Sister Callista Roy’sAdaptation Model

Presented By:

Mrs. Sandeep Kaur

Lecturer ,C.O.N

•Nursing is establishing itself as a scientific discipline. •Its thrust toward scientifically sound social usefulness including the development of conceptual models. •The nursing models provide the basis for selecting knowledge to be transmitted in nursing education.

INTRODUCTION

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It is the framework for nursing practice and the direction for nursing research.

Sister callista Roy’s adaptation theory (Roy and Obloy 1979,Roy 1980,1984,1989) views the client as an adaptive system.

BIOGRAPHICAL SKETCH OF THE NURSE THEORIST

Sister callista Roy was born on oct, 14,1939.

She did her bachelors of arts in nursing from mount st. Mary’s college, losAngeles in 1963 and masters of science in nursing from ,University of California,Los Angeles1966.

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She also received her masters of arts(M.A) in sociology from the same university in 1975 and Ph.D in sociology .

Roy was an associate professor and chairperson of the department of nursing at mount Saint Mary’s college until 1982.

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From 1983 to 1985; she was Post Doctoral fellow at Robert Wood Johnson at University of California, as a clinical nurse scholar in neuroscience.

In 1988 Roy began the newly created position of graduate faculty at, Boston school of nursing.

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According to Roy’s model, the goal of nursing is to help the person’s adaptive system.

According to Roy’s model, the goal of nursing is to help the person adapt to change in physiological needs, self-concepts, role function and interdependent relations during health and illness .

CONTD…. All individual must adapt to

the following demands: 1. Meeting basic

physiological needs. 2. Developing a positive

self-concept. 3. Performing social roles. 4. Achieving a balance

between dependence and interdependence.

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It is role of nurse: To find out demands

which are causing problems for a client.

To assess how well the client is adapting to them. Nursing care is then directed at helping the client to adopt.

 

ORIGIN OF THE MODEL:

While a student of M.sc. nursing, at the university of California sister C. Roy was challenged in a seminar by another nurse theorist Dorothy E.JOHNSON to develop a theory of nursing , subsequently in 1970 the ‘ROY ADAPTATION MODEL’ was born as a derivation of Bertalanfty (1968) general system theory and Harry Helson’s Adaptation level theory (1964).

ASSUMPTIONS OF THE MODEL

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1. The person is a bio-psycho-social being includes biologic components (Anatomy and Physiology), psychological and social components.

2.The person is in constant interaction with a changing environment (interaction with physical, social & psychological environment changes)

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3.To cope with a changing world, the person uses both innate and acquired mechanisms which are biologic,psychological and social in origin.

4.Health and illness are an inevitable dimension of the person’s life.

5.To respond positively to environmental changes, the person must adapt (changing environment demands positive response)

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6.The person’s adaptation is a function of the stimulus, he is exposed to and his adaptation level, which is determined by the combined effect of three classes of stimuli:

*focal stimuli *contextual stimuli *Residual stimuli

CONTD…. *Focal stimuli or stimuli demanding prompt

attention. *Contextual stimuli or stimuli present in a

surrounding and situation. *Residual stimuli such as belief, attitude and

habits, which have an indeterminate on the present situation.

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7. The person’s adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response. (if the stimulus is within the zone the person responds positively, however if the stimulus outside the zone ,the person cannot make a positive response)

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8. The person is conceptualized as having four modes of adaptation:

psychological needs self-concept, role function, and interdependence relations.

 

Four philosophical assumptions based on the humanist principles are as follows.

a. The individual shares in creative power.

b. Behaves purposefully, not in sequence of cause and effect.

c. Possesses intrinsic holism and d. Strives to maintain integrity &

to realize the need for relationship.

                     

CONTD…. VERTIVITY

The term vertivity derived from the Latin ‘veritas’ meaning the trust, was coined by Roy. It’s a principle of human nature that affirms a “common purposefulness of human existence”.

                         

The four principles are :

The individual is viewed in the context of the purposefulness of human existence.

Unity of purpose of human kind

Activity & creativity for the common goods

Value of meaning of life.

5. CONCEPTS OF MODEL Roy’s model is a system model that focuses on

outcomes. the major features of the system models are the:

-System and its environment A system is a set of parts connects to function

as a whole for some purposes and are interdependence of its parts.

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Keys elements in the Roy adaptation model are-

1. The person who is recipient of nursing care

2. The goal of nursing. 3. The concept of health 4. The direction of nursing

activities.

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Person: Roy uses person in her model as a concept to identify the recipient of nursing care. critical to the model is the description of recipient of nsg care as holistic adaptive systems.

Persons as living systems are in constant interactions with their environments between the system and the environment occurs on exchange of information, matter and energy.

Goal-the goal of nsg. as the promotion of adaptive responses in relation to the four adaptive modes (physiological, self concept, role function and interdependence)and contribute to health.

Nsg activities-The nursing activities are delineated by the model as those that promotes adaptive responses in situation of health and illness. The nsg activities are identified as actions taken by nurses to manipulate the focal, contextual residual stimuli impringing on person.

CONTD…. The nsg process acc. to Roy’s

model consists of six steps- (1)Acceptance of behavior (2)Acceptance of stimuli (3)Nsg diagnosis (4)Goal setting (5)Intervention (6)Evaluation

                              

Health-health has been defined as a “state and process of being and becoming an integrate and whole person’’ Health is a process where by individuals are striving to achieve their maximum potentials.

                              

Environment-stimuli from within the person and stimuli from around the person represents the element of environment acc. to Roy.

Environment is specifically defined by Roy as “all conditions, circumstances influences surrounding and affecting the development and behavior of persons and groups.

6. THE PERSON AS AN ADAPTIVE SYSTEM

In addition to the concept of person,goal of nsg,health and environment and nsg activities in the model ,the theory of person as an adaptive system employs additional concepts.

The person as an adaptive system

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(1)Input-input coming from external environment as well as internally from the person as a stimuli(a stimulus is a unit of information,matter,or energy from the environment or a person who elicits a response).The stimuli immediately confronting the person are focal stimuli greatest degree of change impact on person.

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Contextual stimuli-observable, measureable and reported by the person.

Residual stimuli-those make up characteristics of the person that are present and relevant to situation.

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Example: Mr. smith experiencing the chest pain, the stimulus immediately confronting Mr. smith,the focal stimulus ,is the deficit of oxygen supply to his heart muscles.The contextual stimuli include the 90 degree of temperature ,the sensation of pain ,Mr. smith’s age ,weight,blood sugar level,and degree of coronary artery patency.The residual stimuli include his history of cigarette smoking and work relate stress.

Adaptation level is a constantly changing point that represents the person’s ability to cope with the changing environment in a positive manner.

Adaptation level sets up a zone or a range within which stimulation will lead to adaptive responses.

Stimuli falling outside their adaptive zone lead to ineffective responses.

Suicide due to inability to cope up with the child is an extreme example of an ineffective response.

Coping mechanisms some coping mechanisms

are inherited or genetic such as white blood defense system against bacteria seeking to invade the body.

some are learned as use of antiseptics

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Mechanisms are of 2 types: (1)Regulator is used primarily as a

mechanism to cope with physiological stimuli.

(2)Cognator used mainly as mechanism to cope with psychological stimuli dealing primarily in area of cognition, judgment and emotion.

-Regulator and cognator mechanisms are linked through the process of perception.

CONTD…. It is important to recognize that it is the

manifestation of the coping mechanism that can be observed and measured within the adaptive modes. Thus adaptive modes are often referred as effectors.

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Effectors: Roy has identified four adaptive modes;

Physiological self concept role function interdependence.

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Adaptive responses output- The behaviors that contribute to the general

goals of the person(i.e survival,growth,reproduction and mastery)are considered adaptive response.

Behaviors not contributing to general goals are considered ineffective responses.

Adaptive responses being about a state of adaptation.

7. THEORY OF ADAPTIVE MODES:

The theory of adaptive modes was developed in

1981, consist of four parts: physiological, self concept, role function & interdependence.

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Each adaptive mode represents a grouping of behaviors that promote the individuals movements towards the general goals (survival, growth, reproduction, mastery).

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(1)PHYSIOLOGICAL MODE Physiological wholeness is

achieved by adapting to changes in physiological needs.

The regulator coping mechanism is primarily responsible for attaining and maintaining this integrity.

other complex process that influences regulator

activities are the senses, fluids and electrolytes, neurological function & endocrine function.

Five primary needs have been identified as necessary for

physiological integrity:

oxygen, nutrition, activity rest, protection, elimination

                                 

CONTD… (2)SELF CONCEPT MODE Self concept is one of the 3 psychosocial

modes, the basic human need within modes in psychic integrity,which means people need to know who they are so that can exist with a sense of unity.

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Physical self: is an appraisal of one’s physical, attributes, appearance, functioning, sensation(feeling about self) sexually and wellness illness status.

Personal self: is an appraisal of one’s own characteristics, expectations, values & worth. Personal self has been divided into the moral ethical spiritual self ,self consistency & self ideal, self expectancy e.g. I believe God will help me through this surgery.

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(3)ROLE FUNCTION MODE: The basic need in the role function adaptive

model is for social integrity. This means that people need to know who they are in relation to others so that they can act. All people have role in society. With each role there are expected behavior .Role have been divided into primary, secondary and tertiary.

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(4)INTERDEPENDENCE MODE Interdependence is a social adaptive

mode,needs affection adequacy or the feeling of security in nurturing relationships.

Interdependence means the close relationship of people that involves willingness & ability to love, respect & value others and to accept & responds to love, respect and value given by others.

Loneliness as a common adaptation problem resulting from a disruption in the modes.

Those currently identified needs are listed below:

(a) Basic physiological needs-

Exercise and rest Nutrition Elimination Fluid and electrolyte Oxygen Circulations Regulations

                           

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(b)self concepts: Physical self Personal self Interpersonal self

(c) role mastery: -Role failure -Role conflict

CONTD….(d)interdependence:-

Alteration,rejection,aggression,rivalry, hostility,loneliness,dominance,exhibition.

-The aspects of care which are examined in view of the model are:

The nature of the people receiving nursing care.

Cause of problems likely to require nsg intervention.

Nature of assessment

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Nature of planning and goal setting process The focus of nsg interventions during the

implementation of the nsg care plan The nature of the process of evaluating the

quality of effects of the care given.

NURSING PROCESS ACCORDING TO RAM

A problem solving approach for gathering data, identifying the capacities and needs of the human adaptive system, selecting and implementing approaches for nursing care, and evaluation the outcome of care provided.

o Assessment of Behavior: the first step of the nursing process which involves gathering data about the behavior of the person as an adaptive system in each of the adaptive modes.

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Assessment of Stimuli: the second step of the nursing process which involves the identification of internal and external stimuli that are influencing the person’s adaptive behaviors.

Stimuli are classified as: 1) Focal- those most immediately confronting

the person 2) Contextual-all other stimuli present that

are affecting the situation 3) Residual- those stimuli whose effect on the

situation are unclear.

Nursing Diagnosis: step three of the nursing process which involves the formulation of statements that interpret data about the adaptation status of the person, including the behavior and most relevant stimuli

GOAL SETTING the fourth step of the nursing process which

involves the establishment of clear statements of the behavioral outcomes for nursing care.

Intervention: the fifth step of the nursing process which involves the determination of how best to assist the person in attaining the established goals

Evaluation: the sixth and final step of the nursing process which involves judging the effectiveness of the nursing intervention in relation to the behavior after the nursing intervention in comparison with the goal established.

DEMOGRAPHIC DATA Name Mr. NR

Age 53years

Sex Male

IP number ------

Education Degree

Occupation Bank clerk

Marital status Married

Religion Hindu

Informants Patient and Wife

Date of admission 21/01/08

FIRST LEVEL ASSESSMENT PHYSIOLOGIC-PHYSICAL MODE

Oxygenation: Stable process of ventilation and stable process of gas

exchange. RR= 18Bpm.  Chest normal in shape. Chest expansion normal on either

side. Apex beat felt on left 5th inter-costal space mid-clavicular

line. Air entry equal bilaterally. No ronchi or crepitus. No abnormal heart sounds. S1& S2 heard. BP- Normotensive. .

CONTD…. Nutrition He is on diabetic diet (1500kcal). Non

vegetarian. Recently his Weight reduced markedly

(10 kg/ 6 month). He has stable digestive process. He has complaints of anorexia and not

taking adequate food. No abdominal distension. No

tenderness. Bowel sounds heard. Percussion revealed dullness over hepatic area.

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Elimination: No signs of infections, no

pain during micturation or defecation.

Normal bladder pattern. Using urinal for micturation.

Stool is hard and he complaints of constipation.

CONTD…Activity and rest: Taking adequate rest. Sleep pattern

disturbed at night due unfamiliar surrounding.

Not following any peculiar relaxation measure.

Like movies and reading. No regular pattern of exercise.

CONTD….o Now, activity reduced due to

amputated wound. Mobility impaired.  Walking with crutches. Pain from joints present. No

paralysis. ROM is limited in the left leg due to

wound. No contractures present. No swelling

over the joints. Patient need assistance for doing the

activities.

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Protection: Left lower fore foot is amputated. Black discoloration present over the area. No redness, discharge or other signs of infection. Wound healing better now. Pain form knee and hip joint present while walking. Dorsalis pedis pulsation, not present over the left leg.

Right leg is normal in length and size. All peripheral pulses are present with normal rate,

rhythm and depth over right leg.

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Senses: No pain sensation from the wound site.

Relatively, reduced touch and pain sensation in the lower periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses are normal.

Fluids and electrolytes: Drinks approximately 2000ml of water. Stable

intake out put ratio. Serum electrolyte values are with in normal limit.  No signs of acidosis or alkalosis. Blood glucose elevated.

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Neurological function: He is conscious and oriented. He is anxious about the

disease conditon Touch and pain sensation

decreased in lower extrimity. Endocrine function He is on insulin. No signs and

symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands.

CONTD…. Personal self: Self esteem disturbed because of financial

burden and hospitalization. He believes in god and worshiping Hindu culture.  

ROLE PERFORMANCE MODE: He was the earning member in the family. His role

shift is not compensated. His son doesn’t have any work. His role clarity is not achieved. INTERDEPENDENCE MODE:

He has good relationship with the neighbours. Good interaction with the friends relatives.  But he believes, no one is capable of helping him at this moment. He says  ”all are under financial constrains”. He was moderately active in local social activities

SECOND LEVEL ASSESSMENT

FOCAL STIMULUS:  Non-healing wound after amputation of great

and second toe of left leg- 4 week. A wound first found on the junction between first and second toe-4 month back. The wound was non-healing and gradually increased in size with pus collected over the area.

He first showed in a local hospital,referred to medical college; During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour. So the physician suggested for below knee amputation. That made them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.

CONTD…. CONTEXTUAL STIMULI: Known case DM for past 10 years. Was on oral

hypoglycemic agent for initial 2 years, but switched to insulin and using it for 8 years now. Not wearing foot wear in house and premises.

RESIDUAL STIMULI: He had TB attack 10 year back, and took

complete course of treatment. Previously, he admitted in ---Hospital for leg pain about 4 year back. . Mother’s brother had DM. Mother had history of PTB. He is a graduate in humanities, no special knowledge on health matters.

CONCLUSION

Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer and recent amputation made his life more stressful. Nursing care of this patient based on Roy's adaptation model provided had a dramatic change in his condition. He studied how to use crutches and mobilized at least twice in a day. Patient’s anxiety reduced to a great extends by proper explanation and reassurance.  He gained good knowledge on various aspect of diabetic foot ulcer for the future self care activities.

NURSING CARE PLAN

ASSESS. OF

BEHAVIOUR

ASSESSMENT OF STIMULI

NURSING DIAGNOSIS

GOAL INTERVENTION

EVALUATION

Ineffective protection and sense in physical-physiological mode (No pain sensation from the wound site.)  

Focal stimuli: Non-healing wound after amputation of great and second toe of left leg- 4 week

1. Impaired skin integrity related to fragility of the skin secondary to vascular insufficie ncy

Long-term objective: 1. amputated area will be completely healed by 20/5/08 2.Skin will remain intact with no ongoing ulcerations.

 

-   Maintain the wound area clean as contamination affects the healing process. -   Follow sterile technique while providing cares to prevent infection and delay in healing. -   Perform wound dressing with Betadine which promote healing and growth of new tissue. - 

Short term goal: Met: size of wound decreased to less than 1x1 cms. WBC values became normal on 24/4/08

ASSESS. OF

BEHAVIOUR

ASSESSMENT

OF STIMULI

NSG DIAGNO

SIS

GOAL INTERVENTION

EVALUATION

Short-Term Objective:      i. Size of wound decreases to 1x1 cm within 24/4/08.     ii. No signs of infection over the wound within 1-wk   iii. Normal WBC values within 1-wk   iv. Presence of healthy granular tissues in the wound site within 1-wk 

-Do not move the affected area frequently as it affects the granulation tissue formation. - Monitor for signs and symptoms of infection or delay in healing. -   Administer the antibiotics and vitamin C supplementation which will promote the healing process.  

Long term goal: Partially Met: skin partially intact with no Continue ulcerations.

Plan,Reassess goal and intervention

Unmet: not achieved complete healing of amputated area. Continue plan Reassess goal and intervention

ASSESS. OF

BEHAVIOUR

ASSESSMENT OF STIMULI

NURSING DIAGNOSIS

GOAL INTERVENTION

EVALUATION

 

Impaired activity in  physical-physiological mode

 

Focal stimuli: During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour.

 

2.    Impaired physical mobility related to amputation of the left forefoot and presence of unhealed wound

 

Long term Objective:  Patient will attain maximum possible physical mobility with in 6 months.

 

-   Assess the level of restriction of movement -   Provide active and passive exercises to all the extremities to improve the muscle tone and strength. -   Make the patient to perform the ROM exercises to lower extremities which will strengthen the muscle. - 

Short term goal: Met: used crutches correctly on 22/4/08. he is self motivated in doing minor excesses Partially Met: walking with minimum support.

ASSESS. OF

BEHAVIOUR

ASSESSMENT OF STIMULI

NURSING DIAGNOSIS

GOAL INTERVENTION

EVALUATION

Short term objective:   i.Correct use of crutches with in 22/4/08 ii. walking with minimum support-22/4/08 iii.He will be self motivated in activities- 20/4/08.

 -Massage upper and lower extremities which help to improve circulation. - Provide articles near to patient, encourage performing activities within limits which promote a feeling of well being.

Long term goal: Unmet: not attained maximum possible physical mobility- Continue plan Reassess goal and interventions

CRITICISM INTERNAL CRITISIMS

Adequacy synthesis of concepts from multiple

paradigms. Conceptual models are grand theories. Difficult to understand because of

abstractness.

CONTD…Clarity Clarification of assumption needed , especially

philosophical assumptions. Clarification of role , interdepence & self

concepts. Ambiguity regarding concepts of cognator

regulator subsystems, effector mode/focal stimuli, adaptive modes/ mechanism,env./internal stimuli.

Language is clear & easy to read &understand.

CONT… Consistency & congruency Physiologic mode not connected to other 3

modes. Unclear boundaries , abstract , lack of

operational definition. Systemic assessment potential limked to nursing

process. Level of theory development Exemplary theory on development (melius,2007) Grand theory used as conceptual framework for

middle range and micro theories. Used as a framework for addressing adaptive

needs in individual , families & groups.

EXTERNAL CRITICISM Complexity/ simplicity /discrimination

/pragmatism. Simplicity is based on the language & terms. Grand theories are inherently complex. Complexity doesn’t bend into

operationalizability for research . Studies based on the model moved from face

validity to construct validity studies and relational research studies.

CONTD…. Reality convergence Nutrsing interfaces between the individual &

health care system providing holistic care. Nurses need to continue to learn and adapt

to avoid outsourcing. Roy belives nurses can avoid extinction of

the profession by not allowing themselves to nurse solely in the physiologi mode.

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Scope Grand theory RAM Middle range theory evolved RAM:-

Caregivers’s effectiveness & well being. Coping with pain & chronicity. Coping with diabetes. Gentle touch in preterm infants.

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Significance 1987 – over 100,000 nurses have

graduated from program based on RAM

Used by global scholars Models used in research ,

curriculum development, social issues , chronic illness & development of research instruments.

CONTD…. Utility Research tool development

Describes responses to health illness. Evaluates intervention Measures perception of adaptation levels. Measures perception of powerlessness & decision

making. Measures health care outcomes of cancer

patients. Regaining functional abilities after delivery.

Used to identify adaptive and maladaptive behavior to stimuli. Lack of motivation to quit smoking. Assessing & planning care of surgical patients. Care of geriatric patients.

CONTD…. Obstetrical, peadiatric and neonatal settings. Cardiac patients. Elder care Pshychiatric setting & organic brain syndrome.

9. APPLICATION OF R.A.M IN NURSING

(1) Nsg practice- R.A.M is a very useful method in nursing practice specially in those setting where there are convert psychological needs which are as essential as physical one. Roy’s models are very effective in pediatrics as well as community and rehabilatory nsg.

                

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(2)Nursing Research- R.A.M provide a conceptual model for

nursing process and this has been a basis for number of research being done.for e.g measuring functional status after child birth,functional status during pregnancy.

If research is to affect practitioners’ behavior, it must be directed at testing and retesting conceptual models for nursing practice. Roy has stated that theory development and the testing of developed theories are nursing’s highest priorities. The model must be able to regenerate testable hypotheses for it to be researchable.

                           

CONTD….(3)Education- RAM useful in educational setting. Roy states that the model defines for students the distinct purpose of nursing which is to promote man’s adaptation in each of the adaptive modes in situations of health and illness.