Theory Application

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1.THEORY APPLICATION

INTRODUCTION

The history of professional nursing begins with Florence nightingale.

She envisioned nurses as a body of educated women, when women were neither

educated nor employed in the public services. Later in last century nursing

began with a strong emphasis on practice. Following that came the curriculum

era which addressed the questions about what the nursing students should study

in order to achieve the required standard of nursing. As more and more nurses

began to pursue higher degrees in nursing, there emerged the research era. Latergraduate education and masters education was given much importance.

The application of the theory to provide a nursing care is given much of

importance. Many a nursing schools and colleges have developed their

curriculum based on a theory and so only the students apply the theory in the

patient care. As a part of my advanced nursing practice ,I have selected one

patient for providing care based on the Orems Self Care Theory.

The main objectives of this process were:

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

to identify the needs of the patient to demonstrate an effective communication and interaction with the

patient. to select a theory for the application according to the need of the patient to apply the theory to solve the identified problems of the patient to evaluate the extent to which the process was fruitful.


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Demographic dataName Age Sex Education Occupation Marital status Religion War d Hospital No. Address

Diagnosis

Presenting history of

illness

Presenting signs andsymptoms

Past health history

Family history

Mr. Basavaraj B.K

60 years

Male8th standard

Coolie

Married

Hindu

Casuality

02111033

Nelavagilu

Kumarapatanam P.O

Rannebennur T.QHaveri(dist)

Type 2 D.M ,Meningo-encephalitis

Client brought to the hospital with complaint of

body pain ,fever, disorientation, and decreased food

intake on 16/1/2011. Patient has urine output isreduced and blood glucose level is 211mg/dl.

Catheter and ryles tube is inserted. 40% of oxygen

administration given and antibiotics started .Tocorrect blood sugar 40 units of Human Actrapid 40

ml of Normal Saline is infused at rate of 1ml/hr asper GRBS.On 18.1.2011. patient became restless,

non verbalizing and unconscious. So patient is

intubated and connected to ventilator on SIMV

mode due to desaturation.Patient is also having renal

failure now and RFT values are elevated.So they areplanning to do dialysis.

He had past history of DM and was on OHA for

past 20 years.

His family is a joint family .He is living with his

son.


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Socio-economic status

Personal history

Marital/ sexual history

Poor economic status. He is the earning member of

the family.

He was taking a mixed diet.. He had bad habbits of

chewing tobacco.But stopped 1 year back.

Married.

Physical Examination

Region Remarks

General

appearanc

e

Unconscious,moderately built ,now inadequate nutrition.

Skin Skin has the changes as in normal old age, with slight loss of

elasticity. Mild edema present over ankle region.

Eyes Pupil reaction is normal. Pallor of conjunctiva is noted. Nosigns of infection.

Hearing Ears are normal without any discharge. No nodules or ulcers

palpated over the pinna.

Neck &

Throat

Mild distension of neck veins present. Normal thyroid glands.

Tonsils are normal with no signs of inflammation.ET tube

present.

Mouth Oral hygiene is maintained. Slight coating of the tongue

present. Discolouration of the tooth present, no loss of tooth.

Dental caries present.Respiratio

n

Respiratory Rate: 20 breath per minute. Symmetrical chest

expansion. Crackles present.

Heart

Sounds

S1 and S2 heard normally. No murmurs or other abnormal

heart sounds heard. Peripheral pulses were feeble.

Vascular

System

No varicosities present. Peripheral pulses are feebly palpable.

Mild pallor present.

Abdomen Abdomen is distended , hepatomegaly present. Bowel sounds

are sluggish.

Musculoskeletal

He is unconscious .Some involuntary movement o extremitiesporesent.No fracture or joint abnormality present.


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System

Reflexes: All the deep tendon reflexes and superficial reflexes were

poor.

Genito-

urinarysystem

Bladder is catheterized. urine output is less. No urinary

infection.

Application of Orems theory of Self care deficit

The theory of self care deficit was proposed by Dorothea.E.Orem. She was born in Maryland in 1914. She completed her basic nursing

education from Washington in 1930s. She received her Bachelors and Masters

of sciences in nursing education in 1939 and 1945 consecutively. The self care

deficit theory proposed by her is a combination of three theories, i.e. theory of

self care, theory of self care deficit and the theory of nursing systems.

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 agencyis 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. The self care is carried out to fulfill the self-care requisites.

There are mainly 3 types of self care requisites such as universal,

developmentalandhealth deviation self carerequisites. Whenever there is an

inadequacy of any of these self care requisite, the person will be in need of self

care or will have a deficit in self care.

The deficit is identified by the nurse through the thorough

assessment of the patient. 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 ornot. Thus the theory could be successfully applied into the nursing practice.


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In case of Mr. Basavaraj with Meningoencephalites and on

ventilator is not able to do the ADL by himself. Thus, the nursing system is

wholly compensated. Theory of self-care deficit was applied to this patient to

provide a comprehensive need based care to the patient. The application and

evaluation of the theory is as follows.

BASIC

CONDITIONING

FACTORS:

Age Gender Health status

Development state Socio cultural issues

Health care system Family system

Patterns of living

Environment

ResourcesUNIVERSAL

SELFCAREREQUISITES:

60 yrs

maleMeningoencephalites .Now on ventilator due to

unconsciousness and desaturation.

Adult male

He had formal education till 8th std and was

working as a coolie worker.

Institutional health care

Married. Joint family with wife and son.

Living with family members, not sedentary

living.

Rural area.

He is the bread winner of the family.


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Air

Water

Food

Elimination Activity/rest

Social interaction

Prevention ofhazards

Promotion ofhumanfunctioning

DEVELOPEMENTAL

SELFCARE

REQUISITES:

Maintenance of

No spontaneous breathing. Patient is connected

to mechanical ventilator on SIMV mode.

Patient is on I.V. fluids - NS and DNS.

Ryles tube feeding.

The diet was mainly fluid diet rich in protein,

calories ,vitamins and minerals to protect from

bacterial infection and to promote easy

recovery.Sugar is restricted as he is diabetic.

His 24 hrs urine output 350ml .

His daily living activities were restricted since

patient is unconscious and on mechanical

ventilator. Chest physio and limb & ROM

exercises done.

No social interaction.

Side rails of the cot are raised to protect from

hazards. Patient is also restrained to prevent the

accidental self injuries and removal of tubings.

Reassured the client relatives that they shouldcarry out their role or function and meet ADL of

patient and support the patient to return to his

normal level of living.

Not able to feed self and performing the mouthcare ,toileting, bathing and other self care


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developmental

environment

Prevention/managementof the conditions

threatening the normal

development

HEALTH

DEVIATION SELF

CARE REQUISITES

Adherence to medical

regimen

Awareness of potentialproblem 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

activities.

Patient relatives seek medical facilities when

they feel he is disoriented, food intake &

activities are decreased and his temperature is

increased.

Patient relatives report the problems to the

physician when in the hospital and sometimes

neglects and try to manage the problem by self.

They cooperate with the medication. Not much

aware about the use and side effects of

medicines.

Not aware about the actual disease process.

Not aware about the side effects of the

medications and complications of disease

process.

Relatives have adapted to the illness and inability

of patient to carry out daily living activities .

Finding difficulty in adjusting with the patients

illness and hospitalization and role changes in

family.

MEDICAL PROBLEM AND PLAN


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Physicians perspective of the condition:

Diagnosed with Meningoencephalites, Pyogenic meningitis,

Type 2 Diabetes Mellitus.Now he is on ventillator due to unconsciousness &

desaturation.

He is getting the following medications:

Inj. Monocef 2g IV BD

Inj. Ampicillin 2gm IV BD

Tab. Doxy 100mg BD

Inj. Rezat 120mg IV ODInj. Pan 40mg IV OD

Inj. Dalacin 600mg IV TID

Neb. With Asthalin QID

Inj. Dopamine @ 5ml/hr IV Infusion

IVF.DNS/NS with Optineuron @ 75ml/hr

IVF. 40ml NS with 40units of Human Actrapid infusion @1ml/hr as per

GRBS .

Investigations:RBS211 mg/dl(60-150) (elevated)

BUN135 mg/dl(8- 35)(elevated)

S.Creatinine2.8 mg/dl(0.6-1.6)(elevated)

Sodium135mEq/l(135-145)Potassium5.7 mEq/l (3.5- 4.5)(elevated)

Medical Diagnosis: Meningoencephalites, Pyogenic meningitis, Type 2

Diabetes Mellitus.

Medical Treatment: Medication ,ventilator support, respiratory therapy andphysiotherapy.

AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF

SELF-CARE DEFICIT: IMPORTANT FOR PRIORITIZING THE

NURSING DIAGNOSIS.

Air

Water

Food

Elimination

Activity/ Rest

Solitude/ InteractionPrevention of hazards

Promotion of normal functionMaintain a developmental environment.


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Prevent or manage the developmental threats

Maintenance of health status

Awareness and management of the disease process

Adherence to the medical regimen

Awareness of potential problemModify self imageAdjust life style to accommodate health status changes and medical regimen.

Thus in the patient Mr. Basavaraj the areas that need assistance wereAir

WaterFood

Elimination

Activity/ Rest

Prevention of hazards

Promotion of normalcy

Maintenance of health status

Awareness and management of the disease process.

Adherence to the medical regimen

Awareness of potential problem.

Adjust life style to accommodate health status changes and medical regimen

Problems identified and prioritized nursing diagnosis:

1.Ineffective airway clearance related to inability to raise secretions as

evidenced by diminished breath sounds and cough reflex.

2.Fluid volume excess related to reduced renal function and decreased urine

output.3. Altered body temperature, Hyperthermia related to infectious process.

4. Imbalanced nutrition less than body requirement related to inability to take

food secondary to loss of consciousness.

5. Self-care deficit eating, bathing, grooming etc related to altered level of

consciousness secondary to brain infection

6. Impaired physical mobility related to loss of consciousness.

7. Anxiety (family members) related to abrupt change in health status of family

member, hospital environment, role changes and uncertain future.


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8.Deficient knowledge (family members) about the disease process, its

management and complications.

9. Risk for complications increased ICP related to increase in body temperature

and cerebral metabolic demands.

10.Risk for impaired skin integrity related to immobility and prolonged bed rest

secondary to unconsciousness

NURSING PROCESS ACCORDING TO OREMS THEORY OF SELF CARE

DEFICIT

NURSING DIAGNOSIS

(diagnostic prescription)

OUTCOMES

AND PLAN

(Prescriptive

operations)

IMPLEMENTATION

(Control operations)

EVALUATION.

(Regulatory

operations)

THERAPEUTIC SELFCARE DEMAND:

DEFICIENT AREA: Air

ADEQUACY OF SELF

CARE AGENCY:

Inadequate

1. Ineffective airwayclearance related to inability

raise secretions as

evidenced by diminished

breath sounds and cough

reflex.

The patientwill maintain

normal airwayclearance as

evidenced by

ease of

breathing and

ability to

bring out

secretions.

Wholly compensatory

and supportive

educative nursing

system

Assess for thepatency of

airway.

Auscultate breathsounds noting the

areas of

decreased

ventilation and

presence of

The patient is

maintaining

clear airway

as evidenced

by normal

respiratory

rate 20/mtand

SpO2 95% and

absence of


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DEFICIENT AREA: WaterADEQUACY OF SELF

CARE AGENCY:

Inadequate

2.Fluid volume

excess,hypervolemia relatedto reduced renal function

and decreased urine output .

Patient will

maintain

normal fluid

volume as

evidenced by

output in

proportion

with the input.

adventitious

breath sounds .

Place the patientin a slightly head

end up position.

Removesecretions by

suctioning to

clear airway.

Maintainhumidification of

the oxygen.

Provide chestphysiotherapy

and postural

drainage.

Providenebulisation with

duolin respules.

Assess for fluidexcess by

checking intake

output chart,BP

and for edema.

Check for jugularvein distension

and orbital

edema.

Maintain hourly

secretions.

Patients urine

output is less

when

compared to

intake.Output

is 350ml/day.


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THERAPEUTIC SELF

CARE DEMAND:DEFICIENT AREA:

Promotion of normal

functionADEQUACY OF SELF

CAREAGENCY:Inadequate

3.Altered body temperature,

Hyperthermia related to

infectious process.

Patient will

maintain

normal body

temperature as

evidenced by

absence of

infection.

intake output

chart.

Administerdiuretics as per

doctors order.

Routinely checkBUN and

S.creatinine

levels.

Assess the vitalsigns every

second hourly.

Provide wellventilated room.

Apply tepidsponging.

Increase fluids toreplace fluids lost

through increased

metabolism and

diaphoresis as per

intake output

chart.

Administerantipyretics as per

physicians order.

Administerantibiotics as per

Patients fever

has decreased

to 98.8F from

101.2 F


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DEFICIENT AREA: Food

ADEQUACY OF SELFCAREAGENCY:Inadequate

4. Imbalanced nutrition

less than body requirement

related to inability to take

food secondary to loss of

consciousness.

The patient

will maintain

normal

nutritional

status as

evidenced by

adequate

intake of food

and normal

intake and

output chart

order.

Maintain asepticprecaution while

giving suctioning

and during other

procedure.

Removesecretions by

suctioning ,chest

physiotherapy,

and postural

drainage to

prevent

infections.

Provide cathetercare.

Assess thepatients

nutritional status.

Monitor fluidsadministered

through I.V route

and Ryles tube

and calculate

daily caloric

intake to

determine

adequacy of

caloric intake.

Select nutritional

Patients

nutritional

status is

inadequate as

evidenced by

inability to

take food by

self as the

patient is on

ventilator.


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THERAPEUTIC SELF

CARE DEMAND:

DEFICIENT AREA:Activity

ADEQUACY OF SELF

CAREAGENCY:Inadequate

5. Self-care deficit eating,

bathing,toileting, grooming

etc. related to altered

level of consciousnesssecondary to brain infection.

The patient

will achieve

self care

activities

within normal

limit as

evidenced by

normal level

of

consciousness

and ability to

perform

ADLs.

supplements to

provide additional

calories, iron,

protein, and

fluids.

Maintain intakeand output chart.

Educate thepatient family

about prescribed

diet that will

maintain

nutrition.

Provide small andfrequent, easily

digestable fluid

diet.

Assess thepatients level of

consciousness

and ability to

perform the

activities of daily

living.

Meet patientsactivities of daily

living such

as(giving sponge

bath, mouth care,

hair care).

The patient is

unable to

perform self

care activities

and he is still

on ventilator.


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. Meet the patientsnutritional needs

by giving food

through ryles

tube.

Encouragefamily members

to assist in

meeting patients

self care

activities.

Change theposition every

second hourly

and give back

care and massage.

Evaluation of the Application of Self Care Deficit Theory

The theory of self care deficit when applied, could identify the self

care requisites of Mr.Basavaraj from various aspects. This was helpful to

provide care in a comprehensive manner. Patient was unconscious and family

members were very cooperative. The application of this theory revealed how

well the wholly compensatory and supportive and educative system could be

used for solving the problems of unconscious patients who are on ventilator.


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2.THEORY APPLICATION

INTRODUCTIONSYSTEM MODEL- BETTY NEUMAN

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 inter-relationships among concepts for the purposes of describing,

explaining, predicting, and /or prescribing.

The Neumans system model has two major components i.e. stressand reaction to stress. The client in the Neumans system model is viewed as an

open system in which repeated cycles of input, process, out put and feed back

constitute adynamic organizational pattern. The client may be an individual, a

group, a family,a community or an aggregate. In the development towards

growth and development open system continuously become more differentiatedand elaborate or complex. As they become more complex, the internal

conditions of regulation become more complex. Exchange with the environment

are reciprocal, both the client and the environment may be affected eitherpositively or negatively by the other.The system may adjust to the environment

to itself. The ideal is to achieve optimalstability. As an open system the client,the client system has propensity to seek or maintain a balance among the

various factors, both with in and out side the system, that seek to disrupt it.

Neuman seeks these forces as stressors and views them as capable of having

either positive or negative effects. Reaction to the stressors may be possible or

actual with identifiable responses and symptom.

MAJOR CONCEPTS


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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. Sociocultural - refers to relationships; and social/cultural expectations and

activities.4. Spiritual - refers to the influence of spiritual beliefs.

5. Developmental - refers to those processes related to development over the

lifespan.

II. CENTRAL COREThe basic structure, or central core, is made up of the basic survival

factors that are common to the species (Neuman, 1995, in George, 1996). These

factors include: system variables, genetic features, and the strengths and

weaknesses of the system parts. Examples of these may include: hair color,

body temperature regulation ability, functioning of body systems

homeostatically, cognitive ability, physical strength, and value systems. The

person's system is an open system and therefore is dynamic and constantlychanging and evolving. Stability, or homeostasis, occurs when the amount of

energy that is available exceeds that being used by the system. A homeostatic

body system is constantly in a dynamic process of input, output, feedback, and

compensation, which leads to a state of balance.

III. FLEXIBLE LINES OF DEFENSEThe flexible line of defense is the outer barrier or cushion to the normal

line of defense, the line of resistance, and the core structure. If the flexible lineof defense fails to provide adequate protection to the normal line of defense, the

lines of resistance become activated. The flexible line of defense acts as a

cushion and is described as accordion-like as it expands away from or contracts

closer to the normal line of defense. The flexible line of defense is dynamic and

can be changed/altered in a relatively short period of time.

IV. NORMAL LINE OF DEFENSEThe normal line of defense represents system stability over time. It is

considered to be the usual level of stability in the system. The normal line of


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defense can change over time in response to coping or responding to the

environment. An example is skin, which is stable and fairly constant, but can

thicken into a callus over time.

V. LINES OF RESISTANCEThe lines of resistance protect the basic structure and become activated

whenenvironmental stressors invade the normal line of defense. Example:

activation ofthe immune response after invasion of microorganisms. If the lines

of resistanceare effective, the system can reconstitute and if the lines of

resistance are not effective, the resulting energy loss can result in death.

VI. RECONSTITUTIONReconstitution is the increase in energy that occurs in relation to the

degree of reaction to the stressor. Reconstitution begins at any point following

initiation of treatment for invasion of stressors. Reconstitution may expand the

normal line of defense beyond its previous level, stabilize the system at a lower

level, or return it to the level that existed before the illness.

VII. STRESSORSThe 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 anygiven 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

.

VIII. PREVENTIONAs defined by Neuman's model, prevention is the primary nursing

intervention. Prevention focuses on keeping stressors and the stress responsefrom having a detrimental effect on the body.


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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 healthpromotion 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 ofbasic 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 ENVIRONMENT


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The 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 alsoidentified 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 energy is 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, familiesand 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 ofdegrees 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 wellness3. Nursing Outcomes - considered in relation to five variables, and


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achieved through primary, secondary and tertiary interventions.

NURSING PROCESS BASED ON SYSTEM MODEL

Assessment: Neumans first step of nursing process parallels the assessmentand nursing diagnosis of the six phase nursing process. Using system model inthe assessment phase of nursing process the nurse focuses on obtaining a

comprehensive client data base to determine the existing state of wellness and

actual or potential reaction to environmental stressors.

Nursing diagnosis- the synthesis of data with theory also provides the basis for

nursing diagnosis. The nursing diagnostic statement should reflect the entireclient condition.

Outcome identification and planning- it involves negotiation between the care

giver and the client or recipient of care. The overall goal of the care giver is to

guide the client to conserve energy and to use energy as a force to move beyond

the present.

Implementation nursing action are based on the synthesis of a

comprehensive data base about the client and the theory that are appropriate to

the clients and caregivers perception and possibilities for functional

competence in the environment. According to this step the evaluation confirms

that the anticipated or prescribed change has occurred. Immediate and long

range goals are structured in relation to the short term goals.

Evaluationevaluation is the anticipated or prescribed change has occurred. If

it is not met the goals are reformed.

ASSESSMENT

PATIENT PROFILE

1. Name - Mr.Kenchappa

2. Age - 75 years

3. Sex Male4.Hospital No. - 02066670

5. Marital statusmarried.

6.DOA:15/1/11

6.DiagnosisScrub Typhus, Thrombocytopaenia and ARF.

STRESSORS AS PERCEIVED BY CLIENT

(Information collected from the patient and his Daughter)

Major stress area, or areas of health concern:


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Patient was suffering from severe fever associated with chills and body

ache for the past 8 days. Now he is having fatigue and weakness of body, loss

of appetite, nausea and vomiting, decreased urine output.His bladder is

catheterised and is giving Ryles tube feed.

Patient is been diagnosed to have Scrub typhus, thrombocytopaeniaand ARF.

Psychologically disturbed about his disease condition- anticipating it

as a life threatening condition. Patient is in depressive mood and does not

interacting.

Patient is disturbed by the thoughts that he became a burden to his

children with so many serious illnesses which made them to stay with him

at hospital.

He had history of herniorrhaphy 5 yrs back. He has no history of any

disease like DM ,HTN,BA and TB.

Life style patterns:

Patients occupation is agriculture.He cares for wife and other family

members. Living with his son and his family. Participates in community group

meeting i.e. local politics.Has a supportive spouse and family .Taking mixeddiet. Has habits of smoking and occational drinking. Spends leisure time by

reading news paper, watching TV, spending time with family members and

relatives.

Past expereiences

He has no previous experience of hospitalization with similar disease. But

he was hospitalized after herniorraphy. Accordng to him the present disease

condition is much more severe than the previous condition. So he ispsychologically depressed.

Anticipation of the future:

Concerns about the healthy and speedy recovery. Anticipation of changes in the lifestyle and food habits. Anticipating about the demands of modified life style. Anticipating the needs of future follow up.The things going to help himself


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Talking to his friends and relatives while they come to visit him. Instillation of positive thoughts i.e. planning about the activities to be

resume after discharge, spending time with grand children, going to thetemple , return back to the social interactions etc.

Avoiding the negative thoughts i.e. diverts the attentions from the pain ordifficulties and try to eliminate the disturbing thoughts about the disease andhospitalization and trying to accept the reality etc.

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

He sets his major goal i.e. a healthy and speedy recovery. He sees the health care providers as a source of information.He tries to

consider them as a significant members who can help to overcome the stress

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

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

The things expected of others

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

Convey a warm and accepting behaviour towards him. Family members will help him to meet his own personal needs as much aspossible. Involve the patient also in taking decisions about his own care, treatment,

follow up etc.

STRESSORS AS PERCEIVED BY THE CARE GIVER.

Major stress areas:

Altered body temperature ,Fever. Fatigue, Nausea and vomiting ,Decreased appetite. Decreased urine ouput. Hospitalization .Present circumstances differing from the usual pattern of

living.

Anxiety regarding ryles tube feeding and catheterisation of bladder. Anticipatory anxiety concerns the recovery and prognosis of the disease

negative thoughts that he has become a burden to his children.

Anticipatory anxiety concerning the restrictions of diet and the life stylemodifications which are to be followed.


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Clients past experience with the similar situations

He has no previous experience of hospitalization with similar disease. Buthe was hospitalized after appendicectomy and herniorraphy

Client perceived that the present disease condition is much more severethan the previous condition. So patient is psychologically depressed.

Future anticipations

Client is capable of handling the situation- will need support andencouragement to do so.

He has the plans to go back home and to resume the activities which he wasdoing prior to the hospitalization. He also planned in his mind about the future follow up .The things the client can do to help himself

Patient is using his own coping strategies to adjust to the situations. He is trying to clarify his own doubts in an attempt to eliminate doubts and

to instill hope.

He sets his major goal i.e. a healthy and speedy recovery. Client's expectations of family, friends and caregivers. He sees the health

care providers as a source pf information. He tries to consider them as a

significant members who can help to over come the stress

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

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

Evaluation/ summary of impressionsThere is no apparent discrepancies identified between patients perception

and the care givers perceptions.

INTRAPERSONAL FACTORS

Physical examination :

Vital Signs

T- 102F, P100/mt , R30/mt.BP- 120/80 mm of Hg.


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General Appearance

Patient is conscious and oriented,moderately build , now the nutrition is

inadequate due to illness.

Head and face: Hairs are normally distributed Face is bilaterally symmetrical.

Eyes:

Eye lashes: equally distributed Eye lids: no styes or blepheritis Conjunctiva: pale Sclera: white in color Pupils: equally reacting to light No squint or strabismus present.

Ears :

Pinna: no abnormalities and is in straight line with the outer canthus of theeyes.

No wax collection or ear discharge Hearing acuity: normal

Nose: No nasal deviation No nasal discharges. No polyps or obstruction present. Ryles tube present.

Mouth:

Tongue: Normal Tooth : Dental carries present. Gum: No gum bleeding or gingivitis present Uvula: in midline

Throat and Neck:

Throat: No swallowing difficulty or tonsillitis Neck stiffness present. Neck: Trachea is in position. No thyroid gland or lymph node enlargement. Range of motion: Normal .

Chest:Respiratory system:


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Respiratory rate: 30 breaths per minute. Percussion: Normal sounds. Palpation: No palpable mass present . Auscultation: Breath sounds normal.

Cardiovascular system: Heart rate: 100 beat per minute Heart sounds: Normal, no murmurs present.

Gastrointestinal system:

Inspection : Normal Auscultation: Sluggish bowel sounds. Palpation : soft to touch , no organomegaly. Percussion :Normal. Appetite is decreased ,he has nausea and vomiting. Genitourinary system: Bladder is catheterised, urine output is less compared to intake. No haematuria present.

Musculoskeletal system

There are no congenital deformities. Range of motion: normal.

Neurological system:

Alert, conscious and oriented. No sluttering or other speech problems. Reflexes are normal.2.Personal system

Immunizations - It is been told that he has taken the immunizations at thespecific periods itself .

SleepHe told that sleep is reduced because of the pain and otherdifficulties. Sleep is reduced after the hospitalization because of the noisy

environment.

Diet and nutrition- Patient is taking mixed diet, but the food intake is lesswhen compared to previous food intake because of fever , decreased

appetite, nausea and vomiting . Usually he takes food three times a day.

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


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Other complaints - Patient has the complaints of body pain , fatigue andweakness of body, loss of appetite, nausea and vomiting, decreased urineoutput. Bladder is catheterised and ryle,s tube feeding is giving.

3.Psycho- socio cultural system.

Anxious about his condition Depressive mood Patients occupation is agriculture and he is Hindu by religion. Studied up to 9th standard. Married and has 4 children(2sons and 2 daughters) Congenial home environment and good relationship with wife and children Is active in the social activities at his native place and also actively involves

in the religious activities too. Good and congenial relationship with the neighbors Has some good and close friend at his place and he actively interact with

them. They also very supportive to him.

Good social support system is present from the family as well as from theNeighbourhood.

4. Developmental factorsPatient has his own agricultural fields and now also he is working

there.He told that he could manage the house hold activities very well. He wasvery active and once he go back also he will resume the activities.

5. Spiritual belief systemPatient is Hindu by religion. He believes in god and used to go to

temple and also an active member in the religious activities. He has a good

social support system present which helps him to keep his mind active.

INTERPERSONAL FACTORS

Has supportive family and friends. God social interaction with others. Good social support system is present. Active in the agricultural works and household activities at home . Active in the religious activities. Good interpersonal relationship with wife and the children. Good social adjustment present.EXTRAPERSONAL FACTORS

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


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his own place.

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

Financially they are stable and are able to meet the treatment expenses.Investigation Values:Haemoglobin(13-19gm/dl)11.7gm/dl (decreased)

WBC (4000-11000 cells/mm3) - 20,000 cells/mm

3(increased)

Platelet (1,500004,00000 cells/mm3) - 99,000cells/mm3 (decreased)

ESR (0-10mm/hr) - 86mm3 (increased)

RBS (60-150 mg/dl) - 128mg/dl

Urea (8-35mg/dl) - 48 mg/dl (increased)

Creatinine (0.6-1.6mg/dl)1.7 mg/dl

Sodium (130-143 mEq/L)141 mEq/LPotassium (3.5-5 mEq/L)4.1 mEq/LPeripheral smear report Normocytic normochromic anaemia with

thrombocyotopaenia.

Medications:

Inj Monocef 2 gm IV Q12HInj.Pan 40 mg IV BD

T .Dolo 650 mg TID

IVF DNS @ 60ml/hr with 1 amp. MVI

NURSING DIAGNOSIS AND CARE PLAN

1. Altered body temperature, Hyperthermia related to infectious process.

2. Fluid volume excess, hypervolemia related to reduced renal function and

decreased urine output .

3. Imbalanced nutrition less than body requirement related loss of appetite,

nausea and vomiting.

4. Activity intolerance related to fatigue and weakness of body.5. Anxiety related to abrupt change in health status and hospitalization.

6. eficient knowledge about the disease process, its management and

complications.

7. Risk for complications increased ICP related to increase in body temperature

and cerebral metabolic demands.

8. Risk for impaired skin integrity related to decreased level of activity and

strict bed rest.


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CONCLUSION

The Neumans system model when applied in nursing practice helped in

identifying the interpersonal, intrapersonal and extra personal stressors ofMr.Kenchappa 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.).Philadelphia: Mosby publications ;2002.p.

3. George JB. Nursing Theories: The Base for Professional Nursing Practice .

(5th ed). NewJersey : Prentice Hall;2002.4.Jacqueline F. Analysis and evaluation of conceptual models of nursing.

(3rd ed). Philadelphia:FA Davis Company:1995.


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CARE PLAN

ASSESSMENT DIAGNOSIS GOAL PLAN OFACTION

IMPLEMENTATION EVALUATION

Subjective data:

Patient says thatI am feeling

cold.Objective data:

T- 102F P100/mt R30/mt Body is hot

to touch .

Patientlookedfatigue.

Diagnosis ismeningo -encephalitis.

1.Altered

bodytemperature,

Hyperthermiarelatedto infectious

process.

Patient

maintainsnormal

bodytemperatureasevidenced

byreduction

intemperature

to normallevel .

SECONDARY

PREVENTION: Monitor vital signs. Give tepid sponge. Provide a well

ventillated room.

Administerantipyretics.

Administer antibioticsas advised.

Administer fluidsthrough ryles tube as

per doctors order.Maintains aseptic

technique during IVinjections.

Monitored vital signs2

nd

hourly. Gave tepid sponge. Provided a well

ventillated room.

Administeredantipyretics(T.Dolo650 TID).

Administer antibioticsas advised(inj. Pipzo4.5 gm IV )

Administer fluidsthrough ryles tube as

per doctors order.

Maintained aseptictechnique during IVinjections.

Temperature

became normal to99F.


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Subjectivedata:Patientsays that now I

am passingonly smallamount ofurine.

Objective data:

I/O =2000/780

RFT iselevated

Appetite isdecreased.

Fatiguepresent.

2)Fluidvolumeexcess related

to failure ofkidneys to

produceurine.

Patientwillachieve

andmaintain

balance influid

volume

state asevidenced

by normalI/O andRFTvalues.

SECONDARYPREVENTION:

Assess generalcondition of the patient

Maintain I/O chart Check weight daily. Restrict intake of

sodium and potassium Teach patient

regarding importanceof maintaining

prescribed fluid

restriction.

Watch for signs offluid overload;hypertension,

pulmonary edema

Administer diuretics.TERTIARY

PREVENTION

Maintain I/O chart. Check weight daily. Restrict intake of

sodium and potassium.

Teach patient

Assessed generalcondition of the

patient.

Maintained I/O chart Restricted intake of

sodium andpotassium.

Taught patientregarding importanceof maintaining

prescribed fluidrestriction.

Watched for signs offluid overload;hypertension,

pulmonary edema.

Urine output

increased to860ml with intakeof 1800ml.RFTvalues are not

normal.


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Subjective data:Patient says thathe feels fatigue

as not eatinganything.Objective data:

Appetite isdecreased.

Nausea andvomiting

present.

Getting onlyIV fluids andryles tube

3.Imbalancednutrition lessthan body

requirementrelated tonausea,

vomiting,decreased

fatigue andfever.

Patientmaintainsadequate

nutrition asevidenced

by absence

of nauseaand

adequatefood intake.

regarding importanceof maintaining

prescribed fluid

restriction.

Watch for signs offluid overload;hypertension.

Prevent and treatinfections promptly.

Check RFT valuesintermittently.


Check the nutritionalstatus .

Give ryles tube feed asper doctors order.

Provide IV fluids as perorder.

Avoid situations thatstimuiate vomiting.

Provide mouth care. Maintain intake-output

chart.

Checked thenutritional status .Itsinadequate.

Gave ryles tube feed,150ml Q2H.

Provided IV fluids asper order.

Avoided situationsthat stimulatevomiting.

Provided mouth care. Maintained intake-

output chart .

Nausea andvomiting isdecreased.

Nutrition isinadequate as

patient is still

continuing ryle,stube feed.


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feed.

He has fever. He looked

fatigue .

Subjective data:Patient asks that

whether my

condition isimproving andwhen I can starttaking food.Objective data:

Patient hasfacialexpression ofanxiety.

Patient isrepeatedly

askingquestions

regarding hiscondition.

He is lessattentive tospeech.

4.Anxiety

related to

abrupt changein health

status andhospitalization.

Patient

remains

free fromanxiety as

evidencedbyverbalisation and facialexpression.


Explain treatmentmeasures to the patientand their benefits in asimple understandablelanguage.

Clarify the doubts ofthe patient .

Repeat the informationwhenever necessary toremove fear.

Convey a calm andempathic environment.

Provide clearinformation of daily

improvement incondition.

Explained thetreatment measures to

the patient and their

benefits in a simpleunderstandablelanguage.

Clarified the doubtsof the patient .

Repeated theinformation whenever

necessary to removefear.

Conveyed a calm andempathicenvironment.

Provided clearinformation of dailyimprovement in

condition .

Allowed familymembers to visit the

patient and to give

Verbalisedreduction in

anxiety.


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Objective data:

Strict bedrest.

Havingfever.

Inadequatenutririon.

Fatiguepresent.

5.Risk forimpaired skinintegrityrelated to

decreased

level ofactivity and

strict bed rest.

Patient willmaintainintact skin

asevidenced

by absenceof bedsoresor skin

breakdown

PRIMARYPREVENTION

Assess generalcondition of the

patient. Inspect skin for

evidence of skinbreakdown; assess skinturgor.

Turn patient everysecond hour.

Provide back care andback massage.

Make wrinkle-free bed Monitor I/O chart. Give water bed. Provide adequate

nitrition.

support.

Assessed generalcondition of the

patient

Inspected skin forevidence of skin

breakdown; assessedskin turgor

Turned patient everysecond hour

Provided back careand back massage.

Provided wrinkle-freebed.

Monitored I/O chart. Provided ryles tube

feed 150ml Q2H.

Skin is intact.Patient did notdevelop skin

breakdown.


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BETTY NEUMANS MODEL:


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