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Application of theory to
Nursing Practice
Presented by
ARUN.M
• A casual visitor to a hospital or other health care
setting might think that little has changed for nurses
over the past decade. The majority of nurses still
wear a traditional and recognizable uniform, and are
to be found in areas where care is provided or advice
offered to patients, their relatives and their friends.
However, behind this seemingly unchanged exterior,
much has altered. In particular, nurses are now
educated through a different system of training. They
are educated to a higher academic level, and the
work they do and the way in which they do it have, in
many areas of health care, changed considerably.
Aggleton P & Chalmers H, 2000
Introduction
Nursing Science is an identifiable discrete
body of knowledge comprising paradigms,
frameworks and theories. The integration
of nursing theories into practice
demonstrates an evolutionary pathway for
introducing a paradigm shift in the
essence of the science of nursing .
• Theories have been developed in nursing
to explain phenomena important to clinical
practice. For eg,we have a theory of
health promotion behaviour (Pender &Pender &
Pender,1996Pender,1996) and a theory of mother
infant attachment(Walker,1992Walker,1992). Although
we use these theories to guide our
practice, in many cases we have not
tested them to determine whether or not
the nursing actions proposed actually
have the effects claimed.
• The conceptual models and the nursingThe conceptual models and the nursing
theories that provide the basis for clinicaltheories that provide the basis for clinical
practice 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,
• Leininger’s Theory of Culture Care DiversityLeininger’s Theory of Culture Care Diversity
and Universality,and Universality,
• Newman’s Theory of Health as ExpandingNewman’s Theory of Health as Expanding
Consciousness,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 Nursing
Process,Process,
• Wiedenbach’s Clinical Nursing: A HelpingWiedenbach’s Clinical Nursing: A Helping
Art, Henderson’s Nature of Nursing,Art, Henderson’s Nature of Nursing,
• Travelbee’s Interpersonal Aspects ofTravelbee’s Interpersonal Aspects of
Nursing,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 so
forth).forth).
I = integration and synthesis of nursing knowledge through cognitive ,
psychomotor and affective domain
Application of theory to nursing practice
Nursing in its journey to attain
professional status incorporates
several concurrent changes in the
discipline by
• combining research based practice
• upgraded educational requirements
• theory based models .
Why we need to apply nursing
theories ?
Using theory helps to guide nursing
practice. It
 helps to organise data
 understand and analyse patient data
 make appropriate decisions related to
nursing interventions.
Application of Orem’s theory to
nursing practice
• Orem presents her self –care deficit theory
of nursing which is composed of three
interrelated theories
• Theory of self care
• Theory of Self care deficit
• Theory of Nursing Systems
Orem’s Model
Self- CareSelf- Care
Self –careSelf –care
agencyagency
TherapeuticTherapeutic
Self careSelf care
demanddemand
NursingNursing
AgencyAgency
RR RR
RR RR
RR
<
DeficitDeficit
conditioningfactors
conditioningfactors
Orem’s professional- technological
operations of nursing practice
• Step 1: Nursing Diagnosis and
prescription that is, determining why
nursing is needed
• Step 2: Designing the nursing system and
planning for delivery of care
• Step 3: The production and management
of nursing systems, also labelled planning
and controlling
Assessment Phase
The nurse collects data in six areas:
1. The person’s health status
2. The physician’s and nurses perspective of the
person’s health
3. The person’s perspective of his health status
4. The health goals within the context of life history,
lifestyle, and health status
5. The person’s requirements for self care
6. The person’s capacity to perform self care
Application using case study
Basic ConditioningBasic Conditioning
FactorsFactors
48 yrs female,5’2”
82 kg, Italian
Widowed for 6
months after 25 yrs
of happy marriage
Catholic
University faculty
Universal Self
care
Smokes 1.5
packs/day
Frequently eats
fast food; high fat
diet; drinks 2 litres
of water
Largest meal of
the day is late
evening
No difficulties with
elimination,No
regular exercise,
DevelopmentalDevelopmental
Self careSelf care
Loss of husband
Loss of social
activity
Finds work as
university faculty
fulfilling
Works 12 hours a
day
Well groomed
Application using case study
Health DeviationsHealth Deviations
Family History:
F-heart attack, age
50
M-died of stroke, age
53 , cholesterol 260
mg; other lab values
WNL.
Lacks knowledge of
risk factors and
cardio vascular
functioning, B/P
142/88, P 92, R 26
Medical ProblemMedical Problem
And PlanAnd Plan
Diagnoses of
obesity with
potential for
cardiac disease
and low motivation
for weight loss
Prescription to:
Monitor
cholesterol levels
Decrease
cholesterol and fat
intake
Self care deficitsSelf care deficits
Difference between
healthy life style
and Ms M’s
Knowledge base
and life style which
increases her risk
of heart attack or
stroke
Application using case study
Health Deviations
Potential for cardiac
disease related to
obesity, smoking,
elevated cholesterol,
lack of exercise , and
family history
Medical Problem
And Plan
Increase exercise
Decrease or stop
smoking
Re-evaluate and if
needed prescribe
medication to
lower cholesterol
Self care deficits
Application using case study
Nursing Diagnosis
Potential for impaired
cardio vascular
functioning related to
lack of knowledge
about relationship
between current life
style and risk of heart
attack or stroke
Outcome & Plan
Outcome:
↓ cholesterol
Healthier life style
with regular
exercise,↓smoking
,& balanced
nutrition
Nursing Goals &
Objectives:
Goal: To decrease
risk for cardiac
impairement
Implementation
Jointly develop
contract related to:
1. Cholesterol
reduction
Ms M will keep a 3-
day food diary
Ms M will learn about
cholesterol & its
effects on cardio
vascular functioning
Ms M will learn about
low fat foods
Application using case study
Nursing Diagnosis
Potential for
impaired cardio
vascular
functioning
related to lack of
knowledge about
relationship
between current
life style and risk
of heart attack or
stroke
Outcome & Plan
Objectives: Ms M
will state that high
cholesterol levels
increase her risk for
cardiac impairement
Ms M will recognise
the relationship
between smoking
and cardio vascular
risk
Implementation
Ms. M will obtain
cholesterol and its effect
on cardiovascular
functioning
Jointly analyse food
diary and decide how to
decrease cholesterol /
fat intake to reduce M’s
Weight
Jointly determine food
items that are rich in
cholesterol and fat and
how receipes to be
adapted
Application using case study
Nursing
Diagnosis
Potential for
impaired cardio
vascular
functioning
related to lack
of knowledge
about
relationship
between
current life
style and risk
of heart attack
or stroke
Outcome & Plan
Design of Nursing
System:
Supportive
Educative
Methods Of
Helping:
Guidance,support
, teaching and
provision of a
developmental
environment
Implementation
Ms. M’s accomplishments will
be reinforced
Ms M’s will seek advice from
her physician re: medication
to reduce cholesterol
2. Reduction of smoking
Ms M will identify when she
smokes and what initiates the
desire for a cigarrete
Ms M will plan ways to
replace smoking with other
activities( exercising,chewing
gum
Application using case study
Nursing
Diagnosis
Potential for
impaired
cardio
vascular
functioning
related to lack
of knowledge
about
relationship
between
current life
style and risk
of heart attack
or stroke
Outcome & Plan
Design of
Nursing System:
Supportive
Educative
Methods Of
Helping:
Guidance
support,
teaching and
provision of a
developmental
environment
Evaluation
Does Ms M understand that with
her present life style, her risk of
heart attack or stroke is high?
Did Ms M. Select low
cholesterol , low fat foods?
Did Ms M’s Self care deficit
decrease
Is M’s Cholesterol lower?
Did Ms M Lose weight?
Has Ms M ↓ number of
cigarretes smoked daily
Was the supportive educative
system effective
Application of Imogene King’s Theory
PerceptionPerception
JudgementJudgement
Action Reaction Interaction TransactionAction Reaction Interaction Transaction
JudgementJudgement
PerceptionPerception
The basic assumption of the theory of GoalThe basic assumption of the theory of Goal
Attainment-Attainment-
• nurses and clients communicate informationnurses and clients communicate information
• set goals mutuallyset goals mutually
• act to attain those goalsact to attain those goals
AssessmentAssessment NursingNursing
DiagnosisDiagnosis
Mutual goalMutual goal
settingsetting
InterventionsInterventions EvaluationsEvaluations
Assessment
occurs during the
interaction of the
nurse and clients.
The concepts
identified are the
• perception,
communication
and interaction of
nurse and client
• Growth & Devp
• Knowledge of
self & role
• Amount of stress
• Factors
influencing
Clients perception
StatementStatement
thatthat
recognizesrecognizes
thethe
distresses,distresses,
difficulties ordifficulties or
worriesworries
identified byidentified by
the client andthe client and
nursenurse
DecisionDecision
making aboutmaking about
goals andgoals and
agreeing toagreeing to
means tomeans to
attain goalsattain goals
Activities thatActivities that
seek to meetseek to meet
goals. Thegoals. The
conceptconcept
involved is theinvolved is the
making ofmaking of
transactionstransactions
Goals areGoals are
attained orattained or
not.not.
EvaluationEvaluation
not onlynot only
speaks ofspeaks of
goalgoal
attainmentattainment
but alsobut also
effectivenesseffectiveness
of nursingof nursing
carecare
AssessmentAssessment
Nurses Perception:
Mrs X is well groomed pregnant female who appears to be
comfortable in the examination room and makes a eye
contact with the nurse. As they interact nurse finds that she
is 25 years old, married , about six months pregnant, gained
4 kgs of weight so far during the pregnancy( G&D)
X’s perception:
Views herself as healthy( self), recently moved to a new area
Works as a teacher plans to continue work after baby is
born. She keeps in contact with her family regularly. She
asks question about labour process and how she might
identify good paediatrician. She reports her nausea is
subsided and feels that her pregnancy is progressing
normally without any complications
The nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
Nursing DiagnosisNursing Diagnosis
Knowledge deficit about health care resources,
child birth related to recent move to a new locality
Mutual goal setting
To be a healthy mother and to have a successful
pregnancy and delivery of a healthy baby
The nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
Interventions in terms of transactions
Establishing and keeping a schedule of regular
prenatal visits
Providing information about community resources and
health care facilities
Conducting regular child birth education
EvaluationEvaluation
Verbalization of understanding the availability of
resources
Successful experience with pregnancy and birth of a
healthy new born baby . Successful initial experience
of breast feeding
Application of Roy’s Adaptation Theory toApplication of Roy’s Adaptation Theory to
Nursing PracticeNursing Practice
Case study:
Mr Raj is received from surgery after a major
abdominal operation. Before surgery his baseline
vital signs were:heart rate 80 beats per minute;BP
120/80mm of Hg and resp rate 16 per minute. After
45 minutes in post op recovery his vital signs are:
HR 150 beats per minute; BP 90/60mm of Hg; Resp
rate 32 per minute. { Increased regulator output is
signaled by sympahathetic nervous system
stimulation of the heart in response to decreased
blood pressure} The nurse decides that Mr Raj is
showing an ineffective response
Assessment of stimuli
• Focal Stimuli: Decrease in arterial blood
pressure (exact cause is unknown)
• Contextual Stimuli: Age 45 yrs, No food or
drink for 12 hours, IV infusion of 5% dextrose
with lactated ringer’s solution at 100 cc per
hour. 200cc of IV fluids infused during
surgery,20cc of urine excreted during the
first 45 minutes in recovery,1.5 hours of
general anaesthesia, estimated blood loss of
500ml during surgery no operative site
bleeding
• Residual Stimuli: include history of renal
infections
• Nursing Diagnosis:
Fluid Volume deficit related to blood loss,
decreased intake
• Goal:
To maintain adequate circulatory volume as
evidenced by BP within normal range±20mm
of Hg within 15 minutes, Urine output
>30ml/hour,mental alertness, rapid nail
blanching, pulse and respiration within normal
limits
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 monitoring
EvaluationEvaluation
A constant evaluation of the effectiveness of
nursing care is made and patients response
is evaluated
• Application of Betty Neuman’s Model
• Case Study:
Janice is a 34-year-old married woman who
has three elementary school-aged children.
She moved to the Lower Mainland, from
the Interior, six months ago because her
husband was transferred by his employer.
Janice is currently on medical leave from
her job as a teacher's assistant. She was
referred to an outpatient psychiatric group
therapy program in order to gain
assistance in dealing with depression and
anxiety.
• Janice states she was feeling "reasonably
well" until February of last year when her
husband informed her of the likelihood of
his being transferred. She says she had
developed many friends in the Interior in
the five years they had lived there, and
she has made few friends since moving to
the Lower Mainland. Janice's extended
family lives in Ontario, as does her
husband's family.
• Janice says they moved to the Lower Mainland last August, two
weeks before school started. The children, aged six, eight and
ten years, were upset with the move because they were leaving
their friends behind. Janice feels guilty about this.
Another stressor for her is her new job, which she started last
September. She was assigned to work with a child diagnosed
with attention deficit hyperactivity disorder (ADHD). Janice did
not agree with the management style of the teacher when
dealing with this child, and she found it difficult to be assertive
in dealing with this teacher. Janice says she started
experiencing anxiety attacks and insomnia in early December.
• The idea of Christmas approaching, which she had always enjoyed,The idea of Christmas approaching, which she had always enjoyed,
now seemed overwhelming, "I wasn't doing well and I had no one tonow seemed overwhelming, "I wasn't doing well and I had no one to
talk to". The time away from work at Christmas break was helpful, andtalk to". The time away from work at Christmas break was helpful, and
she 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 of
her work return, she wasn't coping well.her work return, she wasn't coping well.
• Janice saw her physician who suggested she take a medical leave. SheJanice saw her physician who suggested she take a medical leave. She
also 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 for
outpatient group therapy. After six weeks on medication, her mood hasoutpatient group therapy. After six weeks on medication, her mood has
improved. 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.
• Janice says that she grew up an only child with an
"alcoholic" father and an "anxious" mother. She says she
married at age twenty years because she couldn't stand
being at home, and she didn't want to live alone.
Despite this, she says her marriage is good which she
qualifies with, "he doesn't run around or anything. He
works hard to provide for us, not like his dad who ran off
with another woman".
Janice's goals for group therapy are to learn ways to
handle her anxiety without medication, and to learn ways
to minimize her depression.
In applying Neuman's model to Janice's
situation, the initial assessment is carried out to
assess prediposing factors and stressors.
• Intrapersonal stressor : depression , insomnia,
guilt feeling
• Interpersonal stressor: social withdrawal and her
lack of her usual supports. Her disturbed sleep
leaves her feeling irritable in dealing with her
children, Conflict with the teacher.
• Extrapersonal stressor : Shift to a new place and
lack of social support.
• In Neuman's model, the nursing diagnosis
describes the whole client situation (Neuman,
1995). The nursing diagnosis could be described
as 'multiple stressors in too short a time frame
penetrated Janice's normal line of defense,
causing an energy drain and a variance from
wellness.
• Subsequently, system integrity was not
maintained and Janice developed symptoms of
anxiety, depression and insomnia'.
• Diagnosis statement : Ineffective coping
• : Anxiety
• :Sleep pattern disturbance
Goals
In Neuman's model, goals are set in collaboration
with the client.
• Janice stated her goals were to learn ways to
handle her anxiety without medication and to
learn ways to minimize her chances of becoming
depressed again.
{ These are reasonable goals in an outpatient
group therapy program. These goals are
relevant because they were determined by the
client and were deemed by the nurse to be
manageable goals in this practice setting.}
Neuman's interventions are carried out at three levels: primary,
secondary and tertiary prevention.
In Janice's situation,In Janice's 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 frequently
causes insomnia,)causes insomnia,)
• Encouraging Janice to talk about ways to handle her anxietyEncouraging Janice to talk about ways to handle her anxiety
II
Tertiary 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 gain
insight about waysinsight about ways
• to minimize the occurrence of future depressive episodes.to 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
The final stage of Neuman's model is nursing
outcomes, or reassessment.
• Perceived progress towards her goals and she
would receive feedback from the nurse.
• Perhaps she still has insomnia after Prozac is
changed to morning administration. This
information leads the nurse back to assessment.
• Changes in intrapersonal, interpersonal and
extrapersonal factors would be noted because
change determines the success of the nursing
interventions.
Fig-1: Conceptual Framework on Postpartum Depressive symptoms, Family Support and Functional Status based on
Mercer’s Maternal role attainment Theory
* Variables under study
+ Positive influence
- Negative influence
Negative life
events
Stressful event
in pregnancy*
Pregnancy
risk
Pregnancy
related
problems*
Parity
Residual risk
factors
Age*
Socio
economic
status*
Substance
abuse*
Premenstrual
syndrome*
Previous or
family history
of depression*
Child care
risk
Child care
stress
Type of
delivery*
Feeding
pattern*
Frequency of
feed*
Sleep pattern*
Satisfaction
with gender of
the child*
Family
support
Informational
support*
Emotional
support*
Instrumental
support*
Esteem
support*
Self
esteem
Health
status
Sense
of
mastery
Anxiety
Depression*
Improved
functiona
l status*
_
_
_ _
__
+
+
+
Conclusion
We have seen that these models continue
to use the nursing process as the core for
decision making in determining if nursing
care to clients is meeting the expected
outcomes as established by the clinical
pathways. Applying these theorist views is
a challenge and it provides opportunity for
meaningful nursing practice
THANK YOUTHANK YOU

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Application of theory to nursing practice

  • 1. Application of theory to Nursing Practice Presented by ARUN.M
  • 2. • A casual visitor to a hospital or other health care setting might think that little has changed for nurses over the past decade. The majority of nurses still wear a traditional and recognizable uniform, and are to be found in areas where care is provided or advice offered to patients, their relatives and their friends. However, behind this seemingly unchanged exterior, much has altered. In particular, nurses are now educated through a different system of training. They are educated to a higher academic level, and the work they do and the way in which they do it have, in many areas of health care, changed considerably. Aggleton P & Chalmers H, 2000
  • 3. Introduction Nursing Science is an identifiable discrete body of knowledge comprising paradigms, frameworks and theories. The integration of nursing theories into practice demonstrates an evolutionary pathway for introducing a paradigm shift in the essence of the science of nursing .
  • 4. • Theories have been developed in nursing to explain phenomena important to clinical practice. For eg,we have a theory of health promotion behaviour (Pender &Pender & Pender,1996Pender,1996) and a theory of mother infant attachment(Walker,1992Walker,1992). Although we use these theories to guide our practice, in many cases we have not tested them to determine whether or not the nursing actions proposed actually have the effects claimed.
  • 5. • The conceptual models and the nursingThe conceptual models and the nursing theories that provide the basis for clinicaltheories that provide the basis for clinical practice 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. • Leininger’s Theory of Culture Care DiversityLeininger’s Theory of Culture Care Diversity and Universality,and Universality, • Newman’s Theory of Health as ExpandingNewman’s Theory of Health as Expanding Consciousness,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 Nursing Process,Process, • Wiedenbach’s Clinical Nursing: A HelpingWiedenbach’s Clinical Nursing: A Helping Art, Henderson’s Nature of Nursing,Art, Henderson’s Nature of Nursing, • Travelbee’s Interpersonal Aspects ofTravelbee’s Interpersonal Aspects of Nursing,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 so forth).forth).
  • 7. I = integration and synthesis of nursing knowledge through cognitive , psychomotor and affective domain
  • 9. Nursing in its journey to attain professional status incorporates several concurrent changes in the discipline by • combining research based practice • upgraded educational requirements • theory based models .
  • 10. Why we need to apply nursing theories ? Using theory helps to guide nursing practice. It  helps to organise data  understand and analyse patient data  make appropriate decisions related to nursing interventions.
  • 11. Application of Orem’s theory to nursing practice • Orem presents her self –care deficit theory of nursing which is composed of three interrelated theories • Theory of self care • Theory of Self care deficit • Theory of Nursing Systems
  • 12. Orem’s Model Self- CareSelf- Care Self –careSelf –care agencyagency TherapeuticTherapeutic Self careSelf care demanddemand NursingNursing AgencyAgency RR RR RR RR RR < DeficitDeficit conditioningfactors conditioningfactors
  • 13. Orem’s professional- technological operations of nursing practice • Step 1: Nursing Diagnosis and prescription that is, determining why nursing is needed • Step 2: Designing the nursing system and planning for delivery of care • Step 3: The production and management of nursing systems, also labelled planning and controlling
  • 14. Assessment Phase The nurse collects data in six areas: 1. The person’s health status 2. The physician’s and nurses perspective of the person’s health 3. The person’s perspective of his health status 4. The health goals within the context of life history, lifestyle, and health status 5. The person’s requirements for self care 6. The person’s capacity to perform self care
  • 15. Application using case study Basic ConditioningBasic Conditioning FactorsFactors 48 yrs female,5’2” 82 kg, Italian Widowed for 6 months after 25 yrs of happy marriage Catholic University faculty Universal Self care Smokes 1.5 packs/day Frequently eats fast food; high fat diet; drinks 2 litres of water Largest meal of the day is late evening No difficulties with elimination,No regular exercise, DevelopmentalDevelopmental Self careSelf care Loss of husband Loss of social activity Finds work as university faculty fulfilling Works 12 hours a day Well groomed
  • 16. Application using case study Health DeviationsHealth Deviations Family History: F-heart attack, age 50 M-died of stroke, age 53 , cholesterol 260 mg; other lab values WNL. Lacks knowledge of risk factors and cardio vascular functioning, B/P 142/88, P 92, R 26 Medical ProblemMedical Problem And PlanAnd Plan Diagnoses of obesity with potential for cardiac disease and low motivation for weight loss Prescription to: Monitor cholesterol levels Decrease cholesterol and fat intake Self care deficitsSelf care deficits Difference between healthy life style and Ms M’s Knowledge base and life style which increases her risk of heart attack or stroke
  • 17. Application using case study Health Deviations Potential for cardiac disease related to obesity, smoking, elevated cholesterol, lack of exercise , and family history Medical Problem And Plan Increase exercise Decrease or stop smoking Re-evaluate and if needed prescribe medication to lower cholesterol Self care deficits
  • 18. Application using case study Nursing Diagnosis Potential for impaired cardio vascular functioning related to lack of knowledge about relationship between current life style and risk of heart attack or stroke Outcome & Plan Outcome: ↓ cholesterol Healthier life style with regular exercise,↓smoking ,& balanced nutrition Nursing Goals & Objectives: Goal: To decrease risk for cardiac impairement Implementation Jointly develop contract related to: 1. Cholesterol reduction Ms M will keep a 3- day food diary Ms M will learn about cholesterol & its effects on cardio vascular functioning Ms M will learn about low fat foods
  • 19. Application using case study Nursing Diagnosis Potential for impaired cardio vascular functioning related to lack of knowledge about relationship between current life style and risk of heart attack or stroke Outcome & Plan Objectives: Ms M will state that high cholesterol levels increase her risk for cardiac impairement Ms M will recognise the relationship between smoking and cardio vascular risk Implementation Ms. M will obtain cholesterol and its effect on cardiovascular functioning Jointly analyse food diary and decide how to decrease cholesterol / fat intake to reduce M’s Weight Jointly determine food items that are rich in cholesterol and fat and how receipes to be adapted
  • 20. Application using case study Nursing Diagnosis Potential for impaired cardio vascular functioning related to lack of knowledge about relationship between current life style and risk of heart attack or stroke Outcome & Plan Design of Nursing System: Supportive Educative Methods Of Helping: Guidance,support , teaching and provision of a developmental environment Implementation Ms. M’s accomplishments will be reinforced Ms M’s will seek advice from her physician re: medication to reduce cholesterol 2. Reduction of smoking Ms M will identify when she smokes and what initiates the desire for a cigarrete Ms M will plan ways to replace smoking with other activities( exercising,chewing gum
  • 21. Application using case study Nursing Diagnosis Potential for impaired cardio vascular functioning related to lack of knowledge about relationship between current life style and risk of heart attack or stroke Outcome & Plan Design of Nursing System: Supportive Educative Methods Of Helping: Guidance support, teaching and provision of a developmental environment Evaluation Does Ms M understand that with her present life style, her risk of heart attack or stroke is high? Did Ms M. Select low cholesterol , low fat foods? Did Ms M’s Self care deficit decrease Is M’s Cholesterol lower? Did Ms M Lose weight? Has Ms M ↓ number of cigarretes smoked daily Was the supportive educative system effective
  • 22. Application of Imogene King’s Theory PerceptionPerception JudgementJudgement Action Reaction Interaction TransactionAction Reaction Interaction Transaction JudgementJudgement PerceptionPerception
  • 23. The basic assumption of the theory of GoalThe basic assumption of the theory of Goal Attainment-Attainment- • nurses and clients communicate informationnurses and clients communicate information • set goals mutuallyset goals mutually • act to attain those goalsact to attain those goals
  • 24. AssessmentAssessment NursingNursing DiagnosisDiagnosis Mutual goalMutual goal settingsetting InterventionsInterventions EvaluationsEvaluations Assessment occurs during the interaction of the nurse and clients. The concepts identified are the • perception, communication and interaction of nurse and client • Growth & Devp • Knowledge of self & role • Amount of stress • Factors influencing Clients perception StatementStatement thatthat recognizesrecognizes thethe distresses,distresses, difficulties ordifficulties or worriesworries identified byidentified by the client andthe client and nursenurse DecisionDecision making aboutmaking about goals andgoals and agreeing toagreeing to means tomeans to attain goalsattain goals Activities thatActivities that seek to meetseek to meet goals. Thegoals. The conceptconcept involved is theinvolved is the making ofmaking of transactionstransactions Goals areGoals are attained orattained or not.not. EvaluationEvaluation not onlynot only speaks ofspeaks of goalgoal attainmentattainment but alsobut also effectivenesseffectiveness of nursingof nursing carecare
  • 25. AssessmentAssessment Nurses Perception: Mrs X is well groomed pregnant female who appears to be comfortable in the examination room and makes a eye contact with the nurse. As they interact nurse finds that she is 25 years old, married , about six months pregnant, gained 4 kgs of weight so far during the pregnancy( G&D) X’s perception: Views herself as healthy( self), recently moved to a new area Works as a teacher plans to continue work after baby is born. She keeps in contact with her family regularly. She asks question about labour process and how she might identify good paediatrician. She reports her nausea is subsided and feels that her pregnancy is progressing normally without any complications The 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. Nursing DiagnosisNursing Diagnosis Knowledge deficit about health care resources, child birth related to recent move to a new locality Mutual goal setting To be a healthy mother and to have a successful pregnancy and delivery of a healthy baby The nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
  • 27. Interventions in terms of transactions Establishing and keeping a schedule of regular prenatal visits Providing information about community resources and health care facilities Conducting regular child birth education EvaluationEvaluation Verbalization of understanding the availability of resources Successful experience with pregnancy and birth of a healthy new born baby . Successful initial experience of breast feeding
  • 28. Application of Roy’s Adaptation Theory toApplication of Roy’s Adaptation Theory to Nursing PracticeNursing Practice Case study: Mr Raj is received from surgery after a major abdominal operation. Before surgery his baseline vital signs were:heart rate 80 beats per minute;BP 120/80mm of Hg and resp rate 16 per minute. After 45 minutes in post op recovery his vital signs are: HR 150 beats per minute; BP 90/60mm of Hg; Resp rate 32 per minute. { Increased regulator output is signaled by sympahathetic nervous system stimulation of the heart in response to decreased blood pressure} The nurse decides that Mr Raj is showing an ineffective response
  • 29. Assessment of stimuli • Focal Stimuli: Decrease in arterial blood pressure (exact cause is unknown) • Contextual Stimuli: Age 45 yrs, No food or drink for 12 hours, IV infusion of 5% dextrose with lactated ringer’s solution at 100 cc per hour. 200cc of IV fluids infused during surgery,20cc of urine excreted during the first 45 minutes in recovery,1.5 hours of general anaesthesia, estimated blood loss of 500ml during surgery no operative site bleeding • Residual Stimuli: include history of renal infections
  • 30. • Nursing Diagnosis: Fluid Volume deficit related to blood loss, decreased intake • Goal: To maintain adequate circulatory volume as evidenced by BP within normal range±20mm of Hg within 15 minutes, Urine output >30ml/hour,mental alertness, rapid nail blanching, pulse and respiration within normal limits
  • 31. 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 monitoring EvaluationEvaluation A constant evaluation of the effectiveness of nursing care is made and patients response is evaluated
  • 32. • Application of Betty Neuman’s Model • Case Study: Janice is a 34-year-old married woman who has three elementary school-aged children. She moved to the Lower Mainland, from the Interior, six months ago because her husband was transferred by his employer. Janice is currently on medical leave from her job as a teacher's assistant. She was referred to an outpatient psychiatric group therapy program in order to gain assistance in dealing with depression and anxiety.
  • 33. • Janice states she was feeling "reasonably well" until February of last year when her husband informed her of the likelihood of his being transferred. She says she had developed many friends in the Interior in the five years they had lived there, and she has made few friends since moving to the Lower Mainland. Janice's extended family lives in Ontario, as does her husband's family.
  • 34. • Janice says they moved to the Lower Mainland last August, two weeks before school started. The children, aged six, eight and ten years, were upset with the move because they were leaving their friends behind. Janice feels guilty about this. Another stressor for her is her new job, which she started last September. She was assigned to work with a child diagnosed with attention deficit hyperactivity disorder (ADHD). Janice did not agree with the management style of the teacher when dealing with this child, and she found it difficult to be assertive in dealing with this teacher. Janice says she started experiencing anxiety attacks and insomnia in early December.
  • 35. • The idea of Christmas approaching, which she had always enjoyed,The idea of Christmas approaching, which she had always enjoyed, now seemed overwhelming, "I wasn't doing well and I had no one tonow seemed overwhelming, "I wasn't doing well and I had no one to talk to". The time away from work at Christmas break was helpful, andtalk to". The time away from work at Christmas break was helpful, and she 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 of her work return, she wasn't coping well.her work return, she wasn't coping well. • Janice saw her physician who suggested she take a medical leave. SheJanice saw her physician who suggested she take a medical leave. She also 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 for outpatient group therapy. After six weeks on medication, her mood hasoutpatient group therapy. After six weeks on medication, her mood has improved. 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.
  • 36. • Janice says that she grew up an only child with an "alcoholic" father and an "anxious" mother. She says she married at age twenty years because she couldn't stand being at home, and she didn't want to live alone. Despite this, she says her marriage is good which she qualifies with, "he doesn't run around or anything. He works hard to provide for us, not like his dad who ran off with another woman". Janice's goals for group therapy are to learn ways to handle her anxiety without medication, and to learn ways to minimize her depression.
  • 37. In applying Neuman's model to Janice's situation, the initial assessment is carried out to assess prediposing factors and stressors. • Intrapersonal stressor : depression , insomnia, guilt feeling • Interpersonal stressor: social withdrawal and her lack of her usual supports. Her disturbed sleep leaves her feeling irritable in dealing with her children, Conflict with the teacher. • Extrapersonal stressor : Shift to a new place and lack of social support.
  • 38. • In Neuman's model, the nursing diagnosis describes the whole client situation (Neuman, 1995). The nursing diagnosis could be described as 'multiple stressors in too short a time frame penetrated Janice's normal line of defense, causing an energy drain and a variance from wellness. • Subsequently, system integrity was not maintained and Janice developed symptoms of anxiety, depression and insomnia'. • Diagnosis statement : Ineffective coping • : Anxiety • :Sleep pattern disturbance
  • 39. Goals In Neuman's model, goals are set in collaboration with the client. • Janice stated her goals were to learn ways to handle her anxiety without medication and to learn ways to minimize her chances of becoming depressed again. { These are reasonable goals in an outpatient group therapy program. These goals are relevant because they were determined by the client and were deemed by the nurse to be manageable goals in this practice setting.}
  • 40. Neuman's interventions are carried out at three levels: primary, secondary and tertiary prevention. In Janice's situation,In Janice's 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 frequently causes insomnia,)causes insomnia,) • Encouraging Janice to talk about ways to handle her anxietyEncouraging Janice to talk about ways to handle her anxiety II Tertiary 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 gain insight about waysinsight about ways • to minimize the occurrence of future depressive episodes.to 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
  • 41. The final stage of Neuman's model is nursing outcomes, or reassessment. • Perceived progress towards her goals and she would receive feedback from the nurse. • Perhaps she still has insomnia after Prozac is changed to morning administration. This information leads the nurse back to assessment. • Changes in intrapersonal, interpersonal and extrapersonal factors would be noted because change determines the success of the nursing interventions.
  • 42. Fig-1: Conceptual Framework on Postpartum Depressive symptoms, Family Support and Functional Status based on Mercer’s Maternal role attainment Theory * Variables under study + Positive influence - Negative influence Negative life events Stressful event in pregnancy* Pregnancy risk Pregnancy related problems* Parity Residual risk factors Age* Socio economic status* Substance abuse* Premenstrual syndrome* Previous or family history of depression* Child care risk Child care stress Type of delivery* Feeding pattern* Frequency of feed* Sleep pattern* Satisfaction with gender of the child* Family support Informational support* Emotional support* Instrumental support* Esteem support* Self esteem Health status Sense of mastery Anxiety Depression* Improved functiona l status* _ _ _ _ __ + + +
  • 43. Conclusion We have seen that these models continue to use the nursing process as the core for decision making in determining if nursing care to clients is meeting the expected outcomes as established by the clinical pathways. Applying these theorist views is a challenge and it provides opportunity for meaningful nursing practice