Theory based Nursing process
- 1. NURSING CARE PLAN IN SURGICAL EMERGENCY WARD (CB TOP) (BASED ON OREM’S SELF CARE DEFICIT THEORY) Submittedby, Koyel Basak M.Scnursing ,Final year College ofNursing, Medical College andHospital
- 2. I N TR O D U C TI O N Dorothea Orem was born in 1914 in Baltimore. She worked as a staff nurse, private duty nurse, nurse educator and administrator and nurse consultant. She received honorary Doctor of Science degree in 1976. Her theory was first published in Nursing: Concepts of Practice in 1971, second in 1980, in 1995, and 2001. D E F I N I T I O N S O F D O M A I N C O N C EP T S Nursing – is art, a helping service, and a technology Actions deliberately selected and performed by nurses to help individuals or groups under their care to maintain or change conditions in themselves or their environments Encompasses the patient’s perspective of health condition ,the physician’s perspective , and the nursing perspective Goal of nursing – to render the patient or members of his family capable of meeting the patient’s self care needs To maintain a state of health To regain normal or near normal state of health in the event of disease or injury To stabilize ,control ,or minimize the effects of chronic poor health or disability Health – health and healthy are terms used to describe living things … It is when they are structurally and functionally whole or sound … wholeness or integrity. .includes that which makes a person human,…operating in conjunction with physiological and psycho-physiological mechanisms and a material structure and in relation to and interacting with other human beings Environment environment components are enthronement factors, enthronement elements, conditions, and developed environment Human being – has the capacity to reflect, symbolize and use symbols Conceptualized as a total being with universal, developmental needs and capable of continuous self care A unity that can function biologically, symbolically and socially
- 3. Nursing client A human being who has "health related /health derived limitations that render him incapable of continuous self care or dependent care or limitations that result in ineffective / incomplete care. A human being is the focus of nursing only when a self –care requisites exceeds self care capabilities Nursing problem deficits in universal, developmental, and health derived or health related conditions Nursing process a system to determine (1)why a person is under care (2)a plan for care , (3)the implementation of care Nursing therapeutics deliberate, systematic and purposeful action, O R EM ’ S G EN ER A L TH EO R Y O F N U R S I N G Orem’s general theory of nursing in three related parts:- Theory of self care Theory of self care deficit Theory of nursing system A . The o ry o f S e l f C a re This theory Includes: Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being Self care agency – is a human ability which is "the ability for engaging in self care" - conditioned by age developmental state, life experience socio-cultural orientation health and available resources
- 4. Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions" Self care requisites - action directed towards provision of self care. 3 categories of self care requisites are- o Universal self care requisites o Developmental self care requisites o Health deviation self care requisites 1. Universal self care requisites Associated with life processes and the maintenance of the integrity of human structure and functioning Common to all , ADL Identifies these requisites as: o Maintenance of sufficient intake of air ,water, food o Provision of care assoc with elimination process o Balance between activity and rest, between solitude and social interaction o Prevention of hazards to human life well being and o Promotion of human functioning 2. Developmental self care requisites Associated with developmental processes/ derived from a condition…. Or associated with an event o E.g. adjusting to a new job o adjusting to body changes 3. Health deviation self care Required in conditions of illness, injury, or disease .these include:-- Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of pathologic conditions Effectively carrying out medically prescribed measures Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care Learning to live with effects of pathologic conditions B . The o ry o f s e l f c a re de f i c i t Specifies when nursing is needed
- 5. Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or limited in the provision of continuous effective self care. Orem identifies 5 methods of helping: o Acting for and doing for others o Guiding others o Supporting another o Providing an environment promoting personal development in relation to meet future demands o Teaching another C . The o ry o f N urs i ng S y s t e ms Describes how the patient’s self care needs will be met by the nurse , the patient, or both Identifies 3 classifications of nursing system to meet the self care requisites of the patient:- Wholly compensatory system Partly compensatory system Supportive – educative system Design and elements of nursing system define Scope of nursing responsibility in health care situations General and specific roles of nurses and patients Reasons for nurses’ relationship with patients and Orem recognized that specialized technologies are usually developed by members of the health profession A technology is systematized information about a process or a method for affecting some desired result through deliberate practical endeavor, with or without use of materials or instruments. O R E M ’S T HE O R Y B AS E D C AR E P LAN O bje c t i v e s : To assess the patient condition by the various methods explained by the nursing 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.
- 6. Pa t i e nt pro f i l e Areas Patient details Name Age Sex Education Occupation Marital status Religion Diagnosis Theory applied Mr. Chandan Biswas 50 years Male Higher Secondary passed Serviceman in private company Married Hindu Peptic perforation with peritonitis Orem’s theory of self care deficit. Mr. Chandan Biswas came to the hospital with complaints of pain in epigastrium region radiating whole abdomen not relieved by any analgesic. He has history of occasional epigastrium pain over 3 yrs. He has the history of smoking and alcoholism for 20-25 years D A TA C O LLEC TI O N A C C O R D I N G TO O R EM ’ S TH EO R Y O F S ELF C A R E D EFI C I T 1. BASIC CONDITIONING FACTORS Age 50year Gender Male Health state Disability due to pain, therapeutic self care demand Development state Ego integrity vs despair Sociocultural orientation Higher secondary passed, Indian, Hindu Health care system Institutional health care Family system Married, wife is homemaker Patterns of living At home with partner Environment Urban area
- 7. resources Wife, son 2. UNIVERSAL SELF-CARE REQUISITES Air Breaths without difficulty, no pallor cyanosis Water Fluid intake is restricted to prevent irritation to peritoneum. Turgor is normal for the age Food Food intake is restricted. Elimination Voids and eliminates bowel without difficulty. Activity/ rest Frequent rest is required due to pain. Pain not relieved, Activity level has come down. Social interaction Communicates well with family members and neighbors. Prevention of hazards Need health education on dietary pattern and lifestyle modification after pancreatitis Promotion of normalcy Has good relation with wife 3. DEVELOPMENTAL SELF-CARE REQUISITES Maintenance of developmental environment Unable to feed, Difficulty in movement due to acute pain Prevention/ management of the conditions threatening the normal development He believes that disease is for his own behavior 4. HEALTH DEVIATION SELF CARE REQUISITES Adherence to medical regimen Reports the problems to the physician when in the hospital. Cooperates with the medication, Not much aware about the use and side effects of medicines Awareness of potential problem associated with the regimen He is aware about the actual disease process. He is compliant with the restricted diet and prevention of hazards.
- 8. Modification of self image to incorporates changes in health status He adopted dietary pattern and , life style changes to improve health status Adjustment of lifestyle to accommodate changes in the health status and medical regimen. Pain tolerance not achieved but he reassured to quit smoking and alcohol intake. He has understood regarding the modified dietary pattern. 5. MEDICAL PROBLEM AND PLAN Physician’s perspective of the condition: Diagnosed with pancreatitis and is on the following treatment: IV fluid NS 8 hourly NPM Continuous gastric drainage Inj. Paracetamol 1gm IV TDS Inj. Voveran 75 mg IM SOS Inj. Pan 40 mg IV OD Inj. Pipzo 4.5 gm IV BD Inj. Metronidazole 500mg IV TDS Inj. Fortwin 1amp IM HS Inj. Calmpose 1amp Im HS Medical Diagnosis: peptic perforation with peritonitis Medical Treatment: Medication and restriction in oral intake Surgical treatment: Repair of perforation is done under general anesthesia on 18.8.15 Applying the O re m’s the o ry o f s e lf -c a re de fic it, a po s t - o pe ra tive nurs ing c a re pla n fo r M r. C ha nda n B is w a s is pre pa re d a s fo llo w s … The patient Mr. Chandan Biswas has the areas that need assistance were- 1. Therapeutic self care demand: deficient area: pain control Adequacy of self care agency: inadequate Nursing diagnosis
- 9. Ineffective pain control related to presence of surgical wound in abdomen a. Outcome: Improved pain control Achieve and maintain a reduction in the pain. b.Goal: To reduce pain c. Designof the nursing system: Acting or doing , supportive and educative d. Method of helping: Guidance: Ask the client to report the intensity, location, severity, associated and aggravating factors. Support: Administer analgesics Provide diversion and psychological support to the patient Teaching: Teach the non – pharmacological method to the patient once the pain is a little reduced. Implementation Assessed the pain along with its location, characteristics, duration, frequency, quality, intensity. Inj. Voveran 75mg is administered IM Inj. Paracetamol 1 gm is administered IV Patient is kept NPM to control pain. Continuous nasogastric drainage is provided for gastric decompression. Non-pharmacological techniques(guided imagery) are taught to the client to perform to reduce pain. Psychological support provided.
- 10. Evaluation Patient explained slight reduction in pain and demonstrated to perform pain relieving non-pharmacological measures. 2. Therapeutic self care demand: deficient area: Food Adequacy of self care agency: Inadequate Nursing diagnosis Imbalanced nutrition:less than body requirement related to restriction in oral intake after surgery a.Outcome: Maintainance of balanced nutrition b.Goal: To achieve optimal levels of nutrition. c. Designof the nursing system: supportive educative d. Method of helping: Guidance support Teaching IMPLEMENTATION Nutritional status is assessed Laboratory value is monitored. Administered IV fluid to maintain fluid status. CBG is monitored thrice a day. Strict intake-output chart is maintained. Reason for restriction of oral intake is explained. EVALUATION
- 11. Intake is 1800ml and output is 1200ml. laboratory values of electrolytes are within normal level except serum potassium (3.2 meq/L). 3. Therapeutic self care demand: deficient area: Activities of daily living Adequacy of self care agency: inadequate Nursing diagnosis Self-care deficit: oral and skin care, going to toilet related to pain secondary to surgery a. Outcome: improved self-care maintain the ability to perform the toileting, oral and skin care with modification as required. b.Goal: To achieve optimal levels of ability for self care. c.Designof the nursing system: Partly compensatory d. Method of helping: Guidance: Assess the various hindering factors for self care and how to tackle them. Support: Provide all the articles needed for self care, near to the patient and ask the family members also to give the articles near to her. Make the patient use bedpan to perform toileting Provide assistance whenever needed for the self care activities Provide encouragement and positive reinforcement for minor improvement in the activity level. Initiate the pain relieving measures always before the patient go for any of the activities of daily living Make the patient to use loose fitting clothes which will be easy to wear and remove. Teaching:
- 12. Teach the family members the limitation in the activity level the patient has and the cooperation required Promoting a developmental environment: Teach the family and help them to practice how to help the patient according to her needs Implementation Assessed the activity level of the patient. Patient is assisted to take oral care 6th hourly as the patient is NPM. Patient’s relative is asked to provide bedpan whenever needed. Skin care and hair care is provided. A neat and tidy bed is provided to the patient. Evaluation Patient was performing some of the activities and he practiced toileting using a bedpan in the hospital. He verbalized an improved comfort and self care ability. The partly compensatory system was useful for Mr. Chandan Biswas 4. Therapeutic self care demand: deficient area: mobility Adequacy of self care agency: inadequate Nursing diagnosis: Impaired physical mobility related to pain and weakness as evidenced by observation of limited movement a. Outcome: Patient will have improved mobility b.Goal: To prevent infection c. Designof the nursing system: supportive educative
- 13. d. Method of helping: Guidance support Teaching Implementation Assessed the causes of immobility. Post operative exercises are taught to the patient. Patient is assisted to perform post operative turning exercise. Patient is provided fowlers position. He is encouraged to perform breathing exercise and leg exercise. Evaluation Patient is able to follow the instructions He is able to perform turning exercise without assistance and leg exercise with assistance. 5. Therapeutic self care demand: deficient area: prevention of infection. Adequacy of self care agency: inadequate Nursing diagnosis: Risk for infection related to IV cannulation, catheterization, hospitalization a. Outcome: Patient will have no infection b.Goal: To prevent infection c. Designof the nursing system: supportive educative d. Method of helping: Guidance support Teaching Implementation
- 14. Assessed the possible entry site of infection. Assessed the sign and symptoms of infection. Hand washing is done before and after every procedure. All the invasive procedures are performed in sterile technique. Patient and his relatives are encouraged to maintained personal hygiene properly. Antibiotic Inj. Pipzo 4.5 gm is administered. Evaluation Patient remained free from any infection He listed the measures to prevent infection The supportive educative system was useful for Mr. Chandan Biswas 6. Therapeutic self care demand: deficient area: awareness of the disease process and management Adequacy of self care agency: Inadequate Nursing diagnosis Ineffective therapeutic management related to lack of knowledge of preventive measures, diet modification and lifestyle modification. a. Outcome: Absence of complications and improved awareness about the disease process. b.Goal: Improve the knowledge of the patient about the disease process and the complications. c. Designof the nursing system: supportive educative d. Methods of helping: Guidance Teaching Promoting a developmental environment IMPLEMENTATION
- 15. Patient’s current level of knowledge is appraised. Pathophysiology of the disease and how it relates with anatomy and physiology is explained to the patient. Needed dietary modification and life style modification is explained to the patient. Patient is informed regarding the sign and symptoms on which he has to report. Patient is instructed to continue follow-up treatment. EVALUATION Patient got adequate information regarding the disease He verbalized what he understood about the disease and its management. Patient has cleared her doubts regarding the medication actions The supportive educative system was useful for Mr. Chandan Biswas EV A LU A TI O N O F TH E A PPLI C A TI O N O F S ELF C A R E D EFI C I T TH EO R Y The theory of self-care deficit when applied could identify the self care requisites of Mr. Chandan Biswas from various aspects. This was helpful to provide care in a comprehensive manner. Patient was very cooperative. The application of this theory revealed how well the supportive and educative and partly compensatory system could be used for solving the problems in a patient with perforative peritonitis.