Application of theory to nursing practice
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Here is an analysis of this case using Neuman's Systems Model: - Janice's normal line of defense was weakened by the stress of moving and adjusting to a new environment and job. - Her flexible line of defense was also impacted as she had difficulty coping with stressors like an unsupportive work environment and missing her social support network. - This left her vulnerable to stressors penetrating her lines of defense and affecting her normal stable state, resulting in symptoms of anxiety and depression. - Nursing interventions could aim to strengthen her normal and flexible lines of defense, such as providing social support, stress management techniques, and assertiveness training to better cope with workplace issues. - The goal would be to help
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