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Nursing Theor ies
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I n t r o d u c t i o n to Nu r s i n gT h eo r i esDeve l o p men t o f Nu r s i n g T h eo r i esV i rg in iaHen d er so n s NeedT h eo r yT h eo r y i f I n te r p er so n a l Re l a t i o n sF ayeG l en n Ab d e l l ah ' sT h eo r yJean Watson 'sth eo r yJo h n so n s b eh av i o r
A p p l i c a t i o n o f O r e m ' s S e l f - C a r e D e f i c i t
t h e o r y i n N u r s i n g P r a c t i c e
This page was last updated on April 22, 2011
OBJECTIVES
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.
PATIENT PROFILE
Areas Patient details
Name
AgeSexEducationOccupationMarital statusReligionDiagnosisTheory applied
Mrs. X
56 yearsFemaleNo formal educationHouse holdMarriedHinduRheumatoid arthritisOrems theory of self care deficit.
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sys tem mo d e l T h eo r y o f G o a lA t ta i n men tBe t ty Neu man ssys tem mo d e l L ev i n ' s F o u r
Co n ser va t i o nPr incip les Nu r s i n gT h eo r i s tsM ar th a Ro g er sS c i en ce o f u n i ta r y h u manb e i n g sT h eo r i es Based o nI n te r ac t i ve P r o cessO r em' sS e l f -Car e De f i c i tT h eo r yNu r s i n g T h eo r i es : AnO ver v i ewResear ch an dNu r s i n g T h eo r i esRo y ' sAd ap ta t i o n M o d e l O r l an d o ' sNu r s i n g P r o cess Ap p l i ca t i o nG o a l A t ta i n men tT h eo r yAp p l i ca t i o n O r em' s
S e l f - ca r e De f i c i tT h eo r y Un d er s tan d i ng th ew o r ks o f Nu r s i n g T h eo r i s ts :A c r ea t i ve b eg i n n i n gHea l thPromot ion Model Hea l thBe l i e f M o d e l T h eo r i es u sedi n Co mmu n i ty Hea l thNu r s i n gAp p l i ca t i o n o f S u ch man s S tag es o f I l l n essM o d e l Ap p l i ca t i o n o f Be t tyNeuman's Systems Model inNu r s i n g Car eAppl icat ion of Ro y ' s Ad ap ta t i o n M o d e l i nNu r s i n g P r o cess Appl icat ion
o f P ep l au ' s I n te r p er so n alth eo r y i n Nu r s i n gP r o cessAp p l i ca t i o n o f Nu r s i n gT h eo r i esT r an scu l tu r a lNu r s i n gHe l p i n g an d Hu manRe l a t i o n sh i p s T h eo r y :Robe rt R. Cark huffModels o f P r even t i o n
OREMS THEORY OF SELF CARE DEFICIT
The self care deficit theory proposed by Orem is a combination of three
theories, i.e. theory of self care, theory of self care deficit and the theory of
nursing systems.
In the theory of self care, she explains self care as the activities carried out
by the individual to maintain their own health.
The self care agency is the acquired ability to perform the self care and this
will be affected by the basic conditioning factors such as age, gender, health
care system, family system etc.
Therapeutic self-care demand is the totality of the self care measures
required.
The self care is carried out to fulfill the self-care requisites.
There are mainly 3 types of self care requisites such as universal,
developmental and health deviation self care requisites.
Whenever there is an inadequacy of any of these self care requisite, the
person will be in need of self care or will have a deficit in self care.
The deficit is identified by the nurse through the thorough assessment of the
patient.
Once the need is identified, the nurse has to select required nursing systems
to provide care: wholly compensatory, partly compensatory or supportive andeducative system.
The care will be provided according to the degree of deficit the patient is
presenting with.
Once the care is provided, the nursing activities and the use of the nursing
systems are to be evaluated to get an idea about whether the mutually
planned goals are met or not.
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Thus the theory could be successfully applied into the nursing practice.
For Mrs. X.
She came to the hospital with complaints of pain over all the joints, stiffness
which is more in the morning and reduces by the activities.
She has these complaints since 5 years and has taken treatment from local
hospital.
The symptoms were not reducing and came to --MC, Hospital for further
management.
Patient was able to do the ADL by herself but the way she performed and the
posture she used was making her prone to develop the complications of the
disease.
She also was malnourished and was not having awareness about the
deficiencies and effects.
DATA COLLECTION ACCORDING TO OREMS THEORY OF SELF CARE
DEFICIT
1. BASIC CONDITIONING FACTORS
Age 56 year
Gender Female
Health state Disability due to health condition,therapeutic self care demand
Development state Ego integrity vs despair
Sociocul tural orientation No formal education, Indian, Hindu
Health care system Institutional health care
Family system Married, husband working
Patterns of living At home with partner
Environment Rural area, items for ADL not in easyreach, no special precautions toprevent injuries
resources Husband, daughter, sisters son
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2. UNIVERSAL SELF-CARE REQUISITES
AirBreaths without difficulty, no pallor cyanosis
Water Fluid intake is sufficient. Edema present over ankles.Turgor normal for the age
Food Hb 9.6gm%, BMI = 14.Food intake is notadequate or the diet is not nutritious.
Elimination Voids and eliminates bowel without difficulty .
Activ ity/ rest Frequent rest is required due to pain.Pain not completely relieved,Activity level ha s come down.Deformity of the joint secondary to the diseaseprocess and use of the joints.
Social interaction Communicates well with neighbors and callsthe daughter by phone Need for medical careis communicated to the daughter.
Prevention of hazards Need instruction on care of joints andprevention of falls. Need instruction onimprovement of nutritional status. Prefer towalk bare foot.
Promotion of normalcy Has good relation with daughter
3. DEVELOPMENTAL SELF-CARE REQUISITES
Maintenance ofdevelopmental
environment
Able to feed self , Difficult to perform thedressing, toileting etc
Prevention/ managementof the conditionsthreatening the normaldevelopment
Feels that the problems are due to her ownbehaviours and discusses the problems withhusband and daughter.
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4. HEALTH DEVIATION SELF CARE REQUISITES
Adherence to medicalregimen
Reports the problems to the physician whenin the hospital. Cooperates with themedication, Not much aware about the useand side effects of medicines
Awareness of potentialproblem associated withthe regimen
Not aware about the actual disease process.
Not compliant with the diet and prevention ofhazards. Not aware about the side effects ofthe medications
Modification of self imageto incorporates changes inhealth status
Has adapted to limitation in mobility.
The adoption of new ways for activities leadsto deformities and progression of the disease.
Adjustment of lifestyle toaccommodate changes inthe health status andmedical regimen.
Adjusted with the deformities.Pain tolerance not achieved
5. MEDICAL PROBLEM AND PLAN
Physicians perspective of the condition: Diagnosed with rheumatoid arthritis and is
on the following medications:
T. Valus SR OD T. Pan 40 mg OD
T. Tramazac 50 mg OD
T. Recofix Forte BD
T. Shelcal BD
Syp. Heamup 2tsp TID
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Medical Diagnosis: Rheumatoid arthritis
Medical Treatment: Medication and physical therapy.
AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF SELF-CARE
DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING DIAGNOSIS.
Air
Water
Food
Elimination
Activity/ Rest
Solitude/ Interaction
Prevention of hazards
Promotion of normalcy
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.
modify self image
Adjust life style to accommodate health status changes and MR
NURSING CARE PLAN ACCORDING TO OREMS THEORY OF SELF CARE
DEFICIT
Nursing Outcome and plan Implementation Evaluation
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diagnosis(diagnosticoperations)
(Prescriptiveoperations)
(controloperations)
(regulatoryoperations)
Based on self
care deficits
Outcome
Nursing goal andobjectivesDesign of nursingsystemAppropriate method ofhelping
Nurse- patient
actions to- Promote patientas self care agent- Meet self careneeds- Decrease the selfcare deficit.
1. Effectiveness of
the nurse patientaction to-Promote patient asself care agent- Meet self careneeds- Decrease the selfcare deficit.2. Effectiveness ofthe selected nursingsystem to meet theneeds.
Thus in the patient Mrs. X the areas that need assistance were
Air
Water
Food
Elimination
Activity/ Rest(2)
Solitude/ Interaction
Prevention of hazards(2)
Promotion of normalcy
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.
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modify self image
Adjust life style to accommodate health status changes and medical regimen
APPLYING THE OREMS THEORY OF SELF-CARE DEFICIT, A NURSING CARE
PLAN FOR MRS. X COULD BE PREPARED AS FOLLOWS
A. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: FOOD
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS
Inability to maintain the ideal nutrition related to inadequate intake andknowledge deficit
OUTCOMES AND PLAN
a. Outcome:
Improved nutrition
Maintenance of a balanced diet with adequate iron supplementation.
b. Nursing Goals and objectives
Goal: to achieve optimal levels of nutrition.
Objectives: Mrs. X will:
state the importance of maintaining a balanced diet.
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List the food items rich in iron , that are available in the locality.
c. Design of the nursing system:
supportive educative
d. Method of helping:
guidance
support
Teaching
Providing developmental environment
IMPLEMENTATION
Mutually planned and identified the objectives and the patient were made to
understand about the required changes in the behaviour to have the
requisites met.
EVALUATION
Mrs. X understood the importance of maintaining an optimum nutrition.
She told that she will select the iron rich diet for her food.
She listed the foods that are rich in iron and that are locally available.
The self care deficit in terms of food will be decreased with the initiation of
the nutritional intake.
The supportive educative system was useful for Mrs. X
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B. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: ACTIVITY
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS
Self-care deficit: dressing, toileting related to restricted joint movement,
secondary to the inflammatory process in the joints.
OUTCOMES AND PLAN
a. Outcome:
improved self-care
maintain the ability to perform the toileting and dressing with modification as
required.
b. Nursing Goals and objectives
Goal: to achieve optimal levels of ability for self care.
Objectives: Mrs. X will:
perform the dressing activities within limitations
utilize the alternative measures available for improving the toileting
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perform the other activities of daily living with minimal assistance.
c. Design of the nursing system: Partly compensatory
d. Method of helping:
1. Guidance:
Assess the various hindering factors for self care and how to tackle them.
2. 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.
Provide passive exercises and make to perform active exercises so as to
promote the mobility of the joint.
Make the patient use commodes or stools to perform toileting and insist on
avoidance of squatting position
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.
3. Teaching:
Teach the family members the limitation in the activity level the patient has
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and the cooperation required
4. Promoting a developmental environment:
Teach the family and help them to practice how to help the patient according
to her needs
IMPLEMENTATION
Mutually planned and identified the objectives and the patient was made to
understand about the required changes in the behaviour to have the
requisites met.
EVALUATION
Patient was performing some of the activities and she practiced toileting
using a commode in the hospital.
She verbalized an improved comfort and self care ability.
She performed the dressing activities with minimal assistance
Patient verbalized that she will perform the activities as instructed to get her
ADL done.
The partly compensatory system was useful for Mrs. X
----------------------------------------------------------------------
C. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: PAIN CONTROL
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ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS
Ineffective pain control related to lack of utilization of pain relief measures
OUTCOMES AND PLAN
a. Outcome:
improved pain self control
achieve and maintain a reduction in the pain.
b. Nursing Goals and objectives
Goal: to achieve reduction in the pain.
Objectives: Mrs. X will:
describe the total plan of pharmacological and non pharmacological pain
relief
demonstrate a reduction in the pain behaviours
verbalize a reduction in the pain scale score from 7 4
c. Design of the nursing system: supportive educative
d. method of helping:
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Guidance:
Explore the past experience of pain and methods used to manage them.
Ask the client to report the intensity, location, severity, associated and
aggravating factors.
Support:
Provide rest to the joints and avoid excessive manipulations
provide hot and cold application to have better mobility.
Encourage exercises to the joints by immersing in the warm water.
Administer T. Ultracet and Tab Diclofecac as prescribed. Provide diversion and psychological support to the patient
Teaching:
Teach the non pharmacological method to the patient once the pain is a
little reduced.
Providing the developmental environment:
Discuss with the patient the necessity to maintain a pain diary with all
information regarding episodes of pain and refer to that periodically
Enquire from the health team, the need for opioid analgesics or other
analgesics and get a prescription for the patient.
IMPLEMENTATION
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---------------------------------------
---------------------------------------
EVALUATION
Patient still has pain over the joints and she agreed that she will use the
measures for pain relief that is told to her.
The pain scale score was 6 after the measures were provided to the patient.
She demonstrated slight reduction in the pain behaviours.
The supportive educative system was useful for Mrs. X
--------------------------------------------------------------
D. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: PREVENTION OF
HAZARDS.
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS
Potential for fall and fractures related to rheumatoid arthritis.
OUTCOMES AND PLAN
a. Outcome:
Absence of falls and injury to the patient
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b. Nursing Goals and objectives
Goal: prevent the falls and injury and to maintain a good body mechanics.
Objectives: Mrs. X will:
remain free from injury as evidenced by:
absence of signs and symptoms of fall or injury
Explaining the methods to prevent the injury.
c. Design of the nursing system: supportive educative
d. method of helping:
Support
Never leave the client alone in the unit
Assess the patients gait, activities and the mental status for any confusion or
disorientation
Encourage the patient to use supportive devices as required.
Provide a safe environment in the hospital by avoiding sharp objects or
wooden objects on the way and slippery floor.
Involve the family members in providing and maintaining a safe environment
in the home
Involve the family members to provide support to the patient whenever
necessary
Plan a balanced diet for the patient with a mutual interaction
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IMPLEMENTATION
---------------------------------
----------------------------------
EVALUATION
Patient remained free from injury as evidenced by absence of signs and
symptoms.
Patient explained the various measures that they will take to prevent the
injury.
The supportive educative system was useful for Mrs. X
------------------------------------------------------------------
E. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: PREVENTION OF
HAZARDS.
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS:
Potential for impaired skin integrity related to edema secondary to renal
cysts.
OUTCOMES AND PLAN:
a. Outcome:
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Maintenance of normal skin integrity.
b. nursing Goals and objectives
Goal: Maintain the skin integrity and take measures to prevent skin impairment.
Objectives: Mrs. X will:
maintain a normal skin integrity
list the measures to prevent the loss of skin integrity
identify the measures to relieve edema.
c. Design of the nursing system: supportive educative
d. method of helping:
Support:
Assess the skin regularly for any excoriation or loss of integrity or colour
changes. Keep the skin clean always
Avoid stress or pressure over the area of edema by providing extra cushions
or padding
Monitor the lab values as well as the patient for any signs and symptoms of
renal failure.
Encourage the patient to use slippers while walking and that should not be
tight fitting.
Assess the edema for its degree, pitting or non pitting and continue the
assessment daily.
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Provide a leg end elevated position or elevation of the leg on a pillow if no
cardiac abnormalities are identified.
Explain the patient the need for taking care of the edematous parts
Explain the patient to report the symptoms like decreased urine output,
palpitations, increased edema etc. to the health team
IMPLEMENTATION
----------------------------------
----------------------------------
EVALUATION
Patient remained free from impaired skin integrity
She listed the measures to prevent the loss of skin integrity
She identified the measures to relieve edema.
The supportive educative system was useful for Mrs. x
-----------------------------------------------------------------
F. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: AWARENESS OF
THE DISEASE PROCESS AND MANAGEMENT
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS
Potential for complications related to rheumatoid arthritis secondary to
knowledge deficit.
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OUTCOMES AND PLAN
a. Outcome:
Absence of complications and improved awareness about the disease
process.
b. nursing Goals and objectives
Goal: Improve the knowledge of the patient about the disease process and the
complications.
Objectives: Mrs. X will:
verbalize the various complication and their preventions
verbalize the changes occurring with the disease process and the treatment
available
describe the actions and side effects of the medications which she is using
c. Design of the nursing system:
supportive educative
d. Methods of helping:
Guidance
Teaching
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Promoting a developmental environment
IMPLEMENTATION
-------------------------------
-------------------------------
EVALUATION
Patient got adequate information regarding the disease
She verbalized what she understood about the disease and its management.
Patient has cleared her doubts regarding the medication actions and the side
effect
The supportive educative system was useful for Mrs. X
EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY
The theory of self-care deficit when applied could identify the self care requisites of
Mrs. X 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 rheumatoid arthritis.
REFERENCES
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed.
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Missouri: Elsevier Mosby Publications; 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).
Mosby, Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice .
5th ed. New Jersey :Prentice Hall;2002.
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