Nursing Theories
Nursing Theories
Nursing Theories
INTRODUCTION TO NURSING
THEORIES
INTRODUCTION
Nursing has made phenomenal achievement in the last century that has lead to
the recognition of nursing as an academic discipline and a profession. A move
towards theory-based practice has made contemporary nursing more meaningful
and significant by shifting nursings focus from vocation to an organised
profession. The need for knowledge-base to guide professional nursing practice
had been realised in the first half of the twentieth century and many theoretical
works have been contributed by nurses ever since, first with the goal of making
nursing a recognised profession and later with the goal of delivering care to
patients as professionals.
A theory is a group of related concepts that propose action that guide practice. 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 interrelationships among concepts for the purposes of describing, explaining,
predicting, and /or prescribing..
Based on the knowledge structure levels the theoretical works in nursing can be
studied under the following headings:
Nursing philosophies.
Key emphasis
Florence Nightingales
Legacy of caring
Ernestine Wiedenbach:
The helping art of clinical
nursing
Virginia Hendersons
Definition of Nursing
Faye
G.Abedellahs Typology of
twenty one Nursing
problems
Conservation
Redundancy
Therapeutic intention
Martha E.Rogers:
Science of unitary
human beings
Dorothy E.Johnsons
Behavioural system
model
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
Kathryn E. Barnards
Parent Child Interaction
Model
Ramona T.Mercers
:Maternal Role
Attainment
Katharine Kolcabas
Theory of comfort
Madeleine Leiningers
Transcultural nursing,
culture-care theory
Rosemarie Rizzo
Parses :Theory of human
becoming
CONCLUSION
The conceptual and theoretical nursing models help to provide knowledge to
improve practice, guide research and curriculum and identify the goals of nursing
practice. The state of art and science of nursing theory is one of continuing
growth. Using the internet the nurses of the world can share ideas and
knowledge, carrying on the work begun by nursing theorists and continue the
growth and development of new nursing knowledge. It is important the nursing
knowledge is learnt, used, and applied in the theory based practice for the
profession and the continued development of nursing and academic discipline
DEVELOPMENT OF NURSING
THEORIES
Introduction
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. Nursing theorists use both of these methods. Theory is a
creative and rigorous structuring of ideas that projects a tentative, purposeful, and
systematic view of phenomena. A theory makes it possible to organize the
relationship among the concepts to describe, explain, predict, and control practice
Definition
Concepts are basically vehicles of thought that involve images. Concepts are
words that describe objects, properties, or events & are basic components of
theory.
Types: Empirical concepts
Inferential concepts
Abstract concepts
1.
2.
3.
Developmental Theory
1. It outlines the process of growth & development of humans as orderly &
predictable, beginning with conception & ending with death.
2. The progress & behaviors of an individual within each stage are unique.
3. The growth & development of an individual are influenced by heredity,
temperament, emotional, & physical environment, life experiences & health
status.
Common concepts in nursing theories
Four concepts common in nursing theory that influence & determine nursing practice
are:
Health
Nursing (goals, roles, functions)
Each of these concepts is usually defined & described by a nursing theorist, often
uniquely; although these concepts are common to all nursing theories. Of the four
concepts, the most important is that of the person. The focus of nursing, regardless
of definition or theory, is the person.
Historical perspectives and key concepts
Prescriptive
These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in Roper, Logan
and Tierneys Model of Nursing (1980).
Needs theories have been criticized for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
Interaction theories
Outcome theories
These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health (Roy 1980).
Outcome theories have been criticized as too abstract and difficult to
implement in practice (Aggleton and Chalmers 1988).
Humanistic Theories
Models of nursing
Until fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
However, from the 1950s to the present, an increasing number of nursing
theorists have developed models of nursing that provide bases for the
development of nursing theories and nursing knowledge.
A model, as an abstraction of reality, provides a way to visualize reality to
simplify thinking.
A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate consequences of alternative actions.
According to Fawcett (2000),
A conceptual model gives direction to the search for relevant questions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems
Four concepts are generally considered central to the discipline of nursing: the
person who receives nursing care (the patient or client); the environment
(society); nursing (goals, roles, functions); and health. These four concepts
form a metaparadigm of nursing.
The term metaparadigm comes from the Greek prefix meta, which means
more comprehensive or transcending, and the word Greek word paradigm,
which means a philosophical or theoretical framework of a discipline upon
which all theories, laws, and generalizations are formulated (MerriamWebsters Collegiate Dictionary, 1994).
There are two major differences in philosophical beliefs, or world views, about
the nature of change.
The world view of change uses the growth metaphor, and the persistence
view focuses
on stability (Fawcett, 1989,).
Within the change world view, change and growth are continual and desirable,
progress is valued, and realization of ones potential is emphasized
(Fawcett).
Persistence is endurance in time
Persistence world view emphasizes equilibrium and balance.
If the flexible line of defense is no longer able to protect the person against a
stressor, the stressor breaks through, disturbs the persons equilibrium, and
triggers a reaction. The reaction may lead toward restoration of balance or
toward death.
Neuman intends for the nurse to assist clients to retain, attain, or maintain
optimal system stability (Neuman, 1996).
Thus, health (wellness) seems to be related to dynamic equilibrium of the
normal line of defense, where stressors are successfully overcome or avoided
by the flexible line of defense.
Neuman defines illness as a state of insufficiency with disrupting needs
unsatisfied (Neuman, 2002).
Illness appears to be a separate state when a stressor breaks through the
normal line of defense and causes a reaction with the persons lines of
resistance.
The drive for a unique body of knowledge is based on the assumption that
borrowed knowledge is less worthy.
However, nurse education is based on theory borrowed from other disciplines,
such as sociology and psychology.
It has been argued that applying knowledge from different disciplines only
serves to dilute nursing practice.
Nevertheless, as the occupation is focused on humans, perhaps it is inevitable
that nursing uses knowledge from other social sciences.
It has been argued that no knowledge is exclusive, and because of nursings
diverse nature it is impossible for it to have a unique body of knowledge and
one unified body of theory (Castledine 1994, Levine 1995).
Scott (1994) states that the crucial ingredients of nursing theory should be
accessibility and clarity. However, one of the main criticisms of nursing theory
is its use of overtly complex language (Kenny 1993). It is important that the
language used in the development of nursing theory be used consistently.
Despite theory and practice being viewed as inseparable concepts, a theorypractice gap still exists in nursing (Upton 1999). Yet despite the availability of
a vast amount of literature on the subject, nursing theory still means very
little to most practicing nurses. Perhaps this is because the majority of
nursing theory is developed by and for nursing academics (Lathlean 1994). It
has been recognised that traditionally nurses are used to speaking with their
hands (Levine 1995). Therefore, many nurses have not had the training or
experience to deal with the abstract concepts presented by nursing theory.
This makes it difficult for the majority of nurses to understand and apply
theory to practice (Miller 1985).
Summarization
1. Definition
2. Importance of Nursing Theories
3. The characteristics of theories:
4. Basic Processes in the Development Of Nursing Theories:
5. Nursing theories are often based on & influenced
6. ANA definition of Nursing Practice
7. Common concepts in Nursing Theories:
8. Historical Perspectives & Key Concepts
9. Clasification of Nursing Theories
10. Models Of Nursing
11. Growth and Stability Models of Change
12. Betty Neumans Health Care Systems Model
13. Stress/Adaptation Theory as a Framework
14. A unique body of knowledge
15. Criticisms of nursing theories
Conclusion
Littlejohn (2002) comments that, irrespective of nursing theories nurses will continue
to exhibit a caring response to the sick and troubled. If this is true, perhaps nurses
are nursing without the knowledge of theories and theory is irrelevant. However,
theory and practice are related, and if nursing is to continue to develop, the concept
of theory must be addressed. If nursing theory does not drive the development of
nursing, it will continue to develop in the footsteps of other disciplines such as
medicine
Reference
Nursing Theorists
Definitions
Theory- a set of related statements that describes or explains phenomena in a
systematic way
Concept-a mental idea of a phenomenon
Construct- a phenomena that cannot be observed and must be inferred
Proposition- a statement of relationship between concepts
Conceptual model- made up of concepts and propositions
Nursing Theorists
Florence Nightingale,
Hildegard Peplau
Virginia Henderson
Fay Abdella
Ida Jean Orlando
Dorothy Johnson
Martha Rogers
Dorothea Orem
Imogene King
Betty Neuman
Sister Calista Roy,
Jean Watson
Rosemary Rizzo Parse
Madeleine Leininger
Patricia Benner
Concepts in the nursing
Metaparadigm
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
Florence Nightingale- Environmental Theory
First nursing theorist
Unsanitary conditions posed health hazard (Notes on Nursing, 1859)
5 components of environment
ventilation, light, warmth, effluvia, noise
External influences can prevent, suppress or contribute to disease or death
Nightingales Concepts
Person
o Patient who is acted on by nurse
o Affected by environment
o Has reparative powers
Environment
o Foundation of theory. Included everything, physical, psychological,
and social
Health
o Maintaining well-being by using a persons powers
o Change
Dorothea Orem- Self-Care Model
Self-care comprises those activities performed independently by an
individual to promote and maintain person well-being
Self care agency is the individuals ability to perform self care activities
Self- care deficit occurs when the person cannot carry out self-care
The nurse then meets the self-care needs by acting or doing for; guiding,
teaching, supporting or providing the environment to promote patients
ability
Wholly compensatory nursing system-Patient dependent
Partially compensatory- Patient can meet some needs but needs nursing
assistance
Supportive educative-Patient can meet self care requisites, but needs
assistance with decision making or knowledge
Imogene King-Goal Attainment Theory
Open systems framework
Human beings are open systems in constant interaction with the
environment
Personal System
o individual; perception, self, growth, development, time space, body
image
o Interpersonal
o Society
Personal System
o Individual; perception, self, growth, development, time space, body
image
Interpersonal
o Socialization; interaction, communication and transaction
Society
o Family, religious groups, schools, work, peers
The nurse and patient mutually communicate, establish goals and take
action to attain goals
Each individual brings a different set of values, ideas, attitudes, perceptions
to exchange
Betty Neuman - Health Care Systems Model
The person is a complete system, with interrelated parts
maintains balance and harmony between internal and external environment
by adjusting to stress and defending against tension-producing stimuli
Focuses on stress and stress reduction
Primarily concerned with effects of stress on health
Simultaneity Paradigm
o Man is a unitary being in continuous, mutual interaction with
environment
Originally Man-Living-Health Theory
Parses Three Principles
Meaning
o Mans reality is given meaning through lived experiences
o Man and environment cocreate
Rhythmicity
o Man and environment cocreate ( imaging, valuing, languaging) in
rhythmical patterns
Cotranscendence
o Refers to reaching out and beyond the limits that a person sets
o One constantly transforms
Person
o Open being who is more than and different from the sum of the parts
Environment
o Everything in the person and his experiences
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Mosby, Philadelphia, 2002.
George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton and Lange.
Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williamsand wilkins.
Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development and
Progress 3rd ed. Philadelphia, Lippincott.
Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
Potter A Patricia, Perry G Anne (1992)Fundamentals Of Nursing Concepts
Process and Practice 3rd ed. London Mosby Year Book.
Definition
Inferential concepts
Abstract concepts.
Models ----- are representations of the interaction among and between the
concepts showing patterns.
A particular theory or conceptual frame work directs how these actions are
carried out . The delivery of nursing care within the nursing process is
directed by the way specific conceptual frameworks and theories define the
person (patient), the environment , health and nursing.
The terms model and theory are often wrongly used interchangeably, which
further confounds matters.
In nursing, models are often designed by theory authors to depict the beliefs
in their theory (Lancaster and Lancaster 1981).
They provide an overview of the thinking behind the theory and may
demonstrate how theory can be introduced into practice, for example,
through specific methods of assessment.
Their main limitation is that they are only as accurate or useful as the
underlying theory.
are generalizable.
increase the general body of knowledge within the discipline through the
research implemented to validate them.
are consistent with other validated theories, laws, and principles but will leave
open unanswered questions that need to be investigated
Of the four concepts , the most important is that of the person. The focus of
nursing , regardless of definition or theory , is the person.
Rogers 1970: to maintain and promote health, prevent illness, and care
for and rehabilitate ill and disabled client through "humanistic science of
nursing" Orem1971: This is self-care deficit theory. Nursing care becomes
necessary when client is unable to fulfill biological, psychological,
developmental, or social needs.
Grand theory: provides a conceptual framework under which the key concepts
and
Middle range theory: is more precise and only analyses a particular situation
with a limited number of variables.
"Needs "theories.
"Interaction" theories.
"Outcome "theories.
"Humanistic theories"
"Needs" theories
These theories are based around helping individuals to fulfill their physical and
mental needs. The basis of these theories is well-illustrated in Roper, Logan
and Tierneys Model of Nursing (1980).
Needs theories have been criticized for relying too much on the medical model
of health and placing the patient in an overtly dependent position.
"Interaction" theories
Such theories have been criticized for largely ignoring the medical model of
health and not attending to basic physical needs.
"Outcome" theories
These portray the nurse as the changing force, who enables individuals to
adapt to or cope with ill health (Roy 1980).
"Humanistic" Theories:
Humanists believes that the person contains within himself the potential for
healthy and creative growth.
MODELS OF NURSING
Until fairly recently, nursing science was derived principally from social,
biologic, and medical science theories.
A conceptual model shows how various concepts are interrelated and applies
theories to predict or evaluate consequences of alternative actions.
A conceptual model "gives direction to the search for relevant questions about
the phenomena of central interest to a discipline and suggests solutions to
practical problems"
upon which all theories, laws, and generalizations are formulated (MerriamWebsters Collegiate Dictionary, 1994).
There are two major differences in philosophical beliefs, or world views, about
the nature of change.
"The world view of change uses the growth metaphor, and the persistence
view focuses
on stability" (Fawcett, 1989,).
Within the change world view, change and growth are continual and desirable,
"progress is valued, and realization of ones potential is emphasized"
(Fawcett).
the world view of change reflected by the model (growth or stability); and
the major theoretical conceptual classification with which the model seems
most consistent (systems, stress/adaptation, caring, or growth/development).
A system is defined as "a whole with interrelated parts, in which the parts
have a function and the system as a totality has a function" (Auger, 1976)
"The goal of nursing is to help individuals and groups attain, maintain, and
restore health"
Stress: "a dynamic state whereby a human being interacts with the
environment to maintain balance for growth, development, and performance"
If the flexible line of defense is no longer able to protect the person against a
stressor, the stressor
breaks through, disturbs the persons equilibrium, and triggers a reaction. The
reaction may lead
Neuman intends for the nurse to "assist clients to retain, attain, or maintain
optimal system stability" (Neuman, 1996).
both how the balance is maintained and the possible effects of disturbed
equilibrium.
This theory has been widely applied to explain, predict, and control biologic
(physiologic and psychological)
less worthy.
It has been argued that applying knowledge from different disciplines only
serves to dilute nursing practice.
Use of language Scott (1994) states that the crucial ingredients of nursing
theory should be accessibility and clarity. However, one of the main criticisms
of nursing theory is its use of overtly complex language (Kenny 1993).
Not part of everyday practice Despite theory and practice being viewed as
inseparable concepts, a theory-practice gap still exists in nursing (Upton
1999).
It has been recognised that traditionally nurses are used to speaking with
their hands (Levine 1995).
Therefore, many nurses have not had the training or experience to deal with
the abstract concepts presented by nursing theory.
This makes it difficult for the majority of nurses to understand and apply
theory to practice (Miller 1985).
Summary
Definition
Models Of Nursing
Conclusion:
Littlejohn (2002) comments that irrespective of nursing theories, nurses will
continue to exhibit a caring response to the sick and troubled. If this is true,
perhaps nurses are nursing without the knowledge of theories and theory is
irrelevant. However, theory and practice are related, and if nursing is to
continue to develop, the concept of theory must be addressed. If nursing
theory does not drive the development of nursing, it will continue to develop
in the footsteps of other disciplines such as medicine
Reference:
4. Taylor Carol,Lillis Carol (2001)The Art and Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
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.
Uses of Theory
Theory is used to:
Describe
Explain
Predict
Prescribe
Uses of Nursing Theory
Define relationships among the variables of
Of health or illness.
Peplaus interpersonal relations model
Nurses enter into a personal relationship with an individual when a felt need
is present
Hendersons definition of nursing
Henderson conceptualized the nurses role as assisting sick or well
individuals to gain independence in meeting 14 fundamental needs
(Henderson)
Breathing normally
Eating and drinking adequately
Eliminating body wastes
Moving and maintaining a desirable position
Sleeping and resting
Selecting suitable clothes
Maintaining body temperature within normal range by adjusting clothing and
modifying the environment.
Keeping the body clean and well groomed to protect the integument.
Avoiding dangers in the environment and avoiding injuring others
Communicating with others in expressing emotions, needs, fears, or
opinions
Worshipping according to ones faith
Working in such a way that one feels a sense of accomplishment
Playing or participating in various forms of recreation.
Learning, discovering, or satisfying the curiosity that leads to normal
development and health, and using available health facilities
Rogers science of unitary human beings
She states that humans are dynamic energy fields in continuous exchange
with environmental fields, both of which are infinite.
Nurses applying Roger's theory in practice (a) focus on the persons
wholeness, (b) seek to promote symphonic interaction between the two
energy fields (human and environment) to strengthen the coherence and
integrity of the person, c) coordinate the human field with the
rhythmicities of the environmental field, and (d) direct and redirect
patterns of interaction between the two energy fields to promote maximum
health potential
Orems general theory of nursing
Orems self-care deficit theory explains not only when nursing is needed but
also how people can be assisted through five methods of helping: acting or
doing for, guiding, teaching, supporting, and providing an environment that
promotes the individuals abilities to meet current and future demands.
Kings goal attainment theory
Kings theory offers insight into nurses interactions with individuals and
groups within the environment. It highlights the importance of clients
participation in decision that influence care and focuses on both the
process of nurse-client interaction and the outcomes of care.
Neumans systems model
4.Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
Mosby, Philadelphia, 2002.
Research without theory results in discreet information or data which does not
add to the accumulated knowledge of the discipline.
Theory guides the research process, forms the research questions, aids in
design, analysis and interpretation.
It enables the scientist to weave the facts together.
Type of theory
Type of research
Descriptive or
explanatory
Co relational
Experimental
Descriptive
Explanatory
Predictive
The interpretation determines whether the study supports are contradicts the
propositional statement.
If a conceptual model is used as a theoretical framework for research it is not
theory testing.
Theory testing requires detailed examination of theoretical relationships.
A Typology of Research
Testing
Analyzing
Experimentation
Deducting
Deductive research
Quantitative research
The scientific method
Theory / hypothesis testing
Assaying
Refining
Interpreting
Reflecting
Inducing
Inductive research
Qualitative research
Phenomenological research
Theory generation
Divining; heuristic research
testing the theories and by using it as a conceptual framework that drives the
study.
Reference
Interaction
theorists
Outcome theorists
Abdellah
King
Johnson
Henderson
Orlando
Levine
Orem
Rogers
Paplau
Roy
Travelbee
Wiedenbach
Analysis of nursing theories according to 1st School
Focus
Problems
Human being
Patient
Need Deficit
Orientation
Illness, disease
Role of nurse
Decision making
She was one of the first nurses to point out that nursing does not
consist of merely following physician's orders.
She described the nurse's role as substitutive (doing for the person),
supplementary (helping the person), complementary (working with the
person), with the goal of helping the person become as independent as
possible.
In the revision she recognized the need to be clear about the functions of
the nurse and she believed that this textbook serves as a main learning
source for nursing practice should present a sound and definitive
description of nursing.
Breathe normally.
Eat and drink adequately.
Eliminate body wastes.
Move and maintain desirable postures.
Sleep and rest.
Select suitable clothes-dress and undress.
Maintain body temperature within normal range by adjusting clothing
and modifying environment
Keep the body clean and well groomed and protect the integument
Avoid dangers in the environment and avoid injuring others.
Communicate with others in expressing emotions, needs, fears, or
opinions.
Worship according to ones faith.
Work in such a way that there is a sense of accomplishment.
Play or participate in various forms of recreation.
Learn, discover, or satisfy the curiosity that leads to normal development
and health and use the available health facilities.
The first 9 components are physiological.
Patients desire to return to health, but this assumption is not
explicitly stated.
Nurses are willing to serve and that nurses will devote themselves to
the patient day and night
Society wants and expects nurses to act for individuals who are
unable to function independently.
Nursing
Assists and supports the individual in life activities and the
attainment of independence.
Categorized
o
Nursing Process
Nursing Assessment
Hendersons 14 components
Analysis: Compare data to knowledge base
of health and disease.
Nursing Diagnosis
Nursing plan
Nursing implementation
Nursing implementation
Nursing process
Nursing evaluation
HENDERSON
Physiological
needs
Breathe normally
Eat and drink adequately
Eliminate by all avenues of elimination
Move and maintain desirable posture
Sleep and rest
Select suitable clothing
Maintain body temperature
Keep body clean and well groomed and protect the
integument
Safety needs
Belongingness
and love needs
Esteem needs
Her definition and components are logical and the 14 components are
a guide for the individual and nurse in reaching the chosen goal.
What priorities are evident in the use of the basic nursing functions?
Theories contribute to and assist in increasing the general body of
knowledge within the discipline through the research implemented to
validate them.
Her ideas of nursing practice are well accepted throughout the world
as a basis for nursing care.
However, the impact of the definition and components has not been
established through research.
The principles of Hendersons theory were published in the major
nursing textbooks used from the 1930s through the 1960s, and the
principles embodied by the 14 activities are still important in evaluating
nursing care in thee21st centaury.
Each of the 14 activities can be the basis for research. Although the
statements are not.
Assisting the individual in the dying process she contends that the
nurse helps, but there is little explanation of what the nurse does.
Provide a rationale for collecting reliable and valid data about the
health status of clients, which are essential for effective decision making
and implementation.
In Research:
Summary
1.
Background
2.
Achievements
3.
Publications
4.
5.
6.
14 components
7.
8.
9.
10.
Assumptions
11.
Usefulness
12.
Testability
13.
Characteristics
14.
imitation
Conclusion
In conclusion, Henderson provides the essence of what she believes is a definition
of nursing. She didnt intend to develop a theory of nursing but rather she
attempted to define the unique focus of nursing. Her emphasis on basic human
needs as the central focus of nursing practice has led to further theory
development regarding the needs of the person and how nursing can assist in
meeting those needs. Her definition of nursing and the 14 components of basic
nursing care are uncomplicated and self-explanatory.
She is founder of the original Center for Human Caring in Colorado and is a
Fellow of the American Academy of Nursing. She previously served as Dean of
Nursing at the University Health Sciences Center and is a Past President of the
National League for Nursing
Dr. Watson has earned undergraduate and graduate degrees in nursing and
psychiatric-mental health nursing and holds her PhD in educational
psychology and counseling.
She is a widely published author and recipient of several awards and honors,
including an international Kellogg Fellowship in Australia, a Fulbright Research
Award in Sweden and six (6) Honorary Doctoral Degrees, including 3
International Honorary Doctorates (Sweden, United Kingdom, Quebec,
Canada).
Her research has been in the area of human caring and loss.
In 1988, her theory was published in nursing: human science and human
care.
Watson believes that the main focus in nursing is on carative factors. She
believes that for nurses to develop humanistic philosophies and value system,
a strong liberal arts background is necessary.
This philosophy and value system provide a solid foundation for the science of
caring. A humanistic value system thus under grids her construction of the
science of caring.
She asserts that the caring stance that nursing has always held is being
threatened by the tasks and technology demands of the curative factors.
Watson proposes even assumptions about the science of caring. The basic
assumptions are:
1. Caring can be effectively demonstrated and practiced only interpersonally.
2. Caring consists of carative factors that result in the satisfaction of certain
human needs.
3. Effective caring promotes health and individual or family growth.
4. Caring responses accept person not only as he or she is now but as what he
or she may become.
5. A caring environment is one that offers the development of potential while
allowing the person to choose the best action for himself or herself at a given
point in time.
6. Caring is more healthogenic than is curing. A science of caring is
complementary to the science of curing.
7. The practice of caring is central to nursing.
The ten primary carative factors
The structure for the science of caring is built upon ten carative factors.
These are:
The provision for a supportive, protective and /or corrective mental, physical,
socio-cultural and spiritual environment.
The first three carative factors form the philosophical foundation for the science of
caring. The remaining seven carative factors spring from the foundation laid by these
first three.
1. The formation of a humanistic- altruistic system of values
Begins developmentally at an early age with values shared with the parents.
Mediated through ones own life experiences, the learning one gains and
exposure to the humanities.
2. Faith-hope
When modern science has nothing further to offer the person, the nurse can
continue to use faith-hope to provide a sense of well-being through beliefs
which are meaningful to the individual.
The nurses promote health and higher level functioning only when they form
person to person relationship.
Empathy
Warmth
She also values the relative nature of nursing and supports the need to
examine and develop the other methods of knowing to provide an holistic
perspective.
The caring nurse must focus on the learning process as much as the teaching
process.
Watson divides these into eternal and internal variables, which the nurse
manipulates in order to provide support and protection for the persons
mental and physical well-being.
Watson suggests that the nurse also must provide comfort, privacy and safety
as a part of this carative factor.
She has created a hierarchy which she believes is relevant to the science of
caring in nursing.
According to her each need is equally important for quality nursing care and
the promotion of optimal health. All the needs deserve to be attended to and
valued.
Example:
Bulemia, anorexia and gastro-intestinal ulcers are a just few of the disorders that
indicate a complex interaction between the physiological and psychological.
10. Allowance for existential-phenomenological forces
Phenomenology is a way of understanding people from the way things appear
to them, from their frame of reference.
Existential psychology is the study of human existence using
phenomenological analysis.
This factor helps the nurse to reconcile and mediate the incongruity of viewing
the person holistically while at the same time attending to the hierarchical
ordering of needs.
Thus the nurse assists the person to find the strength or courage to confront
life or death.
Watsons theory and the four major concepts
1.
Human being
She adopts a view of the human being as: .. a valued person in and of him
or herself to be cared for, respected, nurtured, understood and assisted; in
general a philosophical view of a person as a fully functional integrated self.
He, human is viewed as greater than and different from, the sum of his or her
parts.
2.
Health
Watson believes that there are other factors that are needed to be included in
the WHO definition of health. She adds the following three elements:
A high level of overall physical, mental and social functioning
3.
The absence of illness (or the presence of efforts that leads its absence)
Environment/society
According to Watson caring (and nursing) has existed in every society. A
caring attitude is not transmitted from generation to generation. It is
transmitted by the culture of the profession as a unique way of coping with
its environment.
4.
Nursing
According to Watson nursing is concerned with promoting health, preventing
illness, caring for the sick and restoring health.
It focuses on health promotion and treatment of disease. She believes that
holistic health care is central to the practice of caring in nursing.
She defines nursing as..
A human science of persons and human health-illness experiences that are
mediated by professional, personal, scientific, esthetic and ethical human
transactions.
Watsons theory and nursing process
Watson points out that nursing process contains the same steps as the
scientific research process. They both try to solve a problem. Both provide a
framework for decision making. Watson elaborates the two processes as:
1.
Assessment
Involves observation, identification and review of the problem; use of
applicable knowledge in literature.
Also includes conceptual knowledge for the formulation and conceptualization
of framework.
Includes the formulation of hypothesis; defining variables that will be
examined in solving the problem.
2.
Plan
It helps to determine how variables would be examined or measured; includes
a conceptual approach or design for problem solving. It determines what data
would be collected and how on whom.
3.
Intervention
It is the direct action and implementation of the plan.
4.
Evaluation
Analysis of the data as well as the examination of the effects of interventions
based on the data. Includes the interpretation of the results, the degree to
which positive outcome has occurred and whether the result can be
generalized.
It may also generate additional hypothesis or may even lead to the generation
of a nursing theory.
Watsons work and the characteristic of a theory
According to Watson, a theory is an imaginative grouping of knowledge,
ideas and experiences that are represented symbolically and seek to
illuminate a given phenomenon
She views nursing as,
.both a human science and an art and as such it cannot be considered
qualitatively continuous with traditional, reductionistic, scientific
methodology.
She suggests that nursing might want to develop its own science that would
not be related to the traditional sciences but rather would develop its own
concepts, relationships and methodology.
Theories can interrelate concepts in such a way as to create a different way of
looking at a particular phenomenon
The basic assumptions for the science of caring in nursing and the ten
carative factors that form the structure for that concept is unique in Watsons
theory.
She describes caring in both philosophical and scientific terms.
The science of caring suggests that the nurse recognize and assist with each
of the interrelated needs in order to reach the highest order need of selfactualization.
Theories must be logical in nature
Watsons work is logical in that the factors are based on broad assumptions
which provide a supportive framework.
With these carative factors she delineates nursing from other professions
These carative factors are logically derived from the assumptions and related
to he hierarchy of needs.
Theories should be relatively simple yet generalizable
The theory is relatively simple as it does not use theories from other
disciplines that are familiar to nursing.
The theory is simple relatively but the fact that it de-emphasizes the
pathophysiological for the psychosocial diminishes its ability to be
generalizable.
She discusses this in the preface of her book when she speaks of the trim
and the core of nursing.
She defines trim as the clinical focus, the procedure and the techniques.
The core of the nursing is that which is intrinsic to the nurse-client interaction
that produces a therapeutic result. Core mechanisms are the carative factors.
Theories can be the basis for hypotheses that can be tested
Watsons theory is based on phenomenological studies that generally ask
questions rather than state hypotheses. Its purpose is to describe the
phenomena, to analyze and to gain an understanding.
Theories contribute to and assist in increasing the general body within the
discipline through research implemented to validate them
According to Watson the best method to test this theory is through field
study.
An example is her work in the area of loss and caring that took place in
Cundeelee, Western Australia and involved a tribe of aborigines.
Theories can be utilized by practitioners to guide and improve their practice
Watsons work can be used to guide and improve practice.
It can provide the nurse with the most satisfying aspects of practice and can
provide the client with the holistic care so necessary for human growth and
development.
Theories must be consistent with other validated theories, laws and principles
but will leave open unanswered questions that need to be investigated
Watsons work is supported by the theoretical work of numerous humanists,
philosophers, developmentalists and psychologists.
She clearly designates the theories of stress, development, communication,
teaching-learning, humanistic psychology and existential phenomenology
which provide the foundation for the science of caring.
Strengths
Besides assisting in providing the quality of care that client ought to receive,
it also provides the soul satisfying care for which many nurses enter the
profession.
As the science of caring ranges from the biophysical through the
intrapersonal, each nurse becomes an active coparticipant in the clients
struggle towards self-actualization.
The client is placed in the context of the family, the community and the
culture.
It places the client as the focus of practice rather than the technology.
Limitations
Given the acuity of illness that leads to hospitalization, the short length stay ,
and the increasing complex technology, such quality of care may be deemed
impossible to give in the hospital.
While Watson acknowledges the need for biophysical base to nursing, this
area receives little attention in her writings.
The ten caratiive factors primarily delineate the psychosocial needs of the
person.
While the carative factors have a sound foundation based on other disciplines,
they need further research in nursing to demonstrate their application to
practice.
Summary
Watsons theory
Strengths
Limitations
1.
2.
3.
4.
6. Sexual subsystem:" both biological and social factor affect the behavior in
the sexual subsystem
2. Johnson views human being as having two major systems, the biological
system and the behavioral system. It is role of the medicine to focus on
biological system where as Nursling's focus is the behavioral system.
individual .she stated that nursing is concerned with the organized and
she thought nurse would think she was a bad mother just like her own mother
thought she was a bad mother.
Assessment
1.Affiliative subsystem between mother and John.
2.Dependency subsystem between mother and John
3.Affiliative subsystem between Mrs.Smith and her mother.
4.Insufficiency ingesion subsystem.
Diagnosis
1.Insufficient development of the affiliative subsystem.
2.Insufficient development of the dependency subsystem
Planning and implementation
1.Increasing mothers awareness of the babys clues.
2.Assisting her to talk with the baby.
3.Teach her to bring a bond between her and the baby by touch, pat and
cuddles etc.
Evaluation
1.Johnny's weight gain or weight loss will be carefully assessed.
2.The infant interaction could be reassessed, using the nursing child
assessment feeding scale.
3.The interaction of Mrs. Smith with her mother.
Johnsons and Characteristics of a theory
1.Interrelate concepts to create a different way of viewing a phenomenon.
2.Theories must be logical in nature.
3.Theories must be simple yet generalizable
4.Theories can be bases of hypothesis that can be tested.
5.Theories contribute to and assist in increasing the body of knowledge within
the discipline through the research implemented to validate them
6.Theories can be utilized by practitioners to guide and improve their practice.
7.Theories must be consistent with other validated theories, laws and
principles but will leave unanswered questions that need to be
investigated.
Limitation
Johnson does not clearly interrelate her concepts of subsystems comprising
the behavioral system model.
The definition of concept is so abstract that they are difficult to use.
It is difficult to test Johnson's model by development of hypothesis.
The focus on the behavioral system makes it difficult for nurses to work with
physically impaired individual to use this theory.
The model is very individual oriented so the nurses working with the group
have difficulty in its implementation.
The model is very individual oriented so the family of the client is only
considered as an environment.
Johnson does not define the expected outcomes when one of the system is
affected by the nursing implementation an implicit expectation is made
that all human in all cultures will attain same outcome homeostasis.
Johnsons behavioral system model is not flexible.
Summary
Johnsons Behavioral system model is a model of nursing care that advocates the
fostering of efficient and effective behavioral functioning in the patient to prevent
illness. The patient is defined as behavioral system composed of 7 behavioral
subsystems. Each subsystem composed of four structural characteristics i.e.
drives, set, choices and observable behavior. Three functional requirement of each
subsystem includes (1) Protection from noxious influences, (2) Provision for the
nurturing environment, and (3) stimulation for growth. Any imbalance in each
system results in disequilibrium .it is nursing role to assist the client to return to
the state of equilibrium.
Reference
Born in 1923
Completed her Master of science in nursing from St. Louis University in 1957
Basic assumptions
Interacting systems:
personal system
Interpersonal system
Social system
Perception
Self
Body image
Space
Time
Interaction
Communication
Transaction
Role
Stress
Organization
Authority
Power
Status
Decision making
Theory of goal attainment was first introduced by Imogene King in the early
1960s.
Factors which affects the attainment of goal are: roles, stress, space & time
Proposition cont
If role expectations and role performance as perceived by nurse & client are
congruent, transaction will occur
-choose
-set goals
-select means to achieve goals
-and to make decision
According to King, human being has three fundamental needs:
(a) The need for the health information that is unable at the time
when it is needed and can be used
(b) The need for care that seek to prevent illness, and
(c) The need for care when human beings are unable to help
themselves.
2.
Health:
According to King, health involves dynamic life experiences of a human being, which
implies continuous adjustment to stressors in the internal and external environment
through optimum use of ones resources to achieve maximum potential for daily
living
3.
Environment
Nursing
2.
3.
goal
(b)
domain and
(c)
4.
5.
6.
King said in her theory, A professional nurse, with special knowledge and skills, and
a client in need of nursing, with knowledge of self and perception of personal
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.)
Nursing diagnosis
Planning
Implementations
Evaluation
1. It involves to finding out weather goals are achieved or not.
2. In king description evaluation speaks about attainment of goal and
effectiveness of nursing care.
Nursing Process and Theory of Goal Attainment
Nursing process method
Planning
the goals
Implementation
Transaction made
Evaluation
Goal attained
References
Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
Mosby, Philadelphia, 2002.
Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
The sub specialties include pulmonary, renal, critical care, and hospital
medical units. One of the models strengths is that it can be used in a
variety of settings
Using this conceptual model permits comparison of a nurses interpretation
of a problem with that of the patient, so the patient and nurse do not work
on two separate problems.
The role of the nurse in the model is to work with the patient to move him
as far as possible along a continuum toward wellness.
Because this model requires individual interaction with the total health care
system, it is indicative of the futuristic direction the nursing profession is
taking.
The patient is being relabeled as a consumer with individual needs and
wants.
EDUCATION
The model has also been widely accepted in academic circles.
It has often been selected as a curriculum guide for a conceptual framework
oriented more toward wellness than toward a medical model and has been
used at various levels of nursing education.
In the associate degree program at Indiana University.
One of the objectives for nursing graduate is to demonstrate ability to use
the Neumann health care system in nursing practice. This helps prepare
the students for developing a frame of reference centered on holistic care.
At northwestern State University in Shreveport, Louisiana, the faculty
determined that a systems model approach was preferred for their
masters program because of the universality framework.
Acceptance by the nursing community for education therefore is evident.
RESEARCH
A study was published by Riehl and Roy to test the usefulness of the
Neumann model in nursing practice.
There were two major objectives of the study.
o To test the model/assessment tool for its usefulness as a unifying
method of collecting and analyzing data for identifying client
problems.
o To test the assessment tool for its usefulness in the identification of
congruence between the clients perception of stressors and the
care givers perception of client stressors.
Results indicated that the model can help categorize data for assessing and
planning care and for guiding decision making.
Neumanns model can easily generate nursing research.
It does this by providing a framework to develop goals for desired outcomes.
Acceptance by the nursing community for research applying this model is
in the beginning stages and positive.
NEUMANNS AND THE CHARACTERISTICS OF A THEORY
Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing Concepts
Process & Practice 3rd ed. London Mosby Year Book.
Vandemark L.M. Awareness of self & expanding consciousness: using
Nursing theories to prepare nurse therapists Ment Health Nurs. 2006 Jul;
27(6) : 605-15
Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006
Jul;19(3):225
Cheng MY. Using King's Goal Attainment Theory to facilitate drug compliance
in a psychiatric patient. Hu Li Za Zhi. 2006 Jun;53(3):90-7.
Delaune SC,. Ladner PK, Fundamental of nursing, standard and practice,
2nd edition, Thomson, NY, 2002
External
Preconceptual
Operational
Conceptual
Internal Environment
Homeostasis: A state of energy sparing that also provide the necessary
baselines for a multitude of synchronized physiological and psychological
factors
A state of conservation
Homeorrhesis: A stabilized flow rather than a static state
Emphasis the fluidity of change within a space-time continuum
Describe the pattern of adaptation, which permit the individuals body to
sustain its well being with the vast changes which encroach upon it from
the environment
External Environment
Preconceptual: Aspect of the world that individual are able to intercept
Operational: Elements that may physically affects individuals but not
perceived by hem: radiation, micro-organism and pollution
Conceptual: Part of person's environment including cultural patterns
characterized by spiritual existence, ideas, values, beliefs and tradition
Person and environment
Adaptation
Organismic response
Conservation
Adaptation
Characteristics
Historicity: Adaptations are grounded in history and await the challenges
to which they respond
Specificity: Individual responses and their adaptive pattern varies on the
base of specific genetic structure
Redundancy: Safe and fail options available to the individual to ensure
continued adaptation
Organismic response
A change in behavior of an individual during an attempt to adapt to the
environment
Help individual to protect and maintain their integrity
They co-exist
They are four types
1. Flight or fight: An instantaneous response to real or imagined threat,
most primitive response
Interventions
Testing the hypothesis
Interventions are designed based on the conservation principles
Mutually acceptable
Goal is to maintain wholeness and promoting adaptation
Evaluation
Observation of organismic response to interventions
It is assesses whether hypothesis is supported or not supported
If not supported, plan is revised, new hypothesis is proposed
Conservational models
Conservational model provides the basis for development of two theories
o Theory of redundancy
o Theory of therapeutic intention
Theory of redundancy
Untested ,speculative theory that redefined aging and everything else that
has to do with human life
Aging is diminished availability of redundant system necessary for effective
maintenance of physical and social well being
Theory of therapeutic intention
Goal: To seek a way of organizing nursing interventions out of the biological
realities which the nurse has to confront
Therapeutic regimens should support the following goals:
Facilitate healing through natural response to disease
Provide support for a failing auto regulatory portion of the integrated system
Restore individual integrity and well being
Theory of therapeutic intention
Provide supportive measure to ensures comfort
Balance a toxic risk against the threat of disease
Manipulate diet and activity to correct metabolic imbalance and stimulate
physiological process
Reinforce usual response to create a therapeutic changes
Uses
Critical, acute or long term care unit
Neonates, infant and young children, pregnant young adult and elderly care
unit
Primary health care
OT
Community setting
Utility of Theory
Nursing research
Nursing education
Nursing administration
Nursing practice
Nursing research
Principles of conservation have been used for data collection in various
researches
Conservational model was used by Hanson et al.in their study of incidence
and prevalence of pressure ulcers in hospice patient
Newport used principle of conservation of energy and social integrity for
comparing the body temperature of infants who had been placed on
mothers chest immediately after birth with those who were placed in
warmer
Nursing education
Conservational model was used as guidelines for curriculum development
It was used to develop nursing undergraduate program at Allentown college
of St.Francis de sales, Pennsylvania
Used in nursing education program sponsored by Kapat Holim in Israel
Nursing administration
Taylor described an assessment guide for data collection of neurological
patients which forms basis for development of comprehensive nursing care
plan and thus evaluate nursing care
McCall developed an assessment tool for data collection on the basis of four
conservational principles to identify nursing care needs of epileptic patients
Family assessment tool was designed by Lynn-Mchale and Smith for families
of patient in critical care setting
Nursing practice
Conservational model has been used for nursing practice in different settings
Bayley discussed the care of a severely burned teenagers on the basis of
four conservational principles and discussed patients perceptual,
operational and conceptual environment
Pond used conservation model for guiding the nursing care of homeless at a
clinic, shelters or streets
Nursing process according to Levines model
Mrs. Mona, a wife of an abusive husband, underwent a radical
hysterectomy. Post operatively has pain ,weight loss, nausea and inability
to empty bladder .Patient has history of smoking and stays in house which
is less than sanitary
Assessment
Challenges to the internal env:-weight loss, nausea, loss of reproductive
ability
Challenges to the external env:-abusive husband, insanitary condition in
home
1. Conservation principles
2.Nursing process
1.Assessment
2.Trophicogosis
3.Hypothesis
4.Interventions
5.Evaluation
3. Theory of redundancy
4. Theory of therapeutic intention
5.Utility of theory
1.Nursing research
2.Nursing education
3.Nursing administration
4.Nursing practices
Rogers model provides the way of viewing the unitary human being
The unitary human being and the environment are one ,not dichotomous
Nursing focus on people and the manifestations that emerge from the mutual
human /environmental field process
Change of pattern and organization of the human field and the environmental
field is propagated by waves
The manifestations of the field patterning that emerge are observable events
Basic characteristics which describes the life process of human :energy field,
openness, pattern, and pan dimensionality
The energy field is the fundamental unit of both the living and nonliving
The human field and the environmental field are constantly exchanging their
energy
There are no boundaries or barrier that inhibit energy flow between fields
Pattern
The parameters that human use in language to describe events are arbitrary.
A unitary human being is an "irreducible, indivisible, pan dimensional (fourdimensional) energy field identified by pattern and manifesting characteristics
that are specific to the whole and which cannot be predicted from knowledge
of the parts" and "a unified whole having its own distinctive characteristics
which cannot be perceived by looking at , describing, or summarizing the
parts"
The field coexist and are integral. Manifestation emerge from this field and
are perceived.
Health
Rogers defined health as an expression of the life process; they are the
"characteristics and behavior emerging out of the mutual, simultaneous
interaction of the human and environmental fields"
The multiple events taking place along life's axis denote the extent to which
man is achieving his maximum health potential and very in their expressions
from greatest health to those conditions which are incompatible with the
maintaining life process
Nursing
The safe practice of nursing depends on the nature and amount of scientific
nursing knowledge the individual brings to practice.the imaginative,
intellectual judgment with which such knowledge is made in service to the
man kind
Homeodynamic principles
Resonancy
Helicy
integrality
Resonance
Helicy
Integrality
The fields are one and integrated but unique to each other
Rogerian theories
Rogerian theories-Grand theories
Theory postulates that evolutionary change is speeding up and that the range
of diversity of life process is widening. Rogers explained that higher wave
frequencies are associated with accelerating human development
Theory of Rhythmicity
Theory deals with the manifestations of the whole unitary man as changes in
human sleep wake patterns, indices of human field motion, perception of time
passing, and other rhythmic development
The art of nursing involves the imaginative and creative use of nursing
knowledge
The purpose of nurses is to promote health and well-being for all person and
groups wherever they are using the art and science of nursing
Rogers was one of the first nurse scholars to explicitly identify the person
(unitary man) as the central phenomena of nursing concern
Study participants may be any person or group, with the provision that both
person and environment are taken into account
Research methodology
Case study and longitudinal research are better than cross sectional study
Research instruments that are directly derived from science of unitary human
beings should be used
Nursing programs
Masters program
Doctoral program
She proposes the independent role in various setting like school, industry,
community, space (by 2050AD)
SETTINGS
School
Industry
Family
Community
Space
SPECIALITIES
Pediatrics
Psychiatry
Oncology
Burns
Geriatrics
Neurology
Cardiology
Rehabilitative medicine
Neonatal ICU
Pediatric ICU
Rehabilitation center
Burns unit
Adult ICUs
Neuropsychiatric units
Operation theaters
Legitimate participants
Assessment
Evaluation
Pattern appraisal
Evaluation
Self reflection
Patterning activities
Personal appraisal
Nursing process
Assessment
Areas of assessment
Supplementary data
Subsystem pathology
Pattern appraisal
It is a comprehensive assessment of:
Sharing knowledge
Offering choices
Fostering patterning
Evaluation
Nutrition
Work/leisure activities
Exercise
Relationships
Discomfort or pain
Fear /hopes
With rogerian model, the process of caring Radha begins with pattern
appraisal
Radha has manifestation of fear.her self knowledge links her illness to her
personal belief of being punished for her past sins
Appraisal is needed in her sleep patterns, nutrition and her perception of self
During the process nurse must rely on personal intuition and insight regarding
the emerging pattern
Teach her how to center the energy and channel her energy to the area of
pain
Use humor for increasing socialization and developing self confidence and
developing worthiness
Summary
Rogerian terminologies
Rogerian theories
Clinical example
References
1. George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton & Lange.
2. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
3. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
4. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
5. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing Concepts
Process & Practice 3rd ed. London Mosby Year Book.
Goal-directed
Directly or indirectly
Dynamic state
Time
Sequence of events
Same everywhere
Observable behaviour
Social beings
Sentient beings
Rational beings
Perceiving beings
Controlling beings
Purposeful beings
Open system
Constantly changing
Role
Stress
Social system
Concepts
Organization
Authority
Power
Status
Decision making
ASSUMPTIONS
Perceptions, goals, needs and values of the nurses and client influence
interaction process
Individuals have the right to knowledge about themselves and to participate
in decisions that influence their life, health and community services
Health professionals have the responsibility that helps individuals to make
informed decisions about their health care
Individuals have the right to accept or reject health care
Goals of health professionals and recipients of health care may not be
congruent
II.
SISTER CALLISTA ROY: ADAPTATION MODEL
Introduction
represent the persons own standard of the range of stimuli, to which one can
respond with the ordinary adaptive response
Adaptation problems:
all other stimuli present
responds through
perception, information
processing, learning
involves bodys basic needs and ways of dealing with adaptation in relation to
Fluid and electrolytes
Exercise and rest
Elimination
Nutrition
Circulation
Oxygen
regulation includes:
The senses
Temperature
Endocrine regulation
Self concept mode:
components are :
the physical self
During her professional career ,she worked as a staff nurse ,private duty
nurse ,nurse educator and administrator and nurse consultant
Development of Theory
Health health and healthy are terms used to describe living things it
is when they are structurally and functionally whole or sound wholeness or
integrity. .includes that which makes a person human,operating in
conjunction with physiological and psychophysiological mechanisms and a
material structure and in relation to and interacting with other human beings
Human being has the capacity to reflect ,symbolize and use symbols
Conceptualized as a total being with universal ,developmental needs
and capable of continuous self care
A unity that can function biologically, symbolically and socially
Nursing client- a human being who has "health related /health derived
limitations that render him incapable of continuous self care or dependent
care or limitations that result in ineffective / incomplete care.
A human being is the focus of nursing only when a self care
requisites exceeds self care capabilities
Includes :--
Self care agency is a human ability which is "the ability for engaging in
self care"
-- Conditioned by age developmental state, life experience
sociocultural orientation health and available resources
Universal
Developmental
Health deviation
Universal self care requisites
Guiding others
Supporting another
Describes how the patients self care needs will be met by the nurse , the
patient, or both
Social or interpersonal
Regulatory technologies
Nursing Process
Assessment
Nursing diagnosis
Implementation
evaluation
The health goals within the context of life history ,life style, and health
status
Step 2
evaluation
Personal
factors
Universal
self care
29 yr.
32pack /yr
Female
Water-no
restrictions
Early
adulthood
transition
Food nil
Wt89lb
Wt loss-19%
Developmenta Health
l self care
deviation
Teenage
pregnancy-2
OC-10 yrs
Husband
emotionally
away
nauseated
8th grade
Teenage
pregnancy
No work
Married
Child-2
Lives at
mothers
home.
Environment
unclean
Limited
resources
Urinary
retention
Intermittent
self
catheterizatio
n
Pain
Medical
problem &
plan
Self care
deficits
Surgery on
reproductive
organs
Difference
between
knowledge
base &
lifestyle
Seeks
medical
attention
for overt
s/s
Aware of
disease
No
evidence
No BSE
Infrequent
physical
examination
ability to
manage
effects
No HRT
Poor health
Tearful
EDU deprivation
Husband
abusive
Oppressive
living conditions
Dissatisfied
with home
Will receive RT
,perform
intermittent
catheterizatio
n
RT
Therapeutic
self care
demand
Adequacy
of self
care
agency
Nursing
diagnosis
Methods of helping
Air
Maintain
effective
respiration
Water
No problem
Food maintain
sufficient intake
Actual nutritional
deficit r/t ausea
Inadequate
Teaching
Providing physical
support
Personal development
Hazards
Prevent spouse
abuse
Promotion of
normalcy
Inadequate A/d in
environment
Shared housing
Maintain
developmental
environment
Support ed
normalcy in
environment
Prevent
/manage dev
threat
Inadequate
Maintenance of
health status
Inadequate
Management of
disease process
Inadequate
Adherence to
med regimen
Inadequate
Awareness of
potential
problems
Inadequate
P/F contd.
alterations in
health status
P/F UTI
Guiding &
directing, teaching
Guiding & directing,
teaching
Actual threat to
self image
Providing psy
support
Theory Testing
Orems theory has been used as the basis for the development of research
instruments to assist researchers in using the theory
Strengths
Limitations
Appears that the theory is illness oriented rather with no indication of its
use in wellness settings
Summary
References
Orem, D.E. (1991). Nursing: Concepts of practice (4th ed.). St. Louis, MO:
Mosby-Year Book Inc.
Taylor, S.G. (2006). Dorthea E. Orem: Self-care deficit theory of nursing. In
A.M.
Tomey, A. & Alligood, M. (2002). Significance of theory for nursing as a
discipline and profession. Nursing Theorists and their work. Mosby, St. Louis,
Missouri, United States of America.
Whelan, E. G. (1984). Analysis and application of Dorothea Orems Self-care
Practuce Model. Retrieved October 31, 2006.
George B. Julia , Nursing Theories- The base for professional Nursing
Practice , 3rd ed. Norwalk, Appleton & Lange.
Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing
Philadelphia. Lippincott Williams& wilkins.
Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress
3rd ed. Philadelphia, Lippincott.
Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
Family
Education
Religious Background
Mentors
Clinical Experience
Theory description
Over the years she identified assumptions on which her theory is based.
To cope with a changing world, person uses both innate and acquired
mechanisms which are biological, psychological and social in origin.
The persons adaptation level is such that it comprises a zone indicating the
range of stimulation that will lead to a positive response.
The person has 4 modes of adaptation: physiologic needs, self- concept, role
function and inter-dependence.
Implicit assumptions
Environment -- stimuli
Concepts-Adaptation
The process and outcome of individuals and groups who use conscious
awareness, self reflection and choice to create human and environmental
integration
Concepts-Person
Contextual- all stimuli present in the situation that contribute to effect of focal
stimulus
To promote adaptation for individuals and groups in the four adaptive modes,
thus contributing to health, quality of life, and dying with dignity by assessing
behaviors and factors that influence adaptive abilities and by intervening to
enhance environmental interactions
Concepts-Subsystems
What did the patient look like when needing nursing care?
Four Adaptive Modes
Physiologic Needs
Self Concept
Role Function
Interdependence
Four Adaptive Mode Categories
Theory Development
Derived Theory
91 Propositions
Described relationships between and among regulator and cognator and four
adaptive modes
12 Generic propositions
Questions Raised by 21st Century Changes
How can ethics and public policy keep pace with developments in science?
Persons and the earth have common patterns and integral relations
Philosophical Assumptions
Adaptive Modes
Persons
Physiologic
Self Concept
Role Function
Interdependence
Groups
Physical
Group Identity
Role Function
Interdependence
Role Function Mode
The need to know who one is in relation to others so that one can act
Integrated
Compensatory
Compromised
Integrated Life Processes
Adaptation level where the structures and functions of the life processes work
to meet needs
Adaptation problem
Hypoxia
Unresolved Loss
Stigma
Abusive Relationships
The elements :
Diagnosis
Goal setting
Intervention
evaluation
Research variables
Theories can be the basis for the hypotheses that can be tested
Theories must be consistent with other validated theories, laws and principles
but will leave open unanswered questions that need to be investigated
Testability
RAM is testable
BBARNS (1999) reported that 163 studies have been conducted using this
model.
Dunn, H.C. and Dunn, D. G. (1997). The Roy Adaptation Model and its
application to clinical nursing practice. Journal of Ophthalmic Nursing and
Technology. 6(2), 74-78.
Samarel, N., Fawcett, J., Krippendorf, K., Piacentino, J.C., Eliasof, B., Hughes,
P., Kowitski, C., and Ziegler, E. (1998). Women's perception of group support
and adaptation to breast cancer. Journal of Advanced Nursing. 28(6), 12591268.
Zhan, L. (2000). Cognitive adaptation and self-consistency in hearingimpaired older persons: testing Roy's adaptation model. Nursing Science
Quarterly. 13(2), 158-165.
Summary
1. 5 elements -person, goal of nursing, nursing activities, health and
environment
APPLICATION OF IMOGENE
KINGS THEORY OF GOAL
ATTAINMENT
Objectives
1.to assess the patient condition by the various methods explained by the
nursing theory
2.to identify the needs of the patient
3.to demonstrate an effective communication and interaction with the patient.
4.to select a theory for the application according to the need of the patient
5.to apply the theory to solve the identified problems of the patient
6.to evaluate the extent to which the process was fruitful.
Introduction
Kings theory offers insight into nurses interactions with individuals and groups
within the environment. It highlights the importance of clients 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.
Major Concepts and Definitions
1.
Interaction
Goal-directed
Directly or indirectly
Dynamic state
Human being interacts with the environment
7.
Growth and development
Sequence of events
Same everywhere
Observable behaviour
Open system
Constantly changing
Perception
Self
Body image
Time
Space
Interpersonal system
Concepts
1. Interaction, 2. Transaction 3. Communication 4. Role 5. Stress
Social system
Concepts
1.
Organization 2. Authority 3. Power 4. Status, 5. Decision making
ASSUMPTIONS
Perceptions, goals, needs and values of the nurses and client influence
interaction process
Proposition cont
If role conflict is experienced by nurse or client or both, stress in nurseclient interaction will occur
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 patients
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
Im 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.
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
Patients 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 th 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 collection or ascitis
Genito-Urinary system
Inspection:
Testicles in position, No infection, No swelling or
enlargement
Palpation
No c/o pain,No prostate enlargement
Percussion
No fluid collection in scrotum
Auscultation
Normal Bowel sounds
Laboratory Investigations
FBS - 91 mg/dl
What conclusion
(judgement) does this
patient make?
What conclusions
(judgement) do I make?
Nursing diagnosis
Planning
After diagnosis, planning for interventions to solve those problems is done.
In goal attainment planning is represented by setting goals and making decisions
about and being agreed on the means to achieve goals.
This part of transaction and clients participation is encouraged in making decision
on the means to achieve the goals.
Identifying the goals and planning to achieve these goals(this step is
congruent with planning in the traditional nursing process)
What goals do I think will
1.
evidenced by:
Rapid healing
Yes
Relief of pain
Freedom from infection
Adequate bowel movement
Improvement knowledge aspect of health conditions
Prompt attendance to health problems
health
Yes
What do I perceive to be
the best way to achieve
the goals?
Goal 1:
Assess the characteristics of pain
Administration of prescribed medicine
Monitor the responses to drug therapy
Provide calm, efficient manner that reassures the
client and minimizes anxiety
Provide a comfortable position as per clients
requests.
Goal 2:
Monitor vital signs
Administer antibiotics as advised
Use aseptic techniques while changing dressing
Kept the surgical wound site clean
Report surgeon regarding early signs of infection
Goal 3:
What modifications
required based on
mutuality?
Implementations
1.In nursing process implementation involves the actual activities to achieve
the goals.
2.This step results in transactions being made.
3.Transactions occur as a result of perceiving the other person and the
situation, making judgments about those perceptions, and taking some
actions in response.
4.Reactions to action lead to transactions that reflect a shared view and
commitment
5.This step reflects implementation in the traditional nursing process.
Am I doing what the patient and I
have agreed upon?
Yes
Yes
Evaluation
It involves to finding out weather goals are achieved or not.
In Kings description evaluation speaks about attainment of goal and effectiveness
of nursing care.
Are my actions helping the patient
achieve mutually defined goals?
Yes
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.
Later graduate education and masters education was given much
importance.
Patient details
Name
Mrs. X
Age
56 years
Sex
Female
Education
Occupation
No formal
education
Marital status
Religion
Diagnosis
Theory
applied
House hold
Married
Hindu
Rheumatoid
arthritis
Orems theory of
self care deficit.
In the theory of self care, she explains self care as the activities
carried out by the individual to maintain their own health.
The self care agency is the acquired ability to perform the self care
and this will be affected by the basic conditioning factors such as age,
gender, health care system, family system etc.
Therapeutic self-care demand is the totality of the self care measures
required.
Once the need is identified, the nurse has to select required nursing
systems to provide care: wholly compensatory, partly compensatory or
supportive and educative system.
The care will be provided according to the degree of deficit the patient
is presenting with.
Once the care is provided, the nursing activities and the use of the
nursing systems are to be evaluated to get an idea about whether the
mutually planned goals are met or not.
Thus the theory could be successfully applied into the nursing practice.
For Mrs. X.
1.
She came to the hospital with complaints of pain over all the joints,
stiffness which is more in the morning and reduces by the activities.
2.
She has these complaints since 5 years and has taken treatment from
local hospital.
3.
The symptoms were not reducing and came to --MC, Hospital for
further management.
4.
Patient was able to do the ADL by herself but the way she performed
and the posture she used was making her prone to develop the complications
of the disease.
5.
She also was malnourished and was not having awareness about the
deficiencies and effects.
DATA COLLECTION ACCORDING TO OREMS THEORY OF SELF CARE DEFICIT
1. BASIC CONDITIONING FACTORS
Age
56 year
Gender
Female
Health state
Development state
Sociocultural
orientation
Family system
Patterns of living
Environment
resources
Water
Food
Elimination
Activity/ rest
Promotion of
normalcy
Awareness of potential
problem associated
with the regimen
Modification of self
image to incorporates
changes in health
status
Adjustment of lifestyle
to accommodate
changes in the health
status and medical
regimen.
Solitude/ Interaction
g. Prevention of hazards
h. Promotion of normalcy
i.
j.
Implementation
Evaluation
(Prescriptive
operations)
(control
operations)
(regulatory
operations )
Nurse- patient
actions to
1. Effectiveness of
the nurse patient
action to
1. Outcome
2. Nursing goal
and objectives
3. Design of
nursing system
4. Appropriate
method of
helping
Promote
patient as
self care
agent
Meet self
care needs
-Promote patient
as self care agent
-
Meet self
care needs
- Decrease
Decrease the
the self
self care
care deficit.
deficit.
2. Effectiveness of
the selected
nursing system to
meet the needs.
Thus in the patient Mrs. X the areas that need assistance were
Air
Water
Food
Elimination
Activity/ Rest(2)
Solitude/ Interaction
Prevention of hazards(2)
Promotion of normalcy
NURSING DIAGNOSIS
a. Outcome:
Absence of complications and improved awareness about the disease process.
b. nursing Goals and objectives
Goal: Improve the knowledge of the patient about the disease process and the
complications.
Objectives: Mrs. X will:
-verbalize the various complication and their preventions
-verbalize the changes occurring with the disease process and the treatment
available
-describe the actions and side effects of the medications which she is using
c. Design of the nursing system:
supportive educative
d. Methods of helping:
Guidance
Teaching
IMPLEMENTATION
------------------------------------------------------------EVALUATION
Patient got adequate information regarding the disease
She verbalized what she understood about the disease and its management.
Patient has cleared her doubts regarding the medication actions and the side
effect
The supportive educative system was useful for Mrs. X
EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY
The theory of self-care deficit when applied could identify the self care requisites of
Mrs. X from various aspects. This was helpful to provide care in a comprehensive
manner. Patient was very cooperative. the application of this theory revealed how
well the supportive and educative and partly compensatory system could be used for
solving the problems in a patient with rheumatoid arthritis.
Behavioral outcomes
The health promotion model notes that each person has unique personal
characteristics and experiences that affect subsequent actions. The set of variables
for behavioral specific knowledge and affect have important motivational significance.
These variables can be modified through nursing actions. Health promoting behavior
is the desired behavioral outcome and is the end point in the HPM. Health promoting
behaviors should result in improved health, enhanced functional ability and better
quality of life at all stages of development. The final behavioral demand is also
influenced by the immediate competing demand and preferences, which can derail an
intended health promoting actions.
ASSUMPTIONS OF THE HEALTH PROMOTION MODEL
The HPM is based on the following assumptions, which reflect both nursing and
behavioral science perspectives:
1.
Persons seek to create conditions of living through which they can express
their unique human health potential.
2.
3.
4.
5.
6.
7.
2.
3.
4.
5.
6.
7.
8.
9.
Frequency of the similar behaviour in the past. Direct and indirect effects on the
likelihood of engaging in health promoting behaviors.
v
PERSONAL FACTORS
Anticipated positive out comes that will occur from health behaviour.
v
Subjective positive or negative feeling that occur before, during and following
behavior based on the stimulus properties of the behaviour itself. Activity-related
affect influences perceived self-efficacy, which means the more positive the
subjective feeling, the greater the feeling of efficacy. In turn, increased feelings of
efficacy can generate further positive affect.
v
INTERPERSONAL INFLUENCES
SITUATIONAL INFLUENCES
Personal perceptions and cognitions of any given situation or context that can
facilitate or impede behaviour. Include perceptions of options available, demand
characteristics and aesthetic features of the environment in which given health
promoting is proposed to take place. Situational influences may have direct or
indirect influences on health behaviour.
Behavioural Outcome
v
Competing demands are those alternative behaviour over which individuals have low
control because there are environmental contingencies such as work or family care
responsibilities. Competing preferences are alternative behaviour over which
individuals exert relatively high control, such as choice of ice cream or apple for a
snack
v
Endpoint or action outcome directed toward attaining positive health outcome such
as optimal well-being, personal fulfillment, and productive living.
Perceived Susceptibility
2.
Perceived severity
3.
Perceived benefits
4.
Perceived costs
5.
Motivation
6.
1.
2.
3.
Perceived benefits: refers to the patients belief that a given treatment will
cure the illness or help to prevent it.
4.
5.
Motivation: includes the desire to comply with a treatment and the belief that
people should do what
6.
(5) residential institutions, and (6) the community at large. Community health
nursing practice is not limited to a specific area, but can be practiced anywhere.
Theories and Models for community health nursing
The commonly used theories are:
1. Nightingales theory of environment
2. Orems Self care model
3. Neumanns health care system model
4. Rogers model of the science and unitary man
5. Penders health promotion model
6. Roys adaptation model
7. Milios Framework of prevention
8. Salmon Whites Construct for Public health nursing
9. Block and Jostens Ethical Theory of population focused nursing
10. Canadian Model
Milios Framework of prevention
Nancy Milio a nurse and leader in public health policy and public health education
developed a framework for prevention that includes concepts of community-oriented,
population focused care.(1976,1981).The basic treatise is that behavioral patterns of
populations and individuals who make up populations are a result of habitual
selection from limited choices. She challenged the common notion that a main
determinant for unhealthful behavioral choice is lack of knowledge. Governmental
and institutional policies, she said set the range of options for personal choice
making. It neglected the role of community health nursing, examining the
determinants of community health and attempting to influence those determinants
through public policy.
Salmon Whites construct for public health nursing
Mark Salmon White (1982) describes a public health as an organized societal effort
to protect, promote and restore the health of people and public health nursing as
focused on achieving and maintaining public health.
He gave 3 practice priorities i.e.; prevention of disease and poor health, protection
against disease and external agents and promotion of health. For these 3 general
categories of nursing intervention have also been put forward, they are:
11. education directed toward voluntary change in the attitude and behaviour of
the subjects
12. engineering directed at managing risk-related variables
13. enforcement directed at mandatory regulation to achieve better health.
MAJOR CONCEPTS
I. PERSON VARIABLESEach layer, or concentric circle, of the Neuman model is made up of the five
person variables. Ideally, each of the person variables should be considered
simultaneously and comprehensively.
1. Physiological - refers of the physicochemical structure and function of the body.
2. Psychological - refers to mental processes and emotions.
3.
defense beyond its previous level, stabilize the system at a lower level, or return
it to the level that existed before the illness.
VII. STRESSORS-The Neuman Systems Model looks at the impact of stressors on health and
addresses stress and the reduction of stress (in the form of stressors). Stressors
are capable of having either a positive or negative effect on the client system. A
stressor is any environmental force which can potentially affect the stability of the
system: they may be:
Intrapersonal - occur within person, e.g. emotions and feelings
Interpersonal - occur between individuals, e.g. role expectations
Extra personal - occur outside the individual, e.g. job or finance pressures
The person has a certain degree of reaction to any given stressor at any given
time. The nature of the reaction depends in part on the strength of the lines of
resistance and defense. By means of primary, secondary and tertiary
interventions, the person (or the nurse) attempts to restore or maintain the
stability of the system.
VII. PREVENTIONAs defined by Neuman's model, prevention is the primary nursing intervention.
Prevention focuses on keeping stressors and the stress response from having a
detrimental effect on the body.
Primary -Primary prevention occurs before the system reacts to a stressor.
On the one hand, it strengthens the person (primarily the flexible line of
defense) to enable him to better deal with stressors, and on the other
hand manipulates the environment to reduce or weaken stressors. Primary
prevention includes health promotion and maintenance of wellness.
Secondary-Secondary prevention occurs after the system reacts to a
stressor and is provided in terms of existing systems. Secondary
prevention focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or removing the stressor.
Tertiary -Tertiary prevention occurs after the system has been treated
through secondary prevention strategies. Tertiary prevention offers support
to the client and attempts to add energy to the system or reduce energy
needed in order to facilitate reconstitution.
NURSING METAPARADIGM
A. PERSONThe person is a layered multidimensional being. Each layer consists of five person
variables or subsystems:
Physical/Physiological
Psychological
Socio-cultural
Developmental
Spiritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of flexible defense. The basic
core structure is comprised of survival mechanisms including: organ function,
temperature control, genetic structure, response patterns, ego, and what Neuman
terms 'knowns and commonalities'. Lines of resistance and two lines of defense
protect this core. The person may in fact be an individual, a family, a group, or a
community in Neuman's model. The person, with a core of basic structures, is
seen as being in constant, dynamic interaction with the environment. Around the
basic core structures are lines of defense and resistance (shown diagrammatically
as concentric circles, with the lines of resistance nearer to the core. The person is
seen as being in a state of constant change and-as an open system-in reciprocal
interaction with the environment (i.e. affecting, and being affected by it).
B. THE ENVIRONMENTThe environment is seen to be the totality of the internal and external forces
which surround a person and with which they interact at any given time. These
forces include the intrapersonal, interpersonal and extra personal stressors which
can affect the person's normal line of defense and so can affect the stability of the
system.
The internal environment exists within the client system.
The external environment exists outside the client system.
Neuman also identified a created environment which is an environment
that is created and developed unconsciously by the client and is symbolic
of system wholeness.
C. HEALTHNeuman sees health as being equated with wellness. She defines health/wellness
as "the condition in which all parts and subparts (variables) are in harmony with
the whole of the client (Neuman, 1995)". As the person is in a constant
interaction with the environment, the state of wellness (and by implication any
other state) is in dynamic equilibrium, rather than in any kind of steady state.
Neuman proposes a wellness-illness continuum, with the person's position on that
continuum being influenced by their interaction with the variables and the
stressors they encounter. The client system moves toward illness and death when
more energy is needed than is available. The client system moves toward wellness
when more energyis available than is needed.
D. NURSINGNeuman sees nursing as a unique profession that is concerned with all of the
variables which influence the response a person might have to a stressor. The
person is seen as a whole, and it is the task of nursing to address the whole
person. Neuman defines nursing as actions which assist individuals, families and
groups to maintain a maximum level of wellness, and the primary aim is stability
of the patient/client system, through nursing interventions to reduce stressors.
Neuman states that, because the nurse's perception will influence the care given,
then not only must the patient/client's perceptions be assessed, but so must
those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of
reaction to stressors, and the use of primary, secondary and tertiary
interventions.
Neuman envisions a 3-stage nursing process:
1. Nursing Diagnosis - based of necessity in a thorough assessment, and with
consideration given to five variables in three stressor areas.
2. Nursing Goals - these must be negotiated with the patient, and take account of
patient's and nurse's perceptions of variance from wellness
ASSESSMENT
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
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.
active in church
spends leisure time by reading news paper, watching TV, spending time with
family members and relatives
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.
What helped then- family members psychological support helped him to over
come the crisis situation
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
Family members visiting the patient and spending some time with him will help
to a great extent to relieve his tension.
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
Persistent fatigue
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 concerning the restrictions after the surgery and the life
style modifications which are to be followed.
Patient verbalized that the severity of pain, nausea, fatigue etc was similar to
that of patients 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.
4. 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 is spending time to read religious books and also spends time in talking with
others
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
Evaluation/ summary of impressionsThere 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.
2.
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 persons support. To walk also he needs a support. He do
his personal care activities with the support from the others
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.
Other complaints- patient has the complaints of pain fatigue, loss of appetite,
dizziness, difficulty in urination, etc...
Studied up to BA
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.
Has some good and close friend at his place and he actively interact with them.
They also very supportive to him
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 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.
INTERPERSONAL FACTORS
has supportive family and friends
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- patients 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
Investigations
Values
Hemoglobin(1319g/dl)
6.9
HCT (40-50%)
21.9
WBC (4000-11000
cells/cumm)
12200
Neutrophil
75%)
(40-
77.2
Lymphocyte
45%)
(25-
10.5
Monocyte (2-10%)
4.5
Eosinophil
10%)
2.6
(0-
Basophil (0-2%)
.2
Platelet (150000400000
cells/cumm)
345000
ESR (0-10mm/hr)
86
RBS
mg/dl)
148
(60-150
Pus C/S
USG
Urea (8-35mg/dl)
28
Creatinine (0.6-1.6
mg/dl)
1.8
Sodium (130-143
mEq/L)
136
Potassium (3.5-5
mEq/L)
PT (patient)(11.415.6 sec)
12.3
26.4
Blood group
A+
HIV
Negative
HCV
Negative
HBsAg
Negative
Urine Protein
(negative)
Negative
Nil
RBC (nil )
Nil
Epithelial cell(0-5)
4-5
Nil
THERAPEUTIC MANAGEMENT
Initial Treatment:
Patient got admitted to ---Medical college for 3 days
and the symptoms not
relieved. So they asked for
discharge and came to
---this hospital
Post
operative
period
(immediate post op)
Inj Tramazac
SOS
IV
IV fluids DNS
Inj
Pethedine
1mg SOS
Inj
Phenargan
SOS
Inj Pantodac 40
mg IV OD
Inj Vorth P 40
mg IM Q12H
Tab Clovipas
mg 0-1-0
75
Inj
calcium
Gluconate 10
ml over 10 min
IV fluids DNS
Inj Tramazac
mg IV Q8H
50
Tab Pantodac 40
mg 1-0-0
Inj Emset
Q8H
mg
Cap
beneficiale
0-1-0
Tab Pantodac
mg 1-0-0
40
Tab Clovipas 75
mg 0-1-0
K bind I sachet
TID
Surgical management
Patient underwent Whipples
procedure (pancreato
duodenectomy)
Other instructions
Incentive
spirometry
Steam inhalation
Early ambulation
Diabetic diet
NURSING PROCESS
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 action
Primary prevention
Assess
severity of
pain by
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
Secondary prevention
Teach the
patient about
the 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 strainous
activities. And
explain to the
patient why
those activities
are
contraindicate
d.
Involve the
patient in
Tertiary prevention
Educate the
client about
the 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
making
decisions
about his own
care and
provide a
positive
psychological
support
site of incision
to prevent any
form of
infections
Provide nonpharmacologic
al 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.
measures.
Provide the
primary
preventive
care when
ever
necessary.
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 actions
Primary prevention
Adequately
oxygenate
the client
Instruct the
client to avoid
the activities
Secondary
prevention
Instruct the
client to
avoid the
activities
which
causes
Tertiary prevention
Encourage the
client to do the
mobility
exercises
which causes
extreme
fatigue
Provide the
necessary
articles near
the patients
bed side.
Assist
the
patient
in
early
ambulation
Monitor
clients
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
extreme
fatigue.
Advice the
client to
perform
exercises to
strengthen
the
extremities
& promote
activities
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
provide
nutritious diet
in a frequent
intervals
Teach the
patient and the
family about
the importance
of
psychological
well being in
recovery.
Provide the
primary and
secondary level
care if
necessary.
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 action
Primary 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.
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.
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
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
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
other disciplines
like
physiotherapy.
Teach the
importance of
psychological
well being which
influence
indirectly the
physical
recovery
Provide primary
preventive
measures
whenever
necessary
Evaluation patients physical activity improved and he is able to move from bed
with support. Patient started doing the active and passive exercises and he
verbalized improvement.
----------------------------------------------------------Conclusion
The Neumans 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.
References
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed.
Missouri: Elsevier Mosby Publications; 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5 th ed.
New Jersey :Prentice Hall;2002.
Introduction
Assumptions of Roy's Adaptation Model
Roy's Adaptation Model (RAM) Terms
Nursing Process
First Level Assessment
Second Level Assessment
Nursing Care Plan
Conclusion
Reference
INTRODUCTION
Born at Los Angeles on October 14, 1939 as the 2nd child of Mr. and Mrs.
Fabien Roy
At age 14 she began working at a large general hospital, first as a pantry girl,
then as a maid, and finally as a nurse's aid.
she earned a Bachelor of Arts with a major in nursing from Mount St. Mary's
College, Los Angeles in 1963.
She also earned a masters & PhD in Sociology in 1973 & 1977 ,respectively
Sr. Callista had the significant opportunity of working with Dorothy E. Johnson
Sister Callista Roy (1984), Introduction to Nursing: An Adaptation Model (2nd ed)
ASSUMPTIONS OF ROYS ADAPTATION MODEL
Scientific
Persons and the earth have common patterns and integral relationships
Philosophical
ENVIRONMENT
Health: a state and process of being and becoming integrated and whole that
reflects person and environmental mutuality
Adaptation: the process and outcome whereby thinking and feeling persons,
as individuals and in groups, use conscious awareness and choice to create
human and environmental integration
NURSING
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
NURSING PROCESS
1. 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
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.
DEMOGRAPHIC DATA
Name
Age
Mr. NR
53 years
Sex
Male
IP number
-----
Education
Degree
Occupation
Bank clerk
Marital status
Married
Religion
Hindu
Informants
Date of admission
21/01/08
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. BPNormotensive. . 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
doesnt have any work. His role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbours. 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 showed 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. . Mothers 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. Patients 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.
ASSESSMEN
NURSING
T OF
DIAGNOSIS
STIMULI
GOAL
INTERVENTIO EVALUATIO
N
N
Ineffeciti
ve
protectio
n and
sense in
physicalphysiolog
ical mode
(No pain
sensation
from the
wound
site.)
Focal
stimuli:
1.
Impaired
Non-healing skin
wound after integrity
related to
amputation
of great and fragility of
second toe of the skin
secondary
left leg- 4
to vascular
week
insufficienc
y
Long-term
objective:
Maintain the
wound area
1. amputated clean as
area will be contamination
affects the
completely
healing
healed by
process.
20/5/08
Follow
2.Skin will
sterile
remain
technique while
intact with no providing cares
ongoing
to prevent
ulcerations. infection and
Short-Term delay in
healing.
Objective:
i. Size of
wound
decreases to
1x1 cm
within
24/4/08.
ii. No signs
of infection
over the
wound within
1-wk
Perform
wound dressing
with betadine
which promote
healing and
growth of new
tissue.
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
interventions
Do not
move the
affected area
Unmet: not
frequently as it
achieved
affects the
iii. Normal
complete
granulation
WBC values
healing of
tissue
within 1-wk
amputated
formation.
area.
iv. Presence
Administer
the antibiotics
and vitamin C
supplementatio
n which will
promote the
healing
process.
Impaired
activity
in
physicalphysiolog
ical mode
Focal
stimuli:
2.
Impaired
physical
During
hospital stay mobility
related to
great and
amputation
second toe
amputated. of the left
But surgical forefoot
wound turned and
presence of
to nonhealing with unhealed
pus and black wound
colour.
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
Assess the
level of
restriction of
movement
Provide
active and
passive
exercises to all
the extremities
to improve the
muscle tone
and strength.
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.
Make the
patient to
perform the
ROM exercises
to lower
ii.
walking extremities
Long term
with
which will
goal:
minimum
strengthen the
Unmet: not
supportmuscle.
attained
22/4/08
Massage the maximum
iii.
He will upper and
possible
be self
lower
physical
motivated in extremities
mobilityactivitieswhich help to
Continue plan
20/4/08.
improve the
Reassess goal
circulation.
and
interventions
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.
Alteration
in
Physical
self in
Selfconcept
mode
(He is
anxious
about
changes in
body
image)
Change in
Role
performa
nce mode.
(He was
the earning
member in
the family.
His role
shift is not
compensat
e)
Contextual
stimuli:
3.
Anxiety
Known case related to
DM for past hospital
10 years and admission
on treatment and
unknown
with insulin
for 8 years. Outcome of
the disease
and
financial
Residual
stimuli: no constrains.
special
knowledge in
health
matters
Long term
Objective:
Allow and
encourage the
The client will client and
remain free family to ask
from anxiety questions.
Bring up
common
Short term concerns.
objective:
Allow the
i.
demonstratin
g appropriate
range
effective
coping in the
treatment
ii.
Being
able to rest
and
iii. Asking
fewer
questions
Short term
goal:
Met:
demonstrated
appropriate
range
effective
coping with
treatment
client and
family to
verbalize
anxiety.
He is able to
rest quietly.
Stress that
frequent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
Long term
goal:
Unmet:
client not
completely
remained free
from anxiety
due to
financial
Repeat
information as constrainsContinue plan
necessary
because of the Reassess goal
and
reduced
attention span interventions
of the client
and family
Provide
comfortable
quiet
environment
for the client
and family
Contextual
stimuli:
------
4. deficient
knowledge
Known case regarding
DM for past the foot
10 years and care,
on treatment wound
care,
with insulin
for 8 years. diabetic
diet, and
need of
follow up
Residual
stimuli: no care.
special
knowledge in
health
matters
Long term
Objective:
Explain the
treatment
measures to
Patient will
the patient and
acquire
their benefits in
adequate
a simple
knowledge
regarding the understandable
language.
t foot care,
wound care, Explain
diabetic diet, about the home
and need of care. Include
follow up
the points like
care and
care of wounds,
practice in
nutrition,
their day to activity etc.
day life.
Clear the
Short term
objective:
doubts of the
patient as the
patient may
i.
Verbalization present with
some matters
and
demonstratio of importance.
n of foot
Repeat the
care.
information
ii.
Strictly whenever
necessary to
following
diabetic diet reinforce
learning.
plan
iii.
Demonstratio
n of wound
care.
Short term
goal:
Met:
Verbalization
and
demonstratio
n of foot
care.
Strictly
following
diabetic diet
plan
Unmet:
Demonstratio
n of wound
care.
Long term
goal:
Unmet: not
completely
acquired and
practiced the
required
knowledge.
Continue plan
Reassess goal
and
interventions
APPLICATION OF INTERPERSONAL
THEORY IN NURSING PRACTICE
Outline
Introduction
Introduction
Peplaus theory focuses on the interpersonal processes and therapeutic relationship
that develops between the nurse and client. The interpersonal focus of Peplaus
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 ones 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.
The four phases of nurse-patient relationships are:
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.
Overlapping phases in nurse- patient 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.
Peplaus theory application nursing process:
The nursing process for Mrs. JL based on Peplaus theory is as follows:
Mrs. JL
27 years
Diagnosis: Inter vertebral disc prolapse
Assessment
(Orientatio
n phase)
Mrs. JL is
on pelvic
traction and
she is
restricted
to bed.
The need
for bed rest
and
restriction
was
discussed.
Nursing
diagnosis
Impaired
physical
mobility
related to
the
presence
of pelvic
traction.
Planning
(Identification
phase)
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.
Implementation Evaluation
(Exploitation
(Resolution phase)
phase)
Carried out plans Mrs. JL was free to
mutually agreed express problems
upon.
regarding difficulty in
mobilizing.
Provided active
and passive
exercises to all
the extremities
Make the
patient to
perform the
breathing
exercises which Massaged the
will strengthen upper and lower
the respiratory extremities
muscle.
Provided article
within the reach
Massage the
of the patient
upper and
lower
extremities
which help to
improve the
circulation.
Provided positive
Provide articles reinforcement to
near to the
the patient
patient and
encourage
She expressed
satisfaction when able
to move without
difficulty.
doing activities
within limits.
Provide positive
reinforcement
for even a small
improvement to
increase the
frequency of
the desired
activity.
Assessmen
t
(Orientatio
n phase)
Mrs. JL
expresses
pain in the
low back
region.
Regarding
Nursing
diagnosis
Planning
(Identification
phase)
Implementation
(Exploitation
phase)
Evaluation
(Resolution phase)
Pain related to Goal setting was Carried out plans Mrs. JL was free to
the
done along with mutually agreed express problems of
degenerative patient
upon.
pain.
changes in the
lumbar region. Mrs. JL will have
reduction in pain
as evidenced by
her verbalisation
of reduction in
pain responses.
Provide nonpharmacological
Provided non
pain,
discussion
was made
to assess
the severity
and the
type and
duration of
pain. Also
the
measures
to reduce
pain were
discussed.
measures for
pain relief such
as diversional
activity which
diverts the
patients mind.
Provide pelvic
traction to the
patient
Assessment
(Orientatio
n phase)
Nursing
diagnosis
Planning
(Identification
phase)
Given pelvic
traction and
explained the
need for traction
Implementation
(Exploitation
phase)
Evaluation
(Resolution phase)
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.
Goal setting
Carried out plans Mrs. JL was free to
was done along mutually agreed express problems of
with patient
upon.
self care.
Client
will
achieve
and
maintain
self
care
activities
with assistance
of caregiver or
within
her
limits.
Provide a
bell
to
patient to
in
emergency
call
the
call
any
Frequently visited
the patient and
enquired for any
Frequently visitneeds
the patient and
enquire for any
needs.
Assisted the
client in doing her
self care activities
Assist
the
patient in doing
her self care
Removed the
activities.
weight as and
when needed.
Remove
the
weight of the
traction
as
needed by the
patient.
Assessment
(Orientatio
n 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
Nursing
diagnosis
Anxiety
related to
hospital
admission as
evidenced by
verbalisation
and client &
family
appearing
withdrawn
Planning
(Identification
phase)
Goal setting was
done along with
patient
Implementation Evaluation
(Exploitation
(Resolution phase)
phase)
Carried out plans Mrs. JL was free to
mutually agreed express problems of
upon.
self care.
asking fewer
questions
She verbalized that
Taught the family her anxiety has
reduced to some
regarding the
Teach the family disease process extent.
and client
in simple
regarding the
Kannada
disease process.
Explain in simple
understandable
language of the
client.
Allow and
encourage the
client and family
to ask questions.
She and her
Allow the client
husband
and family to
expressed their
verbalize anxiety.
anxiety
Stress that
frequent
assessment are
routine and do
not necessarily
imply a
deteriorating
condition.
the client
frequently
Assessment
(Orientatio
n 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 need
for follow
up
Nursing
diagnosis
Planning
Implementation Evaluation
(Identification
(Exploitation
(Resolution phase)
phase)
phase)
Goal setting was Carried out plans Mrs. JL was free to
done along with mutually agreed express problems of
patient
upon.
self care.
Deficient
knowledge
related to
the
treatment
measures to
be
Patient will
continued
acquire adequate
even after knowledge
the
regarding the
discharge. treatment and
She expressed
acquisition of
knowledge regarding
the disease and the
signs of aggravation
of illness
home care.
Explained
Explain the
treatment
treatment
measures and the
measures to the need for follow up
patient and their
benefits
Explained
regarding the
Explain to the
signs of
client the signs aggravation of
of aggravation of disease
illness
Client expressed without movement and supine position gave her relief
from pain.
2. Identification
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 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.
APPLICATION OF THEORY IN
NURSING PROCESS
Introduction
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.
Objectives
to select a theory for the application according to the need of the patient
Definition:
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..
Importance of nursing theories:
Characteristics of theories:
Theories are