Application of theory to nursing practice


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Application of theory to nursing practice

  1. 1. Application of theory toNursing PracticePresented byARUN.M
  2. 2. • A casual visitor to a hospital or other health caresetting might think that little has changed for nursesover the past decade. The majority of nurses stillwear a traditional and recognizable uniform, and areto be found in areas where care is provided or adviceoffered to patients, their relatives and their friends.However, behind this seemingly unchanged exterior,much has altered. In particular, nurses are noweducated through a different system of training. Theyare educated to a higher academic level, and thework they do and the way in which they do it have, inmany areas of health care, changed considerably.Aggleton P & Chalmers H, 2000
  3. 3. IntroductionNursing Science is an identifiable discretebody of knowledge comprising paradigms,frameworks and theories. The integrationof nursing theories into practicedemonstrates an evolutionary pathway forintroducing a paradigm shift in theessence of the science of nursing .
  4. 4. • Theories have been developed in nursingto explain phenomena important to clinicalpractice. For eg,we have a theory ofhealth promotion behaviour (Pender &Pender &Pender,1996Pender,1996) and a theory of motherinfant attachment(Walker,1992Walker,1992). Althoughwe use these theories to guide ourpractice, in many cases we have nottested them to determine whether or notthe nursing actions proposed actuallyhave the effects claimed.
  5. 5. • The conceptual models and the nursingThe conceptual models and the nursingtheories that provide the basis for clinicaltheories that provide the basis for clinicalpractice arepractice are• Johnson’s Behavioral System Model,Johnson’s Behavioral System Model,• King’s General Systems framework,King’s General Systems framework,• Levine’s Conservation Model,Levine’s Conservation Model,• Neuman’s Systems Model,Neuman’s Systems Model,• Orem’s Self-Care Framework,Orem’s Self-Care Framework,• Rogers’ Science of Unitary Human Beings,Rogers’ Science of Unitary Human Beings,• Roy’s Adaptation Model,Roy’s Adaptation Model,
  6. 6. • Leininger’s Theory of Culture Care DiversityLeininger’s Theory of Culture Care Diversityand Universality,and Universality,• Newman’s Theory of Health as ExpandingNewman’s Theory of Health as ExpandingConsciousness,Consciousness,• Parse’s Theory of Human Becoming,Parse’s Theory of Human Becoming,• Orlando’s Theory of the Deliberative NursingOrlando’s Theory of the Deliberative NursingProcess,Process,• Wiedenbach’s Clinical Nursing: A HelpingWiedenbach’s Clinical Nursing: A HelpingArt, Henderson’s Nature of Nursing,Art, Henderson’s Nature of Nursing,• Travelbee’s Interpersonal Aspects ofTravelbee’s Interpersonal Aspects ofNursing,Nursing,• Peplau’s Theory of Interpersonal Relations,Peplau’s Theory of Interpersonal Relations,• Watson’s Theory of Human Caring, and soWatson’s Theory of Human Caring, and soforth).forth).
  7. 7. I = integration and synthesis of nursing knowledge through cognitive ,psychomotor and affective domain
  8. 8. Nursing in its journey to attainprofessional status incorporatesseveral concurrent changes in thediscipline by• combining research based practice• upgraded educational requirements• theory based models .
  9. 9. Why we need to apply nursingtheories ?Using theory helps to guide nursingpractice. It helps to organise data understand and analyse patient data make appropriate decisions related tonursing interventions.
  10. 10. Application of Orem’s theory tonursing practice• Orem presents her self –care deficit theoryof nursing which is composed of threeinterrelated theories• Theory of self care• Theory of Self care deficit• Theory of Nursing Systems
  11. 11. Orem’s ModelSelf- CareSelf- CareSelf –careSelf –careagencyagencyTherapeuticTherapeuticSelf careSelf caredemanddemandNursingNursingAgencyAgencyRR RRRR RRRR<DeficitDeficitconditioningfactorsconditioningfactors
  12. 12. Orem’s professional- technologicaloperations of nursing practice• Step 1: Nursing Diagnosis andprescription that is, determining whynursing is needed• Step 2: Designing the nursing system andplanning for delivery of care• Step 3: The production and managementof nursing systems, also labelled planningand controlling
  13. 13. Assessment PhaseThe nurse collects data in six areas:1. The person’s health status2. The physician’s and nurses perspective of theperson’s health3. The person’s perspective of his health status4. The health goals within the context of life history,lifestyle, and health status5. The person’s requirements for self care6. The person’s capacity to perform self care
  14. 14. Application using case studyBasic ConditioningBasic ConditioningFactorsFactors48 yrs female,5’2”82 kg, ItalianWidowed for 6months after 25 yrsof happy marriageCatholicUniversity facultyUniversal SelfcareSmokes 1.5packs/dayFrequently eatsfast food; high fatdiet; drinks 2 litresof waterLargest meal ofthe day is lateeveningNo difficulties withelimination,Noregular exercise,DevelopmentalDevelopmentalSelf careSelf careLoss of husbandLoss of socialactivityFinds work asuniversity facultyfulfillingWorks 12 hours adayWell groomed
  15. 15. Application using case studyHealth DeviationsHealth DeviationsFamily History:F-heart attack, age50M-died of stroke, age53 , cholesterol 260mg; other lab valuesWNL.Lacks knowledge ofrisk factors andcardio vascularfunctioning, B/P142/88, P 92, R 26Medical ProblemMedical ProblemAnd PlanAnd PlanDiagnoses ofobesity withpotential forcardiac diseaseand low motivationfor weight lossPrescription to:Monitorcholesterol levelsDecreasecholesterol and fatintakeSelf care deficitsSelf care deficitsDifference betweenhealthy life styleand Ms M’sKnowledge baseand life style whichincreases her riskof heart attack orstroke
  16. 16. Application using case studyHealth DeviationsPotential for cardiacdisease related toobesity, smoking,elevated cholesterol,lack of exercise , andfamily historyMedical ProblemAnd PlanIncrease exerciseDecrease or stopsmokingRe-evaluate and ifneeded prescribemedication tolower cholesterolSelf care deficits
  17. 17. Application using case studyNursing DiagnosisPotential for impairedcardio vascularfunctioning related tolack of knowledgeabout relationshipbetween current lifestyle and risk of heartattack or strokeOutcome & PlanOutcome:↓ cholesterolHealthier life stylewith regularexercise,↓smoking,& balancednutritionNursing Goals &Objectives:Goal: To decreaserisk for cardiacimpairementImplementationJointly developcontract related to:1. CholesterolreductionMs M will keep a 3-day food diaryMs M will learn aboutcholesterol & itseffects on cardiovascular functioningMs M will learn aboutlow fat foods
  18. 18. Application using case studyNursing DiagnosisPotential forimpaired cardiovascularfunctioningrelated to lack ofknowledge aboutrelationshipbetween currentlife style and riskof heart attack orstrokeOutcome & PlanObjectives: Ms Mwill state that highcholesterol levelsincrease her risk forcardiac impairementMs M will recognisethe relationshipbetween smokingand cardio vascularriskImplementationMs. M will obtaincholesterol and its effecton cardiovascularfunctioningJointly analyse fooddiary and decide how todecrease cholesterol /fat intake to reduce M’sWeightJointly determine fooditems that are rich incholesterol and fat andhow receipes to beadapted
  19. 19. Application using case studyNursingDiagnosisPotential forimpaired cardiovascularfunctioningrelated to lackof knowledgeaboutrelationshipbetweencurrent lifestyle and riskof heart attackor strokeOutcome & PlanDesign of NursingSystem:SupportiveEducativeMethods OfHelping:Guidance,support, teaching andprovision of adevelopmentalenvironmentImplementationMs. M’s accomplishments willbe reinforcedMs M’s will seek advice fromher physician re: medicationto reduce cholesterol2. Reduction of smokingMs M will identify when shesmokes and what initiates thedesire for a cigarreteMs M will plan ways toreplace smoking with otheractivities( exercising,chewinggum
  20. 20. Application using case studyNursingDiagnosisPotential forimpairedcardiovascularfunctioningrelated to lackof knowledgeaboutrelationshipbetweencurrent lifestyle and riskof heart attackor strokeOutcome & PlanDesign ofNursing System:SupportiveEducativeMethods OfHelping:Guidancesupport,teaching andprovision of adevelopmentalenvironmentEvaluationDoes Ms M understand that withher present life style, her risk ofheart attack or stroke is high?Did Ms M. Select lowcholesterol , low fat foods?Did Ms M’s Self care deficitdecreaseIs M’s Cholesterol lower?Did Ms M Lose weight?Has Ms M ↓ number ofcigarretes smoked dailyWas the supportive educativesystem effective
  21. 21. Application of Imogene King’s TheoryPerceptionPerceptionJudgementJudgementAction Reaction Interaction TransactionAction Reaction Interaction TransactionJudgementJudgementPerceptionPerception
  22. 22. The basic assumption of the theory of GoalThe basic assumption of the theory of GoalAttainment-Attainment-• nurses and clients communicate informationnurses and clients communicate information• set goals mutuallyset goals mutually• act to attain those goalsact to attain those goals
  23. 23. AssessmentAssessment NursingNursingDiagnosisDiagnosisMutual goalMutual goalsettingsettingInterventionsInterventions EvaluationsEvaluationsAssessmentoccurs during theinteraction of thenurse and clients.The conceptsidentified are the• perception,communicationand interaction ofnurse and client• Growth & Devp• Knowledge ofself & role• Amount of stress• FactorsinfluencingClients perceptionStatementStatementthatthatrecognizesrecognizesthethedistresses,distresses,difficulties ordifficulties orworriesworriesidentified byidentified bythe client andthe client andnursenurseDecisionDecisionmaking aboutmaking aboutgoals andgoals andagreeing toagreeing tomeans tomeans toattain goalsattain goalsActivities thatActivities thatseek to meetseek to meetgoals. Thegoals. Theconceptconceptinvolved is theinvolved is themaking ofmaking oftransactionstransactionsGoals areGoals areattained orattained ornot.not.EvaluationEvaluationnot onlynot onlyspeaks ofspeaks ofgoalgoalattainmentattainmentbut alsobut alsoeffectivenesseffectivenessof nursingof nursingcarecare
  24. 24. AssessmentAssessmentNurses Perception:Mrs X is well groomed pregnant female who appears to becomfortable in the examination room and makes a eyecontact with the nurse. As they interact nurse finds that sheis 25 years old, married , about six months pregnant, gained4 kgs of weight so far during the pregnancy( G&D)X’s perception:Views herself as healthy( self), recently moved to a new areaWorks as a teacher plans to continue work after baby isborn. She keeps in contact with her family regularly. Sheasks question about labour process and how she mightidentify good paediatrician. She reports her nausea issubsided and feels that her pregnancy is progressingnormally without any complicationsThe nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
  25. 25. Nursing DiagnosisNursing DiagnosisKnowledge deficit about health care resources,child birth related to recent move to a new localityMutual goal settingTo be a healthy mother and to have a successfulpregnancy and delivery of a healthy babyThe nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
  26. 26. Interventions in terms of transactionsEstablishing and keeping a schedule of regularprenatal visitsProviding information about community resources andhealth care facilitiesConducting regular child birth educationEvaluationEvaluationVerbalization of understanding the availability ofresourcesSuccessful experience with pregnancy and birth of ahealthy new born baby . Successful initial experienceof breast feeding
  27. 27. Application of Roy’s Adaptation Theory toApplication of Roy’s Adaptation Theory toNursing PracticeNursing PracticeCase study:Mr Raj is received from surgery after a majorabdominal operation. Before surgery his baselinevital signs were:heart rate 80 beats per minute;BP120/80mm of Hg and resp rate 16 per minute. After45 minutes in post op recovery his vital signs are:HR 150 beats per minute; BP 90/60mm of Hg; Resprate 32 per minute. { Increased regulator output issignaled by sympahathetic nervous systemstimulation of the heart in response to decreasedblood pressure} The nurse decides that Mr Raj isshowing an ineffective response
  28. 28. Assessment of stimuli• Focal Stimuli: Decrease in arterial bloodpressure (exact cause is unknown)• Contextual Stimuli: Age 45 yrs, No food ordrink for 12 hours, IV infusion of 5% dextrosewith lactated ringer’s solution at 100 cc perhour. 200cc of IV fluids infused duringsurgery,20cc of urine excreted during thefirst 45 minutes in recovery,1.5 hours ofgeneral anaesthesia, estimated blood loss of500ml during surgery no operative sitebleeding• Residual Stimuli: include history of renalinfections
  29. 29. • Nursing Diagnosis:Fluid Volume deficit related to blood loss,decreased intake• Goal:To maintain adequate circulatory volume asevidenced by BP within normal range±20mmof Hg within 15 minutes, Urine output>30ml/hour,mental alertness, rapid nailblanching, pulse and respiration within normallimits
  30. 30. Nursing InterventionsNursing InterventionsI.V fluids 300cc per hour.Foot end elevationOxygen 40% by maskVerbal and tactile stimulationAdministration of Vasopressor medicationContinous BP and Vital signs monitoringEvaluationEvaluationA constant evaluation of the effectiveness ofnursing care is made and patients responseis evaluated
  31. 31. • Application of Betty Neuman’s Model• Case Study:Janice is a 34-year-old married woman whohas three elementary school-aged children.She moved to the Lower Mainland, fromthe Interior, six months ago because herhusband was transferred by his employer.Janice is currently on medical leave fromher job as a teachers assistant. She wasreferred to an outpatient psychiatric grouptherapy program in order to gainassistance in dealing with depression andanxiety.
  32. 32. • Janice states she was feeling "reasonablywell" until February of last year when herhusband informed her of the likelihood ofhis being transferred. She says she haddeveloped many friends in the Interior inthe five years they had lived there, andshe has made few friends since moving tothe Lower Mainland. Janices extendedfamily lives in Ontario, as does herhusbands family.
  33. 33. • Janice says they moved to the Lower Mainland last August, twoweeks before school started. The children, aged six, eight andten years, were upset with the move because they were leavingtheir friends behind. Janice feels guilty about this.Another stressor for her is her new job, which she started lastSeptember. She was assigned to work with a child diagnosedwith attention deficit hyperactivity disorder (ADHD). Janice didnot agree with the management style of the teacher whendealing with this child, and she found it difficult to be assertivein dealing with this teacher. Janice says she startedexperiencing anxiety attacks and insomnia in early December.
  34. 34. • The idea of Christmas approaching, which she had always enjoyed,The idea of Christmas approaching, which she had always enjoyed,now seemed overwhelming, "I wasnt doing well and I had no one tonow seemed overwhelming, "I wasnt doing well and I had no one totalk to". The time away from work at Christmas break was helpful, andtalk to". The time away from work at Christmas break was helpful, andshe went back to work in January of this year. By the second week ofshe went back to work in January of this year. By the second week ofher work return, she wasnt coping well.her work return, she wasnt coping well.• Janice saw her physician who suggested she take a medical leave. SheJanice saw her physician who suggested she take a medical leave. Shealso ordered her Prozac 20 mg OD, which she says she takes at HS,also ordered her Prozac 20 mg OD, which she says she takes at HS,and Xanax 0.5mg PRN up to QID. Additionally, she was referred forand Xanax 0.5mg PRN up to QID. Additionally, she was referred foroutpatient group therapy. After six weeks on medication, her mood hasoutpatient group therapy. After six weeks on medication, her mood hasimproved. Xanax, which she uses BID, "takes the edge off" her anxiety.improved. Xanax, which she uses BID, "takes the edge off" her anxiety.Insomnia remains a problem.Insomnia remains a problem.
  35. 35. • Janice says that she grew up an only child with an"alcoholic" father and an "anxious" mother. She says shemarried at age twenty years because she couldnt standbeing at home, and she didnt want to live alone.Despite this, she says her marriage is good which shequalifies with, "he doesnt run around or anything. Heworks hard to provide for us, not like his dad who ran offwith another woman".Janices goals for group therapy are to learn ways tohandle her anxiety without medication, and to learn waysto minimize her depression.
  36. 36. In applying Neumans model to Janicessituation, the initial assessment is carried out toassess prediposing factors and stressors.• Intrapersonal stressor : depression , insomnia,guilt feeling• Interpersonal stressor: social withdrawal and herlack of her usual supports. Her disturbed sleepleaves her feeling irritable in dealing with herchildren, Conflict with the teacher.• Extrapersonal stressor : Shift to a new place andlack of social support.
  37. 37. • In Neumans model, the nursing diagnosisdescribes the whole client situation (Neuman,1995). The nursing diagnosis could be describedas multiple stressors in too short a time framepenetrated Janices normal line of defense,causing an energy drain and a variance fromwellness.• Subsequently, system integrity was notmaintained and Janice developed symptoms ofanxiety, depression and insomnia.• Diagnosis statement : Ineffective coping• : Anxiety• :Sleep pattern disturbance
  38. 38. GoalsIn Neumans model, goals are set in collaborationwith the client.• Janice stated her goals were to learn ways tohandle her anxiety without medication and tolearn ways to minimize her chances of becomingdepressed again.{ These are reasonable goals in an outpatientgroup therapy program. These goals arerelevant because they were determined by theclient and were deemed by the nurse to bemanageable goals in this practice setting.}
  39. 39. Neumans interventions are carried out at three levels: primary,secondary and tertiary prevention.In Janices situation,In Janices situation, Secondary prevention:Secondary prevention:• assess her sleep pattern.(Janice reveals she takes Prozac at HS.)assess her sleep pattern.(Janice reveals she takes Prozac at HS.)• Advising her to take Prozac in the morning,( as Prozac frequentlyAdvising her to take Prozac in the morning,( as Prozac frequentlycauses insomnia,)causes insomnia,)• Encouraging Janice to talk about ways to handle her anxietyEncouraging Janice to talk about ways to handle her anxietyIITertiary prevention :Tertiary prevention :• exploring anxiety triggers.exploring anxiety triggers.• Her depression would also be explored and she could expect to gainHer depression would also be explored and she could expect to gaininsight about waysinsight about ways• to minimize the occurrence of future depressive minimize the occurrence of future depressive episodes.Tertiary prevention focus is to return the person to WellnessTertiary prevention focus is to return the person to Wellness
  40. 40. The final stage of Neumans model is nursingoutcomes, or reassessment.• Perceived progress towards her goals and shewould receive feedback from the nurse.• Perhaps she still has insomnia after Prozac ischanged to morning administration. Thisinformation leads the nurse back to assessment.• Changes in intrapersonal, interpersonal andextrapersonal factors would be noted becausechange determines the success of the nursinginterventions.
  41. 41. Fig-1: Conceptual Framework on Postpartum Depressive symptoms, Family Support and Functional Status based onMercer’s Maternal role attainment Theory* Variables under study+ Positive influence- Negative influenceNegative lifeeventsStressful eventin pregnancy*PregnancyriskPregnancyrelatedproblems*ParityResidual riskfactorsAge*Socioeconomicstatus*Substanceabuse*Premenstrualsyndrome*Previous orfamily historyof depression*Child careriskChild carestressType ofdelivery*Feedingpattern*Frequency offeed*Sleep pattern*Satisfactionwith gender ofthe child*FamilysupportInformationalsupport*Emotionalsupport*Instrumentalsupport*Esteemsupport*SelfesteemHealthstatusSenseofmasteryAnxietyDepression*Improvedfunctional status*___ ___+++
  42. 42. ConclusionWe have seen that these models continueto use the nursing process as the core fordecision making in determining if nursingcare to clients is meeting the expectedoutcomes as established by the clinicalpathways. Applying these theorist views isa challenge and it provides opportunity formeaningful nursing practice