


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

E . T H E R A P E U T I C S E L F C A R E D E M A N D : D E F I C I E N T A R E A :

P R E V E N T I O N O F H A Z A R D S .


N U R S I N G D I A G N O S I S :

P o t e n t i a l f o r i m p a i r e d s k i n i n t e g r i t y r e l a t e d t o e d e m a

s e c o n d a r y t o r e n a l c y s t s .

O U T C O M E S A N D P L A N :

a . O u t c o m e :

M a i n t e n a n c e o f n o r m a l s k i n i n t e g r i t y .

b . n u r s i n g G o a l s a n d o b j e c t i v e s

G o a l : M a i n t a i n t h e s k i n i n t e g r i t y a n d t a k e m e a s u r e s t o p r e v e n t s k i n

i m p a i r m e n t .


m a i n t a i n a n o r m a l s k i n i n t e g r i t y

l i s t t h e m e a s u r e s t o p r e v e n t t h e l o s s o f s k i n i n t e g r i t y

i d e n t i f y t h e m e a s u r e s t o r e l i e v e e d e m a .



S u p p o r t :

A s s e s s t h e s k i n r e g u l a r l y f o r a n y e x c o r i a t i o n o r l o s s o f

i n t e g r i t y o r c o l o u r c h a n g e s . K e e p t h e s k i n c l e a n a l w a y s A v o i d s t r e s s o r p r e s s u r e o v e r t h e a r e a o f e d e m a b y p r o v i d i n g

e x t r a c u s h i o n s o r p a d d i n g

M o n i t o r t h e l a b v a l u e s a s w e l l a s t h e p a t i e n t f o r a n y s i g n s

a n d s y m p t o m s o f r e n a l f a i l u r e .

E n c o u r a g e t h e p a t i e n t t o u s e s l i p p e r s w h i l e w a l k i n g a n d t h a t

s h o u l d n o t b e t i g h t f i t t i n g .

A s s e s s t h e e d e m a f o r i t s d e g r e e , p i t t i n g o r n o n p i t t i n g a n d

c o n t i n u e t h e a s s e s s m e n t d a i l y .

P r o v i d e a l e g e n d e l e v a t e d p o s i t i o n o r e l e v a t i o n o f t h e l e g o n

a p i l l o w i f n o c a r d i a c a b n o r m a l i t i e s a r e i d e n t i f i e d .

E x p l a i n t h e p a t i e n t t h e n e e d f o r t a k i n g c a r e o f t h e e d e m a t o u s

p a r t s

E x p l a i n t h e p a t i e n t t o r e p o r t t h e s y m p t o m s l i k e d e c r e a s e d

u r i n e o u t p u t , p a l p i t a t i o n s , i n c r e a s e d e d e m a e t c . t o t h e h e a l t h

t e a m


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

E V A L U A T I O N

P a t i e n t r e m a i n e d f r e e f r o m i m p a i r e d s k i n i n t e g r i t y

S h e l i s t e d t h e m e a s u r e s t o p r e v e n t t h e l o s s o f s k i n i n t e g r i t y

S h e i d e n t i f i e d t h e m e a s u r e s t o r e l i e v e e d e m a .

T h e s u p p o r t i v e e d u c a t i v e s y s t e m w a s u s e f u l f o r M r s . x

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

F . T H E R A P E U T I C S E L F C A R E D E M A N D : D E F I C I E N T A R E A :

A W A R E N E S S O F T H E D I S E A S E P R O C E S S A N D M A N A G E M E N T



P o t e n t i a l f o r c o m p l i c a t i o n s r e l a t e d t o r h e u m a t o i d a r t h r i t i s

s e c o n d a r y t o k n o w l e d g e d e f i c i t .


a . O u t c o m e :

A b s e n c e o f c o m p l i c a t i o n s a n d i m p r o v e d a w a r e n e s s a b o u t t h e

d i s e a s e p r o c e s s .

b . n u r s i n g G o a l s a n d o b j e c t i v e s

G o a l : I m p r o v e t h e k n o w l e d g e o f t h e p a t i e n t a b o u t t h e d i s e a s e

p r o c e s s a n d t h e c o m p l i c a t i o n s .


v e r b a l i z e t h e v a r i o u s c o m p l i c a t i o n a n d t h e i r p r e v e n t i o n s

v e r b a l i z e t h e c h a n g e s o c c u r r i n g w i t h t h e d i s e a s e p r o c e s s a n d

t h e t r e a t m e n t a v a i l a b l e

d e s c r i b e t h e a c t i o n s a n d s i d e e f f e c t s o f t h e m e d i c a t i o n s

w h i c h s h e i s u s i n g

c . D e s i g n o f t h e n u r s i n g s y s t e m :

s u p p o r t i v e e d u c a t i v e

d . M e t h o d s o f h e l p i n g :

G u i d a n c e

T e a c h i n g

P r o m o t i n g a d e v e l o p m e n t a l e n v i r o n m e n t


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

E V A L U A T I O N

P a t i e n t g o t a d e q u a t e i n f o r m a t i o n r e g a r d i n g t h e d i s e a s e

S h e v e r b a l i z e d w h a t s h e u n d e r s t o o d a b o u t t h e d i s e a s e a n d i t s

m a n a g e m e n t .

P a t i e n t h a s c l e a r e d h e r d o u b t s r e g a r d i n g t h e m e d i c a t i o n

a c t i o n s a n d t h e s i d e e f f e c t


E V A L U A T I O N O F T H E A P P L I C A T I O N O F S E L F C A R E D E F I C I T T H E O R Y

T h e t h e o r y o f s e l f - c a r e d e f i c i t w h e n a p p l i e d c o u l d i d e n t i f y t h e s e l f

c a r e r e q u i s i t e s o f M r s . X f r o m v a r i o u s a s p e c t s . T h i s w a s h e l p f u l t o

p r o v i d e c a r e i n a c o m p r e h e n s i v e m a n n e r . P a t i e n t w a s v e r y

c o o p e r a t i v e . t h e a p p l i c a t i o n o f t h i s t h e o r y r e v e a l e d h o w w e l l t h e

s u p p o r t i v e a n d e d u c a t i v e a n d p a r t l y c o m p e n s a t o r y s y s t e m c o u l d b e

u s e d f o r s o l v i n g t h e p r o b l e m s i n a p a t i e n t w i t h r h e u m a t o i d

a r t h r i t i s .

R E F E R E N C E S

1 . A l l i g o o d M R , T o m e y A M . N u r s i n g T h e o r y : U t i l i z a t i o n

& A p p l i c a t i o n . 3 r d e d . M i s s o u r i : E l s e v i e r M o s b y P u b l i c a t i o n s ;

2 0 0 2 .

2 . T o m e y A M , A l l i g o o d . M R . N u r s i n g t h e o r i s t s a n d t h e i r w o r k .

( 5 t h e d . ) . M o s b y , P h i l a d e l p h i a , 2 0 0 2

3 . G e o r g e J B . N u r s i n g T h e o r i e s : T h e B a s e f o r P r o f e s s i o n a l

N u r s i n g P r a c t i c e . 5 t h e d . N e w J e r s e y : P r e n t i c e H a l l ; 2 0 0 2 .

A P P L I C A T I O N O F S U C H M A N ’ S S T A G E S O F I L L N E S S M O D E L

This page was last updated on October 28, 2011

I n t r o d u c t i o n

Man is a social being.

Social factors play important role in health.

Social conditions and not only promote the possibility of illness and disability, they also enhance prospect

for disease prevention and health maintenance.

Health life style and the avoidance of high-risk behaviour, advance the individual’s potential for a longer

and healthier life.

The recognition of the fact that the health of an individual is more than biological phenomena has brought

in to the forefront the significance of behavioural dimension of health.

Mr. AS, a 73 years old, Muslim, male patient admitted in ---ward of ---Hospital with a diagnosis of prostate cancer.

Data regarding psychosocial aspects of his life and illness were collected through interview. He was cooperative

and interactive with me for most part. But later he was found to be reluctant to talk ...as he was frequently

expressing his financial troubles which could not be helped by anyone related to him

Cancer Prostate

Prostate cancer is the fifth most common type of cancer in men and its incidence rises with advancing years. It

occurs in 1 in 10 in the men living to the age of 70 years. Early clinical features are indistinguishable from those of

BPH and the gland may feel normal on digital examination. The PSA may be elevated (>4 ng/ml). As the tumour

grows locally it may produce bladder neck obstruction, obstruct the ureters and rapidly lead to renal impairment. In

late disease rectal examination shows the prostate to be large, hard and irregular. Rectal ultrasound may show the

spread of the cancer and this should also be used for directing needle or aspiration biopsy. Prostatic biopsy is

important in giving prognostic information- prognosis being poorer with poorly differentiated tumours.

Therapy depends on staging. Early disease is treated with local radiotherapy and more advanced disease by

orchidectomy and hormone therapy with oestrogen. It has been suggested that all men over the age of 50 years

should be screened by rectal examination, transrectal ultrasound and PSA measurement.

General information

Name : Mr. AS

Age : 73 years

Gender : Male

Marital status : Married

Place : ---/ ----

Hosp. No. : ------

Date of admission : 1-4-08

Ward/Unit : --------

Education : No formal education

Culture & life-style

Religion : Islam, Muslim, believes in 'Durgas', and has gone there too.

Food habits : four time in a day & Non-vegetarian once in a day

Socioeconomic condition

Lower socioeconomic status

Occupation

Fisher man for 12 years

He was a beedi worker for 10 years

went to gulf and worked there for 4 years

Cook for 35 years

His son is in Gulf country, but earns only Rs.5000/month

His residence is about 80 km away from ----,

to and fro journey costs rs.50/ person

Role in the family

Head of the family, earning member, and father

These role are affected due the illness “ everything is disturbed at home”

Social Support Network

Patient has poor social support network

There is no one to support him financially for treatment of his illness

His daughter visited him twice in the hospital, no other person visited him or enquired him about his

illness after coming in the hospital

Patient complaints (on the first meeting)

Pain at the genital area (on catheterization)

Urine tube needs to be removed

No taste for anything he eats

No money in hand to pay the hospital bill

No sleep at night

Identification of patient needs Collection, observing/ performing activities relating to caring

Interpretation and analysis

Needs arising from present illness and the consequent response to cope with

· “I have pain at genital region”· “I have problem of passing urine without control, that is why tube is inserted”· “I want to get this urine tube removed”· “Who will pay my hospital bill of Rs.50,000?”· Patient complains that he is not getting adequate sleep during night· He sleeps during daytime

· Patient’s main complaints are pain, irritation at the site of urinary catheter, and sleep disturbance

· He was a cook, working most of his life in night time for marriage parties · Currently, he is hospitalised for cancer, prostate and is receiving radiotherapy for the last one month

Basic physical needs · He is advised not to take bath till the end of radiotherapy to avoid skin excoriation at the site· He maintains adequate cleanliness· He visits toilet with assistance from his wife· He is catheterized for the last 2

· He says is a practicing Muslim· He is taking bath means it interferes with his religious practices· He is advised not to take bath because he may wet the irradiation area, but the cultural issues are not addressed.

months

Needs related to life style · He is a non-vegetarian· But he not getting any non-veg food in the hospital

· His life style related needs hindered in this hospital environment

Needs related to habits · He does not take tea or coffee· He does not smoke or take drinks

· As he has any regular habits of taking tea or coffee or drinking alcohol

Individual’s knowledge and experience of illness

Patient’s Knowledge of Present illnessPatient explains his illness: · “I have pain and urine block for the last 6 months” · “My illness is serious”· “I have diabetes for the last one year”· “I underwent a surgery for urinary block and pain in ----- 4 months back”What the patient wants to know about the illness?“will this illness get cured” “I have come here because, doctors in ---- told me my illness can be cured only in this Hospital”

· Patient has understanding of the illness as his illness is serious.· Patient underwent orchidectomy and TURP in -------- 4 months back and later referred to a tertiary care hospital for further management· Patient wants to know whether his illness will get cured.· He says he has no money to spend her.· But his expenses are met by his daughter and one brother

Experience of illness What has been his past experience with illness?Past Illness History· “Earlier I went to many local folk doctors, they only made all these illness”· “I have sugar illness for the last one year”· “ The doctor in Kundapura told me to check sugar, so I know I have sugar problem”· “I have not had any major illness in my life other than this”Family History· No major illness in his knowledgeWhether patient has accepted his illness· “I don’t have any habits, drinking, smoking or taking even coffee since childhood. I don’t know why I got this illness”

· Patient has consulted many folk doctors for minor illness and never satisfied with them.· He had minor troubles with urinary frequency for about 4 years· So he consulted some folk people for some remedies · But never satisfied

· Patient has accepted the illness as some thing which he does not deserve.· He puts it on fate

Knowledge of formal and alternative therapies

· He has adequate information about formal and folk medicines· “I have gone to them, but no benefits”

He had tried alternative medicines and found to have no benefit in his illness

Knowledge at present and future course of action.What is the treatment planDoes the person knows about it

· Patient says he has one month duration of x-ray treatment· “nobody tells me what is my illness”· “I’m taking medicines regularly”

· Patient has only partial knowledge of his illness and treatment plans· He is illiterate, but nobody has explained him about his treatment plans

Coping with the illness and its outcome (Patient and family)

· “What will we do?”· “We have to suffer everything”· He looks depressed and tries to avoid visitors · “I don’t have money pay here, I don’t know what to do”

· Patient is not showing adaptive responses· He has depressive cognitions· He has financial problems

Analyse the individuals and family’s views on · health team · doctors· nurses

· “Doctor People come and asks how you are? (he explains sarcastically), nothing else”· “They do not want to know about my pain”

He is not satisfied with the psychological attention given to him by nurse or doctorHis wife too has the same opinion Doctor has explained about the illness

· “sometimes, nurses come asks about me”“Doctor has told something to my daughter”

to his daughter about the diagnosis and prognosis

Distinguish between the meanings of the patient, doctor, nurse

Patient: “they are not asking me anything”Doctor: “he will not understand anything, it is explained to his daughter”Nurse: “doctor has explained everything to him, we cannot tell anything to the patient”

Patient wants to know about his illness, and course of treatment, but doctor is preoccupied with the patient’s educational status.

Nursing staff is bothered whether they may convey wrong message to the patient.There is a communication gap exists among these people.

Observe the patient, doctor and nurse interaction

What patient says has reason.· Doctor has advised him RT for 1 month, so he feels there is nothing more to talk to the patient than enquiring any problems· Nurse is largely functionally oriented and interact with patient only in such occasions

The mutual interaction among the treating team and patient is missing in this situation

Suchman’s Stages of illness Model

Application of Suchman's Model

Conclusion

Mr. AS has been suffering form Prostate cancer for the last 1 year. But his symptoms started about 4 years back.

For about 3 years he tried folk remedies based on the advice of other people. He approached medical advice when

his symptoms aggravated. He is currently undergoing radiotherapy for prostate cancer and medications for

diabetes and other symptoms. This case study helps to understand the psychosocial aspects of illness

development and application illness behaviour model in nursing practice.

References

1. Guptha MC, Mahajan B. Text book of Social Medicine, 3rd Edn. JayPee, ND,2003

2. Coe RM. Sociology of Medicine. McGraw-Hill Inc. New York, 1978.

Application of Betty Neuman's System ModelThis page was last updated on January 28, 2012


Assessment Nursing diagnosis

Outcome identification and planning

Implementation

Evaluation

A S S E S S M E N T

PATIENT PROFILE

1. Name- Mr. AM 2. Age- 66 years

3. Sex-Male

4. Marital status-married

5. Referral source- Referred from ------- Medical College, -------

STRESSORS AS PERCEIVED BY CLIENT

(Information collected from the patient and his wife) Major stress area, or areas of health concern

Patient was suffering from severe abdominal pain, nausea, vomiting, yellowish discolorations of eye, palm, and urine, reduced appetite and gross weight loss(8kg with in 4 months)

Patient is been diagnosed to have Periampullary carcinoma one week back.

Patient underwent operative procedure i.e. WHIPPLE’S PROCEDURE- Pancreato duodenectomy on 27/3/08.

Psychologically disturbed about his disease condition- anticipating it as a life threatening condition. Patient is in depressive mood and does not interacting.

Patient is disturbed by the thoughts that he became a burden to his children with so many serious illnesses which made them to stay with him at hospital.

Patient has pitting type of edema over the ankle region, and it is more during the evening and will not be relieved by elevation of the affected extremities.

He had developed BPH few months back (2008 January) and underwent surgery TURP on January 17. Still he has mild difficulty in initiating the stream of urine.

Patient is a known case of Diabetes since last 28 years and for the last 4 years he is on Inj. H.Insulin (4U-0-0). It is adding up his distress regarding his health.

Life style patterns

patient is a retired school teacher cares for wife and other family members

living with his son and his family

active in church

participates in community group meeting i.e. local politics

has a supportive spouse and family

taking mixed diet

no habits of smoking or drinking

spends leisure time by reading news paper, watching TV, spending time with family members and relatives

Have you experienced a similar problem?

The fatigue is similar to that of previous hospitalization (after the surgery of the BPH) Severity of pain was some what similar in the previous time of surgery i.e. TURP.

Was psychologically disturbed during the previous surgery i.e. TURP.

What helped then- family members psychological support helped him to over come the crisis situation

Anticipation of the future

Concerns about the healthy and speedy recovery. Anticipation of changes in the lifestyle and food habits

Anticipating about the demands of modified life style

Anticipating the needs of future follow up

What doing to help himself?

Talking to his friends and relatives Reading the religious materials i.e. reading the Bible

Instillation of positive thoughts i.e. planning about the activities to be resume after discharge, spending time with grand children, going to the church, return back to the social interactions etc

Avoiding the negative thoughts i.e. diverts the attentions from the pain or difficulties, try to eliminate the disturbing thoughts about the disease and surgery etc

Trying to accept the reality etc..

What is expected of others?

Family members visiting the patient and spending some time with him will help to a great extent to relieve his tension.

Convey a warm and accepting behaviour towards him.

Family members will help him to meet his own personal needs as much as possible.

Involve the patient also in taking decisions about his own care, treatment, follow up etc

STRESSORS AS PERCEIVED BY THE CARE GIVER.

Major stress areas

Persistent fatigue Massive weight loss i.e.( 8 kg of body weight with in 4 months)

History of BPH and its surgery

Persistence of urinary symptoms (difficulty in initiating the stream of urine) and edema of the lower extremities

Persistent disease- chronic hypertensive since last 28 years

Depressive ideations and negative thoughts

Present circumstances differing from the usual pattern of living

Hospitalization

acute pain ( before the surgery patient had pain because of the underlying pathology and after the surgery pain is present at the surgical site)

nausea and vomiting which was present before the surgery and is still persisting after the surgery also

anticipatory anxiety concerns the recovery and prognosis of the disease

negative thoughts that he has become a burden to his children

Anticipatory anxiety concerning the restrictions after the surgery and the life style modifications which are to be followed.

Clients past experience with the similar situations

Patient verbalized that the severity of pain, nausea, fatigue etc was similar to that of patient’s previous surgery. Counter checked with the family members that what they observed.

Psychologically disturbed previously also before the surgery. (collected from the patient and counter checked with the relatives)

Client perceived that the present disease condition is much more severe than the previous condition. He thinks it is a serious form of cancer and the recovery is very poor. So patient is psychologically depressed.

Future anticipations

Client is capable of handling the situation- will need support and encouragement to do so. He has the plans to go back home and to resume the activities which he was doing prior to the

hospitalization.

He also planned in his mind about the future follow up ie continuation of chemotherapy

What client can do to help himself?

Patient is using his own coping strategies to adjust to the situations. He is spending time to read religious books and also spends time in talking with others

He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope.

He sets his major goal i.e. a healthy and speedy recovery.

Client's expectations of family, friends and caregivers

he sees the health care providers as a source pf information.

He tries to consider them as a significant members who can help to over come the stress

He seeks both psychological and physical support from the care givers, friends and family members

He sees the family members as helping hands and feels relaxed when they are with him.

Evaluation/ summary of impressions-

There is no apparent discrepancies identified between patients perception and the care givers perceptions.

INTRAPERSONAL FACTORS

1. Physical examination and investigations

Height- 162 cm Weight – 42 kg

TPR- 37o C, 74 b/m, 14 breaths per min

BP- 130/78 mm of Hg

Eye- vision is normal, on examination the appearance of eye is normal. Conjunctiva is pale in appearance. Pupils reacting to the light.

Ear- appearance of ears normal. No wax deposition. Pinna is normal in appearance and hearing ability is also normal.

Respiratory system- respiratory rate is normal, no abnormal sounds on auscultation. Respiratory rate is 16 breaths per min.

Cardiovascular system- heart rate is 76 per min. on auscultation no abnormalities detected. Edema is present over the left ankle which is non pitting in nature.

GIT- patient has the complaints of reduced appetite, nausea; vomiting etc. food intake is very less. Mouth- on examination is normal. Bowel sounds are reduced. Abdomen could not be palpated because of the presence of the surgical incision. Bowel habits are not regular after the hospitalization

Extremities- range of motion of the extremities are normal. Edema is present over the left ankle which is non pitting in nature. Because of weakness and fatigue he is not able to walk with out support

Integumentary system- extremities are mild yellowish in color. No cyanosis. Capillary refill is normal.

Genitor urinary system- patient has difficulty in initiating the urine stream. No complaints of painful micturation or difficulty in passing urine.

Self acre activities- perform some of his activities, for getting up from the bed he needs some other person’s support. To walk also he needs a support. He do his personal care activities with the support from the others

Immunizations- it is been told that he has taken the immunizations at the specific periods itself and he also had taken hepatitis immunization around 8 years back

Sleep –. He told that sleep is reduced because of the pain and other difficulties. Sleep is reduced after the hospitalization because of the noisy environment.

Diet and nutrition- patient is taking mixed diet, but the food intake is less when compared to previous food intake because of the nausea and vomiting. Usually he takes food three times a day.

Habits- patient does not have the habit of drinking or smoking.

Other complaints- patient has the complaints of pain fatigue, loss of appetite, dizziness, difficulty in urination, etc...

2. Psycho- socio cultural

Anxious about his condition Depressive mood

Patient is a retired teacher and he is Christian by religion.

Studied up to BA

Married and has 4 children(2sons and 2 daughters)

Congenial home environment and good relationship with wife and children

Is active in the social activities at his native place and also actively involves in the religious activities too.

Good and congenial relationship with the neighbors

Has some good and close friend at his place and he actively interact with them. They also very supportive to him

Good social support system is present from the family as well as from the neighborhood

3. Developmental factors

Patient confidently says that he had been worked for 32 years as a teacher and he was a very good teacher for students and was a good coworker for the friends.

He told that he could manage the official and house hold activities very well

He was very active after the retirement and once he go back also he will resume the activities

4. Spiritual belief system

Patient is Christian by religion He believes in got and used to go to church and also an active member in the religious activities.

He has a personal Bible and he used to read it min of 2 times a day and also whenever he is worried or tensed he used to pray or read Bible.

He has a good social support system present which helps him to keep his mind active.

INTERPERSONAL FACTORS

has supportive family and friends good social interaction with others

good social support system is present

active in the agricultural works at home after the retirement

active in the religious activities.

Good interpersonal relationship with wife and the children

Good social adjustment present

EXTRAPERSONAL FACTORS

All the health care facilities are present at his place All communication facilities, travel and transport facilities etc are present at his own place.

His house at a village which is not much far from the city and the facilities are available at the place.

Financially they are stable and are able to meet the treatment expenses.

Summary

Physiological- thin body built pallor of extremities, yellowish discoloration of the mucus membrane and sclera of eye. Nausea, vomiting, reduced appetite, reduced urinary out put. Diagnosed to have periampullary carcinoma.

Psycho socio cultural factors- patient is anxious abut his condition. Depressive mood. Not interacting much with others. Good support system is present.

Developmental –no developmental abnormalities. Appropriate to the age.

Spiritual- patient’s belief system has a positive contribution to his recovery and adjustment.

CLINICAL FEATURES

pain abdomen since 4 days

Discoloration of urine

Complaints of vomiting

Fatigue

Reduced appetite

on and off fever

Yellowish discoloration of eye, palms and nails

Complaints of weight loss

Edema over the left leg

Investigations ValuesHemoglobin(13-19g/dl) 6.9HCT (40-50%) 21.9WBC (4000-11000 cells/cumm)

12200

Neutrophil (40-75%) 77.2Lymphocyte (25-45%) 10.5Monocyte (2-10%) 4.5Eosinophil (0-10%) 2.6Basophil (0-2%) .2Platelet (150000-400000 cells/cumm)

345000

ESR (0-10mm/hr) 86RBS (60-150 mg/dl) 148Pus C/S _USG USG shows mild diffuse cell growth at the Ampulla of Vater which suggests peri

ampullary carcinoma of Grade I with out metastasis and gross spread.Urea (8-35mg/dl) 28Creatinine (0.6-1.6 mg/dl) 1.8Sodium (130-143 mEq/L) 136Potassium (3.5-5 mEq/L) 4PT (patient)(11.4-15.6 sec) 12.3APTT- patient (24- 32.4 sec)

26.4

Blood group A+HIV NegativeHCV NegativeHBsAg NegativeUrine Protein (negative) NegativeUrine WBC (0-5 cells/hpf) NilRBC (nil ) Nil

Initial Treatment Post operative period (immediate post op)

Patient got admitted to ---- Medical college for 3 days and the symptoms not relieved. So they asked for discharge and came to ---this hospital. There he was treated with:

Inj Tramazac IV SOS

Inj Pethedine 1mg SOS

Inj Phenargan SOS

Inj Pantodac 40 mg IV OD

IV fluids – DNS

Treatment at this hospital...

Pre operative period Tab Clovipas 75 mg 0-1-0 Tab Monotrate 1-0-1

Tab Metalor XL 1-0-0

Inj H Insulin S/C 6-0-6U

Inj Tramazac 50 mg IV Q8H

Inj Emset 4 mg Q8H

Tab Pantodac 40 mg 1-0-0

Cap beneficiale 0-1-0

Syp Aristozyme 1-1-1

K bind I sachet TID

Surgical management

Patient underwent Whipple’s procedure (pancreato duodenectomy)

Inj Clexane 0.3 ml S/C OD

Inj Vorth P 40 mg IM Q12H

Inj calcium Gluconate 10 ml over 10 min

IV fluids – DNS

Late post op period after 3 days of surgery)

Inj H Insulin S/C 6-0-6U Tab Pantodac 40 mg 1-0-0

Cap beneficiale 0-1-0

Tab Clovipas 75 mg 0-1-0

Tab Monotrate 1-0-1

Tab Metalor XL 1-0-0

Other instructions

Incentive spirometry

Steam inhalation

Eearly ambulation

Diabetic dietN U R S I N G P R O C E S S

I. NURSING DIAGNOSIS

Acute pain related to the presence of surgical wound on abdomen secondary to periampullary carcinoma

Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and verbalization.

Nursing ActionsPrimary Prevention secondary Prevention Tertiary Prevention Assess severity of pain by Teach the patient about the educate the client about the

using a pain scale Check the surgical site for

any signs of infection or complications

Support the areas with extra pillow to allow the normal alignment and to prevent strain

Handle the area gently. Avoid unnecessary handling as this will affect the healing process

lean the area around the incision and do surgical dressing at the site of incision to prevent any form of infections

Provide non-pharmacological measures for pain relief such as diversional activity which diverts the patients mind.

Administer the pain medications as per the prescription by the pain clinics to relieve the severity of pain.

Keep the patients body clean in order to avoid infection

relaxation techniques and make him to do it

Encourage the patient to divert his mind from pain and to engage in pleasurable activities like taking with others

Do not allow the patient to do strenuous activities. And explain to the patient why those activities are contraindicated.

Involve the patient in making decisions about his own care and provide a positive psychological support

Provide the primary preventive care when ever necessary.

importance of cleanliness and encourage him to maintain good personal hygiene.

Involve the family members in the care of patient

Encourage relatives to be with the client in order provide a psychological well being to patient .

Educate the family members about the pain management measures.

Provide the primary and secondary preventive measures to the client whenever necessary.

Evaluation – patient verbalized that the pain got reduced and the pain scale score also was zero. His facial expression also reveals that he got relief from pain.

II. NURSING DIAGNOSIS

Activity intolerance related to fatigue secondary to pain at the surgery site, and dietary restrictions

Outcome/ goals: Client will develop appropriate levels of activity free from excess fatigue, as evidenced by normal vital signs & verbalized understanding of the benefits of gradual increase in activity & exercise.

Nursing actionsPrimary prevention Secondary prevention Tertiary prevention Adequately

oxygenate the client

Instruct the client to avoid the activities which causes extreme fatigue

Provide the necessary articles near the patients bed side.

Instruct the client to avoid the activities which causes extreme fatigue.

Advice the client to perform exercises to strengthen the extremities& promote activities

Encourage the client to do the mobility exercises

Tell the family members to provide nutritious diet in a frequent intervals

Teach the patient and the family about the importance of

Assist the patient in early ambulation

Monitor client’s response to the activities in order to reduce discomforts.

Provide nutritious diet to the client.

Avoid psychological distress to the client. Tell the family members to be with him.

Schedule rest periods because it helps to alleviate fatigue

Tell the client to avoid the activities such as straining at stool etc

Teach the client about the importance of early ambulation and assist the patient in early ambulation

Teach the mobility exercises appropriate for the patient to improve the circulation

psychological well being in recovery.

Provide the primary and secondary level care if necessary.

Evaluation – patient verbalized that his activity level improved. He is able to do some of his activities with assistance. Fatigue relieved and patient looks much more active and interactive.

NURSING DIAGNOSIS-III

Impaired physical mobility related to presence of dressing, pain at the site of surgical incision

Outcomes/goals: Patient will have improved physical mobility as evidenced by walking with minimum support and doing the activities in limit.

Nursing actionsPrimary prevention Secondary prevention Tertiary prevention Provide active and

passive exercises to all the extremities to improve the muscle tone and strength.

Make the patient to perform the breathing exercises which will strengthen the respiratory muscle.

Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity.

Teach the mobility exercises appropriate for the patient to improve the circulation and to prevent contractures

Educate and reeducate the client and family about the patients care and recovery

Support the patient, and family towards the attainment of the goals

Coordinate the care activities with the family members and

Massage the upper and lower extremities which help to improve the circulation.

Provide articles near to the patient and encourage doing activities within limits which promote a feeling of well being.

Mobilize the patient and encourage him to do so whenever possible

Motivate the client to involve in his own care activities

Provide primary preventive measures whenever necessary

other disciplines like physiotherapy.

Teach the importance of psychological well being which influence indirectly the physical recovery

Provide primary preventive measures whenever necessary

C O N C L U S I O N

The Neuman’s system model when applied in nursing practice helped in identifying the interpersonal, intrapersonal and extra personal stressors of Mr. AM from various aspects. This was helpful to provide care in a comprehensive manner. The application of this theory revealed how well the primary, secondary and tertiary prevention interventions could be used for solving the problems in the client.

R E F E R E N C E S

1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications; 2002.


3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5thed. New Jersey :Prentice Hall;2002.

Application of Roy's Adaptation Model (RAM)Last updated on January 26, 2012


Roy's Adaptation Model (RAM) was developed by Sr.Callista Roy.

RAM is one of the widely applied nursing models in nursing practice, education and research.

Nursing is the science and practice that expands adaptive abilities and enhances person and

environment transformation

Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes, thus

contributing to health, quality of life, and dying with dignity

This is done by assessing behavior and factors that influence adaptive abilities and by intervening to

expand those abilities and to enhance environmental interactions.

Mr.NR who was suffering with diabetes mellitus for past 10 years. He developed a diabetic foot ulcer and

had to undergo amputation. He was admitted in __ Hospital. Mr. NR was selected for application of RAM

in providing nursing care.


According to RAM, nursing process is a problem solving approach for gathering data, identifying the

capacities and needs of the human adaptive system, selecting and implementing approaches for nursing

care, and evaluation the outcome of care provided.

Assessment of Behavior

the first step of the nursing process which involves gathering data about the behavior of the person as an

adaptive system in each of the adaptive modes.

Assessment of Stimuli

the second step of the nursing process which involves the identification of internal and external stimuli

that are influencing the person’s adaptive behaviors.

Stimuli are classified as:

1. Focal- those most immediately confronting the person,

2. Contextual-all other stimuli present that are affecting the situation and

3. Residual- those stimuli whose effect on the situation are unclear.

Nursing Diagnosis

step three of the nursing process which involves the formulation of statements that interpret data about

the adaptation status of the person, including the behavior and most relevant stimuli

Goal Setting

the forth step of the nursing process which involves the establishment of clear statements of the

behavioral outcomes for nursing care.

Intervention

the fifth step of the nursing process which involves the determination of how best to assist the person in

attaining the established goals

Evaluation

the sixth and final step of the nursing process which involves judging the effectiveness of the nursing

intervention in relation to the behavior after the nursing intervention in comparison with the goal

established.

D E M O G R A P H I C D A T A

Name Age Sex IP number Education Occupation Marital status Religion Informants Date of admission

Mr. NR 53 years Male ----- Degree Bank clerk Married Hindu Patient and Wife 21/01/08

F I R S T L E V E L A S S E S S M E N T

PHYSIOLOGIC-PHYSICAL MODE

Oxygenation

Stable process of ventilation and stable process of gas exchange. RR= 18Bpm.

Chest normal in shape. Chest expansion normal on either side.

Apex beat felt on left 5th inter-costal space mid-clavicular line.

Air entry equal bilaterally. No ronchi or crepitus. NVBS. S1& S2 heard.

No abnormal heart sounds.

Delayed capillary refill+. JVP0.

Apex beat felt- normal rhythm, depth and rate.

Dorsalis pedis pulsation of affected limp is not palpable.

All other pulsations are normal in rate, depth, tension with regular rhythm.

Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line.

S1& S2 heard.

No abnormal heart sounds. BP- Normotensive. .

Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.

Nutrition

He is on diabetic diet (1500kcal). Non vegetarian.

Recently his Weight reduced markedly (10 kg/ 6 month).

He has stable digestive process.

He has complaints of anorexia and not taking adequate food.

No abdominal distension. Soft on palpation. No tenderness.

No visible peristaltic movements.

Bowel sounds heard.

Percussion revealed dullness over hepatic area.

Oral mucosa is normal. No difficulty to swallow food

Elimination:

No signs of infections, no pain during micturation or defecation.

Normal bladder pattern. Using urinal for micturation.

Stool is hard and he complaints of constipation.

Activity and rest:

Taking adequate rest.

Sleep pattern disturbed at night due unfamiliar surrounding.

Not following any peculiar relaxation measure.

Like movies and reading. No regular pattern of exercise.

Walking from home to office during morning and evening.

Now, activity reduced due to amputated wound. Mobility impaired.

Walking with crutches.

Pain from joints present. No paralysis.

ROM is limited in the left leg due to wound.

No contractures present. No swelling over the joints.

Patient need assistance for doing the activities.

Protection:

Left lower fore foot is amputated.

Black discoloration present over the area.

No redness, discharge or other signs of infection.

Nomothermic.

Wound healing better now.

Walking with the use of left leg is not possible.

Using crutches.

Pain form knee and hip joint present while walking.

Dorsalis pedis pulsation, not present over the left leg. Right leg is normal in length and size.

Several papules present over the foot.

All peripheral pulses are present with normal rate, rhythm and depth over right leg.

Senses:

No pain sensation from the wound site. Relatively, reduced touch and pain sensation in the lower

periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses

are normal.

Fluids and electrolytes:

Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte values are with in

normal limit. No signs of acidosis or alkalosis. Blood glucose elevated.

Neurological function:

He is conscious and oriented.

He is anxious about the disease condition.

Like to go home as early as possible.

Showing signs of stress.

Touch and pain sensation decreased in lower extremity. Thinking and memory is intact.

Endocrine function

He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No

enlarged glands.

SELF CONCEPT MODE

Physical self:

He is anxious about changes in body image, but accepting treatment and coping with the situation. He

deprived of sexual activity after amputation.

Belongs to a Nuclear family. 5 members. Stays along with wife and three children. Good relationship with

the neighbours. Good interaction with the friends. Moderately active in local social activities

Personal self:

Self esteem disturbed because of financial burden and hospitalization. He believes in god and worshiping

Hindu culture.

ROLE PERFORMANCE MODE:

He was the earning member in the family. His role shift is not compensated. His son doesn't’t have any

work. His role clarity is not achieved.

INTERDEPENDENCE MODE:

He has good relationship with the neighbors. Good interaction with the friends relatives. But he believes,

no one is capable of helping him at this moment. He says ”all are under financial constrains”. He was

moderately active in local social activities

SECOND LEVEL ASSESSMENT

FOCAL STIMULUS

Non-healing wound after amputation of great and second toe of left leg- 4 week. A wound first found on

the junction between first and second toe-4 month back. The wound was non-healing and gradually

increased in size with pus collected over the area.

He first consulted in a local (---) hospital. From there, they referred to ---- medical college; where he was

admitted for 1 month and 4 days. During hospital stay great and second toe amputated. But surgical

wound turned to non- healing with pus and black colour. So the physician suggested for below knee

amputation. That made them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.

CONTEXTUAL STIMULI:

Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years, but switched to

insulin and using it for 8 years now. Not wearing foot wear in house and premises.

RESIDUAL STIMULI:

He had TB attack 10 year back, and took complete course of treatment. Previously, he admitted in ---

Hospital for leg pain about 4 year back. . Mother’s brother had DM. Mother had history of PTB. He is a

graduate in humanities, no special knowledge on health matters.

CONCLUSION

Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer and recent amputation made

his life more stressful. Nursing care of this patient based on Roy's adaptation model provided had a dramatic

change in his condition. Wound started healing and he planned to discharge on 25th april. He studied how to use

crutches and mobilized at least twice in a day. Patient’s anxiety reduced to a great extends by proper explanation

and reassurance. He gained good knowledge on various aspect of diabetic foot ulcer for the future self care

activities.

NURSING CARE PLAN

ASSESS. OF BEHAVIOUR

ASSESSMENT OF STIMULI

NURSING DIAGNOSIS GOAL INTERVENTION EVALUATION

Ineffective protection and sense in physical-physiological mode

(No pain sensation from the wound site.)

Focal stimuli: Non-healing wound after amputation of great and second toe of left leg- 4 week

1. Impaired skin integrity related to fragility of the skin secondary to vascular insufficiency

Long-term objective:1. amputated area will be completely healed by 20/5/08 2.Skin will remain intact with no ongoing ulcerations. Short-Term Objective: i. Size of wound decreases to 1x1 cm within 24/4/08. ii. No signs of infection over the wound within 1-wk iii. Normal WBC values within 1-wk iv. Presence of healthy granular tissues in the wound site within 1-wk

- Maintain the wound area clean as contamination affects the healing process.- Follow sterile technique while providing cares to prevent infection and delay in healing.- Perform wound dressing with Betadine which promote healing and growth of new tissue. - Do not move the affected area frequently as it affects the granulation tissue formation. - Monitor for signs and symptoms of infection or delay in healing.- Administer the antibiotics and vitamin C supplementation which will promote the healing process.

Short term goal: Met: size of wound decreased to less than 1x1 cms. WBC values became normal on 24/4/08

Long term goal: Partially Met: skin partially intact with no ulcerations. Continue plan Reassess goal and interventionsUnmet: not achieved complete healing of amputated area. Continue plan Reassess goal and interventions

Impaired activity in physical-physiological mode

Focal stimuli: During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour.

2. Impaired physical mobility related to amputation of the left forefoot and presence of unhealed wound

Long term Objective:

Patient will attain maximum possible physical mobility with in 6 months. Short term objective:

i. Correct use of crutches with in 22/4/08 ii. walking with minimum support-22/4/08

iii. He will be self motivated in activities- 20/4/08.

- Assess the level of restriction of movement - Provide active and passive exercises to all the extremities to improve the muscle tone and strength. - Make the patient to perform the ROM exercises to lower extremities which will strengthen the muscle. - Massage the upper and lower extremities which help to improve the circulation. - Provide articles near to the patient and encourage performing activities within limits which promote a feeling of well being. - Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity. - Measures for pain relief should be taken before the activities are initiated as pain can hinder with the activity.

Short term goal: Met: used crutches correctly on 22/4/08. he is self motivated in doing minor excesses Partially Met: walking with minimum support.

Long term goal: Unmet: not attained maximum possible physical mobility- Continue plan Reassess goal and interventions

Alteration in Physical self in Self-concept mode

(He is anxious about changes in

Contextual stimuli: Known case DM for past 10 years and on treatment with insulin for 8 years.

3. Anxiety related to hospital admission and unknown Outcome of the disease and financial constrains.

Long term Objective: The client will remain free from anxiety

Short term objective: i. demonstrating

- Allow and encourage the client and family to ask questions. Bring up common concerns. - Allow the client and family to verbalize

Short term goal: Met: demonstrated appropriate range effective coping with treatment He is able to rest

body image)

Change in Role performance mode. (He was the earning member in the family. His role shift is not compensate)

Residual stimuli: no special knowledge in health matters

appropriate range effective coping in the treatment ii. Being able to rest and iii. Asking fewer questions

anxiety. - Stress that frequent assessment are routine and do not necessarily imply a deteriorating condition. - Repeat information as necessary because of the reduced attention span of the client and family - Provide comfortable quiet environment for the client and family

quietly.

Long term goal: Unmet: client not completely remained free from anxiety due to financial constrains- Continue plan Reassess goal and interventions

------

Contextual stimuli: Known case DM for past 10 years and on treatment with insulin for 8 years.

Residual stimuli: no special knowledge in health matters

4. deficient knowledge regarding the foot care, wound care, diabetic diet, and need of follow up care.

Long term Objective: Patient will acquire adequate knowledge regarding the t foot care, wound care, diabetic diet, and need of follow up care and practice in their day to day life.Short term objective: i. Verbalization and demonstration of foot care. ii. Strictly following diabetic diet plan iii. Demonstration of wound care.

- Explain the treatment measures to the patient and their benefits in a simple understandable language. - Explain about the home care. Include the points like care of wounds, nutrition, activity etc.

Clear the doubts of the patient as the patient may present with some matters of importance. - Repeat the information whenever necessary to reinforce learning.

Short term goal: Met: Verbalization and demonstration of foot care. Strictly following diabetic diet plan

Unmet: Demonstration of wound care.

Long term goal: Unmet: not completely acquired and practiced the required knowledge. Continue plan Reassess goal and interventions

REFERENCE

1. Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. St Louis: Mosby; 2005

2. George BJ, Nursing Theories- The Base for Nursing Practice.3rd ed. Chapter 8. Lobo ML. Behavioral

System Model. St Louis: Mosby; 2005

3. Alligood MR “Nursing Theory Utilization and Application” 5th ed. St Louis: Mosby; 2005

4. Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006.

5. Brunner LS, Suddharth DS. Text book of Medical Surgical Nursing. 6th ed. London: Mosby; 2002

6. Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principle and practices of medicine. 20th ed.

London: Churchill Livingstone Elsevier; 2006.

A p p l i c a t i o n o f I n t e r p e r s o n a l T h e o r y i n N u r s i n g P r a c t i c e


Introduction

Peplau’s theory focuses on the interpersonal processes and therapeutic relationship that develops

between the nurse and client.

The interpersonal focus of Peplau’s theory requires that the nurse attend to the interpersonal processes

that occur between the nurse and client.

Interpersonal process is maturing force for personality. Interpersonal processes include the nurse- client

relationship, communication, pattern integration and the roles of the nurse.

Psychodynamic nursing is being able to understand one’s own behavior to help others identify felt

difficulties and to apply principles of human relations to the problems that arise at all levels of experience.

This theory stressed the importance of nurses’ ability to understand own behavior to help others identify

perceived difficulties.


1. Orientation:

During this phase, the individual has a felt need and seeks professional assistance.

The nurse helps the individual to recognize and understand his/ her problem and determine the need for

help.

2. Identification

The patient identifies with those who can help him/ her.

The nurse permits exploration of feelings to aid the patient in undergoing illness as an experience that

reorients feelings and strengthens positive forces in the personality and provides needed satisfaction.

3. Exploitation

During this phase, the patient attempts to derive full value from what he/ she are offered through the

relationship.

The nurse can project new goals to be achieved through personal effort and power shifts from the nurse

to the patient as the patient delays gratification to achieve the newly formed goals.

4. Resolution

The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient

frees himself from identification with the nurse.

Peplau’s theory and nursing process

Peplau defines Nursing Process as a deliberate intellectual activity that guides the professional practice of nursing

in providing care in an orderly, systematic manner.

Peplau explains 4 phases such as:

Orientation: Nurse and patient come together as strangers; meeting initiated by patient who expresses a

“felt need”; work together to recognize, clarify and define facts related to need.

Identification: Patient participates in goal setting; has feeling of belonging and selectively responds to

those who can meet his or her needs.

Exploitation: Patient actively seeks and draws knowledge and expertise of those who can help.

Resolution: Occurs after other phases are completed successfully. This leads to termination of the

relationship.

In Nursing Process, the orientation phase parallels with assessment phase where both the patient and nurse are

strangers; meeting initiated by patient who expresses a felt need.

Conjointly, the nurse and patient work together, clarifies and gathers important information.

Based on this assessment the nursing diagnoses are formulated, outcome and goal set.

The interventions are planned, carried out and evaluation done based on mutually established expected

behaviours.

Peplau’s theory application nursing process:

The nursing process for Mrs. JL based on Peplau’s theory is as follows:

Mrs. JL

27 years

Diagnosis: Inter vertebral disc prolapse

Assessment (Orientation

phase)

Nursing diagnosis

Planning (Identification phase)

Implementation (Exploitation phase)

Evaluation (Resolution

phase)Mrs. JL is on pelvic traction and she is restricted to bed.

The need for bed rest and restriction was discussed.

Impaired physical mobility related to the presence of pelvic traction.

Goal setting was done along with patient

Patient will have improved physical mobility as evidenced by participating in self care within the limits.

Provide active and passive exercises to all the extremities to improve the muscle tone and strength.



Carried out plans mutually agreed upon.

Provided active and passive exercises to all the extremities

Made the patient to perform breathing exercises

Massaged the upper and lower extremities Provided article within the reach of the patient

Mrs. JL was free to express problems regarding difficulty in mobilizing.

She expressed satisfaction when able to move without difficulty.

Provide articles near to the patient and encourage doing activities within limits.


Provided positive reinforcement to the patient

Assessment (Orientation phase)

Nursing diagnosis



Evaluation (Resolution phase)

Mrs. JL expresses pain in the low back region.

Regarding pain, discussion was made to assess the severity and the type and duration of pain. Also the measures to reduce pain were discussed.

Pain related to the degenerative changes in the lumbar region.


Mrs. JL will have reduction in pain as evidenced by her verbalisation of reduction in pain responses.


Give the client a neutral position

Always use back support while turning the patient that reduces the strain on the back.

Support the areas with extra pillow to allow the normal alignment and to prevent strain.

Administer analgesics as prescribed by the physician.

Provide pelvic traction to the patient


Provided non pharmacological measures like diversion, massaging, and pelvic traction.

Provided supine position to the client Supported the back during position change

Used pillows to support the back.

Administered Tab. Hifenac P and Cap. Myoril 4mg as prescribed.

Given pelvic traction and explained the need for traction

Mrs. JL was free to express problems of pain.

Expressed that she got slight relief from pain.


Nursing diagnosis




Mrs. JL expresses that she need assistance to get down from bed.

Regarding self care discussion was done and discussed regarding the measures to solve the problems.

Self care deficit related to the presence of pelvic traction.


Client will achieve and maintain self care activities with assistance of caregiver or within her limits.

Keep all the articles within the reach of the patient.

Provide a call bell to the patient to call in any emergency

Frequently visit the patient and enquire for any needs.

Assist the patient in doing her self care activities.

Remove the weight of the traction as needed by the patient.


Kept the articles within t he reach of the client

Frequently visited the patient and enquired for any needs

Assisted the client in doing her self care activities

Removed the weight as and when needed.

Mrs. JL was free to express problems of self care.

She used to call for the needs and all her needs were met appropriately

She achieved and maintained self care activities within her limits


Nursing diagnosis Planning (Identification phase)



Mrs. JL is enquiring about the disease condition, its outcome and need for surgery

Discussed with the client regarding the disease process and the findings in the client

Anxiety related to hospital admission as evidenced by verbalisation and client & family appearing withdrawn


Client will have reduced feeling of anxiety as evidenced by asking fewer questions

Teach the family and client regarding the disease process. Explain in simple understandable language of the client.

Allow and encourage the client and family to ask questions. Allow the client and family to verbalize anxiety.

Stress that frequent assessment are routine and do not necessarily imply a deteriorating condition.


Taught the family regarding the disease process in simple Kannada

Allowed the client and family members to ask questions

She and her husband expressed their anxiety


She asked her doubts regarding the illness and the diagnostic procedures

She verbalized that her anxiety has reduced to some extent.

Allow the family members to visit the client frequently

Allowed the family members to frequently visit the client


Nursing diagnosis





Discussed with the client regarding the disease process and the need for follow up

Deficient knowledge related to the treatment measures to be continued even after the discharge.


Patient will acquire adequate knowledge regarding the treatment and home care.

Explain the treatment measures to the patient and their benefits

Explain to the client the signs of aggravation of illness

Use simple and understandable terms

Clarify all the doubts of the patient of importance.

Repeat the information whenever necessary to reinforce learning.


Explained treatment measures and the need for follow up

Explained regarding the signs of aggravation of disease

Used simple and understandable terms for explaining Clarified her doubts

Repeated the information


She expressed acquisition of knowledge regarding the disease and the signs of aggravation of illness

S u m m a r y

1. Orientation phase

Client is initially reluctant to talk due to pain.

Client is expressing that while standing she is having much pain.

Client expressed without movement and supine position gave her relief from pain.

2. Identification

The client participates and interdependent with the nurse

Expresses the need for measure to get relief from pain

Expresses need for improving the mobility

Expresses need to know more about prognosis, discharge and home care and follow up.

3. Exploitation

Client explains that she gets relief of pain when lying down supine.

Cooperates and participates actively in performing exercises.

Client mobilizes changes position and cooperates during position changes.

4. Resolution

Client expressed that pain has reduced a lot and she is able to tolerate it now

She has agreed upon to continue the exercises at home

She also expressed that she would come for regular follow up after discharge.

Evaluation of the theory of interpersonal relations by Peplau

With the help of the theory of interpersonal relations, the client's needs could be assessed.

It helped her to achieve them within her limits. This theory application helped in providing comprehensive

care to the client.

References

1. Chinn PL, and Kramer MK. Theory and nursing- a systemic approach. 3rd edition. Philadelphia: Mosby

year book;1991.

2. George JB. Nursing theories. 5th edition. New Jersey: Prentice hall; 2002.

3. Alligood MR, Tomey AM. Nursing theory- utilization and application. 3rd edition. Missouri: Mosby

Elsevier; 2006.

4. Craven RF, Hirnle CJ. Fundamentals of nursing – human health and function. 5th edition. Philadelphia:

Lippincott Williams and Wilkins; 2007.

5. McQuiston CM and Webb AA. Foundations of nursing theory- Contributions of 12 key theorists. New

Delhi: Sage Publications; 1995.

A p p l i c a t i o n o f I n t e r p e r s o n a l T h e o r y i n N u r s i n g P r a c t i c e


Introduction

Peplau’s theory focuses on the interpersonal processes and therapeutic

relationship that develops between the nurse and client.

The interpersonal focus of Peplau’s theory requires that the nurse attend to the

interpersonal processes that occur between the nurse and client.

Interpersonal process is maturing force for personality. Interpersonal processes

include the nurse- client relationship, communication, pattern integration and the

roles of the nurse.

Psychodynamic nursing is being able to understand one’s own behavior to help

others identify felt difficulties and to apply principles of human relations to the

problems that arise at all levels of experience.

This theory stressed the importance of nurses’ ability to understand own

behavior to help others identify perceived difficulties.


1. Orientation:

During this phase, the individual has a felt need and seeks professional

assistance.

The nurse helps the individual to recognize and understand his/ her problem

and determine the need for help.

2. Identification

The patient identifies with those who can help him/ her.

The nurse permits exploration of feelings to aid the patient in undergoing illness

as an experience that reorients feelings and strengthens positive forces in the

personality and provides needed satisfaction.

3. Exploitation

During this phase, the patient attempts to derive full value from what he/ she are

offered through the relationship.

The nurse can project new goals to be achieved through personal effort and

power shifts from the nurse to the patient as the patient delays gratification to

achieve the newly formed goals.

4. Resolution

The patient gradually puts aside old goals and adopts new goals. This is a

process in which the patient frees himself from identification with the nurse.

Peplau’s theory and nursing process

Peplau defines Nursing Process as a deliberate intellectual activity that guides the

professional practice of nursing in providing care in an orderly, systematic manner.

Peplau explains 4 phases such as:

Orientation: Nurse and patient come together as strangers; meeting initiated by

patient who expresses a “felt need”; work together to recognize, clarify and

define facts related to need.

Identification: Patient participates in goal setting; has feeling of belonging and

selectively responds to those who can meet his or her needs.

Exploitation: Patient actively seeks and draws knowledge and expertise of

those who can help.

Resolution: Occurs after other phases are completed successfully. This leads

to termination of the relationship.

In Nursing Process, the orientation phase parallels with assessment phase where both

the patient and nurse are strangers; meeting initiated by patient who expresses a felt

need.

Conjointly, the nurse and patient work together, clarifies and gathers important

information.

Based on this assessment the nursing diagnoses are formulated, outcome and goal set.

The interventions are planned, carried out and evaluation done based on mutually

established expected behaviours.

Peplau’s theory application nursing process:

The nursing process for Mrs. JL based on Peplau’s theory is as follows:

Mrs. JL

27 years

Diagnosis: Inter vertebral disc prolapse

Assessment (Orientation

phase)

Nursing diagnosis

Planning (Identification

phase)

Implementation (Exploitation

phase)

Evaluation (Resolution

phase)Mrs. JL is on pelvic traction and she is restricted to bed.

The need for bed rest and restriction was discussed.

Impaired physical mobility related to the presence of pelvic traction.


Patient will have improved physical mobility as evidenced by participating in self care within the limits.

Provide active and passive exercises to all the extremities to improve the muscle tone and strength.


Provided active and passive exercises to all the extremities

Made the patient to perform breathing exercises

Mrs. JL was free to express problems regarding difficulty in mobilizing.

She expressed satisfaction when able to move without difficulty.



Provide articles near to the patient and encourage doing activities within limits.


Massaged the upper and lower extremities Provided article within the reach of the patient

Provided positive reinforcement to the patient


Nursing diagnosis




Mrs. JL expresses pain in the low back region.

Regarding pain, discussion was made to assess the severity and the type and duration of pain. Also the measures to reduce pain were discussed.

Pain related to the degenerative changes in the lumbar region.


Mrs. JL will have reduction in pain as evidenced by her verbalisation of reduction in pain responses.


Give the client a neutral position

Always use back support while turning the patient that reduces the


Provided non pharmacological measures like diversion, massaging, and pelvic traction.

Provided supine position to the client Supported the back during position change

Used pillows to support the back.

Administered Tab. Hifenac P and Cap. Myoril

Mrs. JL was free to express problems of pain.

Expressed that she got slight relief from pain.

strain on the back.

Support the areas with extra pillow to allow the normal alignment and to prevent strain.

Administer analgesics as prescribed by the physician.

Provide pelvic traction to the patient

4mg as prescribed.

Given pelvic traction and explained the need for traction


Nursing diagnosis




Mrs. JL expresses that she need assistance to get down from bed.

Regarding self care discussion was done and discussed regarding the measures to solve the problems.

Self care deficit related to the presence of pelvic traction.


Client will achieve and maintain self care activities with assistance of caregiver or within her limits.

Keep all the articles within the reach of the patient.

Provide a call bell to the patient to call in any emergency

Frequently visit the patient and enquire for any needs.

Assist the patient in doing her self care activities.

Remove the weight of the traction as needed by the patient.


Kept the articles within t he reach of the client

Frequently visited the patient and enquired for any needs

Assisted the client in doing her self care activities

Removed the weight as and when needed.


She used to call for the needs and all her needs were met appropriately

She achieved and maintained self care activities within her limits


Nursing diagnosis





Discussed with the client regarding the disease process and the findings in the client

Anxiety related to hospital admission as evidenced by verbalisation and client & family appearing withdrawn


Client will have reduced feeling of anxiety as evidenced by asking fewer questions

Teach the family and client regarding the disease process. Explain in simple understandable language of the client.

Allow and encourage the client and family to ask questions. Allow the client and family to verbalize anxiety.

Stress that frequent assessment are routine and do not necessarily imply a deteriorating condition.

Allow the family members to visit the client frequently


Taught the family regarding the disease process in simple Kannada

Allowed the client and family members to ask questions

She and her husband expressed their anxiety

Allowed the family members to frequently visit the client


She asked her doubts regarding the illness and the diagnostic procedures

She verbalized that her anxiety has reduced to some extent.


Nursing diagnosis





Discussed with the client regarding the disease process and the need for follow up

Deficient knowledge related to the treatment measures to be continued even after the discharge.


Patient will acquire adequate knowledge regarding the treatment and home care.

Explain the treatment measures to the patient and their


Explained treatment measures and the need for follow up

Explained regarding the signs


She expressed acquisition of knowledge regarding the disease and the signs of aggravation of illness

benefits

Explain to the client the signs of aggravation of illness

Use simple and understandable terms

Clarify all the doubts of the patient of importance.

Repeat the information whenever necessary to reinforce learning.

of aggravation of disease

Used simple and understandable terms for explaining Clarified her doubts

Repeated the information

S u m m a r y

1. Orientation phase

Client is initially reluctant to talk due to pain.

Client is expressing that while standing she is having much pain.

Client expressed without movement and supine position gave her relief from

pain.

2. Identification

The client participates and interdependent with the nurse

Expresses the need for measure to get relief from pain

Expresses need for improving the mobility

Expresses need to know more about prognosis, discharge and home care and

follow up.

3. Exploitation

Client explains that she gets relief of pain when lying down supine.

Cooperates and participates actively in performing exercises.

Client mobilizes changes position and cooperates during position changes.

4. Resolution

Client expressed that pain has reduced a lot and she is able to tolerate it now

She has agreed upon to continue the exercises at home

She also expressed that she would come for regular follow up after discharge.

Evaluation of the theory of interpersonal relations by Peplau

With the help of the theory of interpersonal relations, the client's needs could be

assessed.

It helped her to achieve them within her limits. This theory application helped in

providing comprehensive care to the client.

References

1. Chinn PL, and Kramer MK. Theory and nursing- a systemic approach. 3rd

edition. Philadelphia: Mosby year book;1991.

2. George JB. Nursing theories. 5th edition. New Jersey: Prentice hall; 2002.

3. Alligood MR, Tomey AM. Nursing theory- utilization and application. 3rd edition.

Missouri: Mosby Elsevier; 2006.

4. Craven RF, Hirnle CJ. Fundamentals of nursing – human health and function.

5th edition. Philadelphia: Lippincott Williams and Wilkins; 2007.

5. McQuiston CM and Webb AA. Foundations of nursing theory- Contributions of

12 key theorists. New Delhi: Sage Publications; 1995.

Introduction to Nursing Theories

Documents

Transcript of Introduction to Nursing Theories