Edward Paul M. Noveda

8/6/2019 Edward Paul M. Noveda

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D o r o t h e a O r e m ' s S e l f - C a r e T h e o r y

D o r o t h e a O r e m ( 1 9 1 4 - 2 0 0 7 )

This page was last updated on January 4, 2011

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INTRODUCTION

y One of foremost nursing theorists.

y Born 1914 in Baltimore.

y Earned her diploma at Providence Hospital ± Washington, DC

y 1939 ± BSN Ed., Catholic University of America

y 1945 ± MSN Ed., Catholic University of America

y Involved in nursing practice, nursing service, and nursing education

y During her professional career, she worked as a staff nurse, private duty

nurse, nurse educator and administrator and nurse consultant

y Received honorary Doctor of Science degree in 1976

y Published first formal articulation of her ideas in Nursing: Concepts of

Practicein 197, second in 1980, and in 1995.

DEVELOPMENT OF THEORY

y 1949-1957 Orem worked for the Division of Hospital and Institutional Services

of the Indiana State Board of Health.

y Her goal was to upgrade the quality of nursing in general hospitals throughout

the state. During this time she developed her definition of nursing practice.

y 1959 Orem subsequently served as acting dean of the school of Nursing and

as an assistant professor of nursing education at CUA. She continued to

develop her concept of nursing and self care during this time.

y Orem¶s Nursing: Concept of Practice was first published in 1971 and

subsequently in 1980, 1985, 1991, 1995, and 2001.

MAJOR ASSUMPTIONS

y People should be self-reliant and responsible for their own care and others in

their family needing care

y People are distinct individuals

y Nursing is a form of action ± interaction between two or more persons

y Successfully meeting universal and development self-care requisites is an

important component of primary care prevention and ill health

y A person¶s knowledge of potential health problems is necessary for promoting

self-care behaviors

y Self care and dependent care are behaviors learned within a socio-cultural

context

DEFINITIONS OF DOMAIN CONCEPTS

Nursing ± is art, a helping service, and a technology

y 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

y Encompasses the patient¶s perspective of health condition ,the physician¶s

perspective , and the nursing perspective

y Goal of nursing ± to render the patient or members of his family capable of

meeting the patient¶s self care needs

y To maintain a state of health

y To regain normal or near normal state of health in the event of disease or

injury

y To stabilize ,control ,or minimize the effects of chronic poor health or disability

Health ± health and healthy are terms used to describe living things «

y 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 psychophysiological mechanisms and a

material structure and in relation to and interacting with other human beings

Environment

y environment components are enthronement factors, enthronement elements,

conditions, and developed environment

Human being ± has the capacity to reflect, symbolize and use symbols

y Conceptualized as a total being with universal, developmental needs and

capable of continuous self care

y A unity that can function biologically, symbolically and socially

Nursing client

y 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.

y A human being is the focus of nursing only when a self ±care requisites

exceeds self care capabilities

Nursing problem

y deficits in universal, developmental, and health derived or health related

conditions

Nursing process

y a system to determine (1)why a person is under care (2)a plan for care ,(3)the

implementation of care



Nursing therapeutics

y deliberate, systematic and purposeful action

OREM¶S GENERAL THEORY OF NURSING

Orem¶s general theory of nursing in three related parts:-

y Theory of self care

y Theory of self care deficit

y Theory of nursing system

A. Theory of Self Care

This theory Includes:

y Self care ± practice of activities that individual initiates and perform on their

own behalf in maintaining life ,health and well being

y Self care agency ± is a human ability which is "the ability for engaging in self

care" -conditioned by age developmental state, life experience sociocultural

orientation health and available resources

y 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"

y Self care requisites-action directed towards provision of self care. 3

categories of self care requisites are-

1. Universal

y Developmental

y Health deviation

2. Universal self care requisites

y Associated with life processes and the maintenance of the integrity of human

structure and functioning

y Common to all , ADL

y Identifies these requisites as:

y Maintenance of sufficient intake of air ,water, food

y Provision of care assoc with elimination process

y Balance between activity and rest, between solitude and social interaction

y Prevention of hazards to human life well being and

y Promotion of human functioning

3. Developmental self care requisites

y 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

y Health deviation self care

o Required in conditions of illness, injury, or disease .these include:--

o Seeking and securing appropriate medical assistance

o Being aware of and attending to the effects and results of pathologic

conditions

o Effectively carrying out medically prescribed measureso Modifying self concepts in accepting oneself as being in a particular

state of health and in specific forms of health care

o Learning to live with effects of pathologic conditions

B. Theory of self care deficit

y Specifies when nursing is needed

y 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. Theory of Nursing Systems

y Describes how the patient¶s self care needs will be met by the nurse , the

patient, or both

y Identifies 3 classifications of nursing system to meet the self care requisites of

the patient:-

y Wholly compensatory system

y Partly compensatory system

y Supportive ± educative system

y Design and elements of nursing system define

y Scope of nursing responsibility in health care situations

y General and specific roles of nurses and patients

y Reasons for nurses¶ relationship with patients and

y The kinds of actions to be performed and the performance patterns and

nurses¶ and patients¶ actions in regulating patients¶ self care agency and in

meeting their self care demand

y Orem recognized that specialized technologies are usually developed by

members of the health profession

y 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



Categories of technologies

1. Social or interpersonal

y Communication adjusted to age, health status

y Maintaining interpersonal, intra group or inter group relations for coordination

of efforts

y

Maintaining therapeutic relationship in light of psychosocial modes of functioning in health and disease

y Giving human assistance adapted to human needs ,action abilities and

limitations

2. Regulatory technologies

y Maintaining and promoting life processes

y Regulating psycho physiological modes of functioning in health and disease

y Promoting human growth and development

y Regulating position and movement in space

OREM¶S THEORY AND NURSING PROCESS

y Orem¶s approach to the nursing process presents a method to determine the

self care deficits and then to define the roles of person or nurse to meet the

self care demands.

y The steps within the approach are considered to be the technical component

of the nursing process.

y Orem emphasizes that the technological component "must be coordinated

with interpersonal and social processes within nursing situations.

OREM¶S WORK AND THE CHARACTERISTICS OF A THEORY

y Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon

y Theories must be logical in nature

y Theories must be relatively simple yet generalizable

y Theories are the basis for hypothesis that can be tested

y Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented

to validate them

y

Theories can be used by the practitioners to guide and improve their practicey Theories must be consistent with other validated theories ,laws and principles

Theory Testing

y Orem¶s theory has been used as the basis for the development of research instruments to assist researchers in using the theory

y A self care questionnaire was developed and tested by Moore(1995) for the special purpose of measuring the self care practice of

children and adolescents

y The theory has been used as a conceptual framework in assoc. degree programs also in many nursing schools



Strengths

y Provides a comprehensive base to nursing practice

y It has utility for professional nursing in the areas of nursing practice nursing curricula ,nursing education administration ,and nursing

research

y Specifies when nursing is needed

y Also includes continuing education as part of the professional component of nursing education

y

Her self care approach is contemporary with the concepts of health promotion and health maintenancey Expanded her focus of individual self care to include multi person units

Limitations

y In general system theory a system is viewed as a single whole thing while Orem defines a system as a single whole ,thing

y Health is often viewed as dynamic and ever changing .Orem¶s visual presentation of the boxed nursing systems implies three static

conditions of health

y Appears that the theory is illness oriented rather with no indication of its use in wellness settings

Summary

y Orem¶s general theory of nursing is composed of three constructs .Throughout her work ,she interprets the concepts of human beings

health, nursing and society .and has defined 3 steps of nursing process. It has a broad scope in clinical practice and to lesser extent

in research ,education and administration



Johnson's Behaviour System Model

Introduction

y Dorothy E. Johnson was born August 21, 1919, in Savannah, Georgia.

y B. S. N. from Vanderbilt University in Nashville, Tennessee, in 1942; and her M.P.H. from Harvard University in Boston in 1948.

y From 1949 until her retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and aprofessor of nursing at the University of California in Los Angeles.

y Dorothy Johnson has had an influence on nursing through her publications since the 1950s.

y

Johnson stressed the importance of research-based knowledge about the effect of nursing care on clients.

Johnson¶s behavior system model

y In 1968 Dorothy first proposed her model of nursing care as fostering of ³the efficient and effective behavioral functioning in thepatient to prevent illness".

y She also stated that nursing was ³concerned with man as an integrated whole and this is the specific knowledge of order we require´.

y In 1980 Johnson published her conceptualization of ³behavioral system of model for nursing´ this is the first work of Dorothy thatexplicates her definitions of the behavioral system model.

Definition of nursing

She defined nursing as ³an external regulatory force which acts to preserve the organization and integration of the patients behaviors at an

optimum level under those conditions in which the behaviors constitutes a threat to the physical or social health, or in which illness is found´

Based on this definition there are four goals of nursing are to assist the patient:

y Whose behavior commensurate with social demands.

y Who is able to modify his behavior in ways that it supports biological imperatives

y Who is able to benefit to the fullest extent during illness from the physicians knowledge and skill.

y Whose behavior does not give evidence of unnecessary trauma as a consequence of illness

Assumptions of behavioral system model

There are several layers of assumptions that Johnson makes in the development of conceptualization of the behavioral system model

There are 4 assumptions of system:

1. First assumption states that there is ³organization, interaction, interdependency and integration of the parts and elements of behaviorsthat go to make up The system ´

2. A system ³tends to achieve a balance among the various forces operating within and upon it', and that man strive continually tomaintain a behavioral system balance and steady state by more or less automatic adjustments and adaptations to the natural forcesimpinging upon him.´

3. A behavioral system, which both requires and results in some degree of regularity and constancy in behavior, is essential to man thatis to say, it is functionally significant in that it serves a useful purpose, both in social life and for the individual.

4. The final assumption states ³system balance reflects adjustments and adaptations that are successful in some way and to some

degree.´

The integration of these assumptions provides the behavioral system with the pattern of action to form ³an organized and integrated functionalunit that determines and limits the interaction between the person and his environment and establishes the relation of the person to the objects,events and situations in his environment.

Assumptions about structure and function of each subsystem

y ³from the form the behavior takes and the consequences it achieves can be inferred what ³drive´ has been stimulated or what ³goal´ isbeing sought´

y Each individual has a ³predisposition to act with reference to the goal, in certain ways rather than the other ways´. This predispositionis called as ³set´.

y Each subsystem has a repertoire of choices or ³scope of action´

y The fourth assumption is that it produce ³observable outcome´ that is the individual¶s behavior.

Each subsystem has three functional requirements



y System must be ³protected" from noxious influences with which system cannot cope´.

y Each subsystem must be ³nurtured´ through the input of appropriate supplies from the environment.

y Each subsystem must be ³stimulated´ for use to enhance growth and prevent stagnation.

y Johnson believes each individual has patterned, purposeful, repetitive ways of acting that comprise a behavioral system specific to

that individual.

y These actions and behaviors form an organized and integrated functional unit that determines and limits the interaction between the

person and his environment and establishes the relationship of the person to the objects event situations in the environment.

y These behaviors are ³orderly, purposeful and predictable and sufficiently stable and recurrent to be amenable to description and

explanation´

Johnson¶s Behavioral Subsystem

y Attachment or affiliative subsystem: ³social inclusion intimacy and the formation and attachment of a strong social bond.´

y Dependency subsystem: ³approval, attention or recognition and physical assistance´

y Ingestive subsystem: ³the emphasis is on the meaning and structures of the social events surrounding the occasion when the foodis eaten´

y Eliminative subsystem: ³human cultures have defined different socially acceptable behaviors for excretion of waste ,but theexistence of such a pattern remains different from culture to Culture.´

y Sexual subsystem:" both biological and social factor affect the behavior in the sexual subsystem´

y Aggressive subsystem: " it relates to the behaviors concerned with protection and self preservation Johnson views aggressive

subsystem as one that generates defensive response from the individual when life or territory is being threatened´y Achievement subsystem: " provokes behavior that attempt to control the environment intellectual, physical, creative, mechanical

and social skills achievement are some of the areas that Johnson recognizes".

Representation of Johnson's Model

Goal ----- Set --- Choice of Behavior --- Behavior

y Affiliation

y Dependency

y Sexuality

y Aggression

y Elimination

y

Ingestiony Achievement

The four major concepts

Johnson views ³human being´ as having two major systems, the biological system and the behavioral system. It is role of the medicine to focus

on biological system where as Nursling's focus is the behavioral system.

y ³Society´ relates to the environment on which the individual exists. According to Johnson an individual¶s behavior is influenced by theevents in the environment

y ³Health´ is a purposeful adaptive response, physically mentally, emotionally, and socially to internal and external stimuli in order tomaintain stability and comfort.

y ³Nursing´ has a primary goal that is to foster equilibrium within the individual. She stated that nursing is concerned with the organizedand integrated whole, but that the major focus is on maintaining a balance in the Behavior system when illness occurs in an individual.

Nursing process

Assessment

Grubbs developed an assessment tool based on Johnson¶s seven subsystems plus a subsystem she labeled as restorative which focused onactivities of daily living. .An assessment based on behavioral model does not easily permit the nurse to gather detailed information about the

biological systems:

y Affiliation

y Dependency

y Sexuality



y Aggression

y Elimination

y Ingestion

y Achievement

y Restorative

Diagnosis

Diagnosis tends to be general to the system than specific to the problem. Grubb has proposed 4 categories of nursing diagnosis derived from

Johnson's behavioral system model:

y Insufficiency

y Discrepancy

y Incompatibility

y Dominance

Planning and implementation

Implementation of the nursing care related to the diagnosis may be difficult because of lack of clients input in to the plan. the plan will focus onnurses actions to modify clients behavior, these plan than have a goal ,to bring about homeostasis in a subsystem, based on nursingassessment of the individuals drive, set behavior, repertoire, and observable behavior. The plan may include protection, nurturance or stimulation of the identified subsystem.

Evaluation

Evaluation is based on the attainment of a goal of balance in the identified subsystems. If the baseline data are available for an individual, thenurse may have goal for the individual to return to the baseline behavior. If the alterations in the behavior that are planned do occur, the nurseshould be able to observe the return to the previous behavior patterns. Johnson's behavioral model with the nursing process is a nurse

centered activity, with the nurse determining the clients needs and state behavior appropriate for that need.

Assessment

y Affiliative subsystem between mother and John.

y Dependency subsystem between mother and John

y Affiliative subsystem between Mrs.Kim and her mother.

y Insufficiency ingestion subsystem.

Diagnosis

y Insufficient development of the affiliative subsystem.

y Insufficient development of the dependency subsystem

Planning and implementation

y Increasing mother¶s awareness of the baby¶s clues.

y Assisting her to talk with the baby.

y Teach her to bring a bond between her and the baby by touch, pat and cuddles etc.

Evaluation

y Johnny's weight gain or weight loss will be carefully assessed.

y The ±infant interaction could be reassessed, using the nursing child assessment feeding scale.

y The interaction of Mrs. Kim with her mother.

Johnson¶s and Characteristics of a theory

y Interrelate concepts to create a different way of viewing a phenomenon.

y Theories must be logical in nature.

y Theories must be simple yet generalizable

y Theories can be bases of hypothesis that can be tested.



y Theories contribute to and assist in increasing the body of knowledge within the discipline through the research implemented tovalidate them

y Theories can be utilized by practitioners to guide and improve their practice.

y Theories must be consistent with other validated theories, laws and principles but will leave unanswered questions that need to beinvestigated.

Limitation

y Johnson does not clearly interrelate her concepts of subsystems comprising the behavioral system model.

y The definition of concept is so abstract that they are difficult to use.

y It is difficult to test Johnson's model by development of hypothesis.

y The focus on the behavioral system makes it difficult for nurses to work with physically impaired individual to use this theory.

y The model is very individual oriented so the nurses working with the group have difficulty in its implementation.

y The model is very individual oriented so the family of the client is only considered as an environment.

y Johnson does not define the expected outcomes when one of the system is affected by the nursing implementation an implicitexpectation is made that all human in all cultures will attain same outcome ±homeostasis.

y Johnson¶s behavioral system model is not flexible.

Summary

Johnson¶s Behavioral system model is a model of nursing care that advocates the fostering of efficient and effective behavioral functioning inthe patient to prevent illness. The patient is defined as behavioral system composed of 7 behavioral subsystems. Each subsystem composed of

four structural characteristics i.e. drives, set, choices and observable behavior.

Three functional requirement of each subsystem includes

y (1) Protection from noxious influences,

y (2) Provision for the nurturing environment, and

y (3) stimulation for growth.

Any imbalance in each system results in disequilibrium .it is nursing role to assist the client to return to the state of equilibrium.



Faye Glenn Abdellah's Theory

I N T R O D U C T I O N

y Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education

y Birth:1919

y Dr Abdellah worked as Deputy Surgeon General in US and Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C.

y She was a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practicein nursing and nursing research.

y According to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of theindividual nurse into the desire and ability to help people , sick or well, cope with their health needs.

As per Abdellah, nursing as a comprehensive service includes:

1. Recognizing the nursing problems of the patient2. Deciding the appropriate course of action to take in terms of relevant nursing principles3. Providing continuous care of the individuals total needs4. Providing continuous care to relieve pain and discomfort and provide immediate security for the individual5. Adjusting the total nursing care plan to meet the patient¶s individual needs6. Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body7. Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations8. Helping the individual to adjust to his limitations and emotional problems9. Working with allied health professions in planning for optimum health on local, state, national and international levels10. Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health

needs of people

(In 1973, the item 3, - ³providing continuous care of the individual¶s total health needs´ was eliminated.)

P H I L O S O P H I C A L U N D E R P I N N I N G S O F T H E T H E O R Y

y Abdellah¶s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory.

y The theory was created to assist with nursing education and is most applicable to the education of nurses.

y Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings.

M A J O R A S S U M P T I O N S , C O N C E P T S & R E L A T I O N S H I P S

y The language of Abdellah¶s framework is readable and clear.

y She uses the term µshe¶ for nurses, µhe¶ for doctors and patients, and refers to the object of nursing as µpatient¶ rather than client or consumer.

y She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses¶ prerogative.

Assumptions were related to

y change and anticipated changes that affect nursing;

y the need to appreciate the interconnectedness of social enterprises and social problems;

y

the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery;y changing nursing education

y continuing education for professional nurses

y development of nursing leaders from under reserved groups

Abdellah and colleagues developed a list of 21 nursing problems.They also identified 10 steps to identify the client¶s problems. 11 nursing skills

to be used in developing a treatment typology

10 steps to identify the client¶s problems

y Learn to know the patient

y Sort out relevant and significant data



y Make generalizations about available data in relation to similar nursing problems presented by other patients

y Identify the therapeutic plan

y Test generalizations with the patient and make additional generalizations

y Validate the patient¶s conclusions about his nursing problems

y Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior

y Explore the patient¶s and family¶s reaction to the therapeutic plan and involve them in the plan

y Identify how the nurses feels about the patient¶s nursing problems

y Discuss and develop a comprehensive nursing care plan

11 nursing skills

y Observation of health status

y Skills of communication

y Application of knowledge

y Teaching of patients and families

y Planning and organization of work

y Use of resource materials

y Use of personnel resources

y Problem-solving

y Direction of work of others

y Therapeutic use of the self

y Nursing procedure

2 1 N U R S I N G P R O B L E M S

Three major categories

y Physical, sociological, and emotional needs of clients

y Types of interpersonal relationships between the nurse and patient

y Common elements of client care

BASIC TO ALL PATIENTS

y

To maintain good hygiene and physical comforty To promote optimal activity: exercise, rest and sleep

y To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection

y To maintain good body mechanics and prevent and correct deformity

SUSTENAL CARE NEEDS

y To facilitate the maintenance of a supply of oxygen to all body cells

y To facilitate the maintenance of nutrition of all body cells

y To facilitate the maintenance of elimination

y To facilitate the maintenance of fluid and electrolyte balance

y To recognize the physiological responses of the body to disease conditions

y To facilitate the maintenance of regulatory mechanisms and functions

y To facilitate the maintenance of sensory function.

REMEDIAL CARE NEEDS

y To identify and accept positive and negative expressions, feelings, and reactions

y To identify and accept the interrelatedness of emotions and organic illness

y To facilitate the maintenance of effective verbal and non verbal communication

y To promote the development of productive interpersonal relationships

y To facilitate progress toward achievement of personal spiritual goals

y To create and / or maintain a therapeutic environment

y To facilitate awareness of self as an individual with varying physical , emotional, and developmental needs



RESTORATIVE CARE NEEDS

y To accept the optimum possible goals in the light of limitations, physical and emotional

y To use community resources as an aid in resolving problems arising from illness

y To understand the role of social problems as influencing factors in the case of illness

A B D E L L A H ¶ S T H E O R Y A N D T H E F O U R M A J O R C O N C E P T S

NURSING

y Nursing is a helping profession.

y In Abdellah¶s model, nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment.

y Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment.

y She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope withtheir health needs.

PERSON

y Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largelyphysical needs, or covert, such as emotional and social needs.

y Patient is described as the only justification for the existence of nursing.

y Individuals (and families) are the recipients of nursing

y Health, or achieving of it, is the purpose of nursing services.

HEALTH

y In Patient±Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness.

y Although Abdellah does not give a definition of health, she speaks to ³total health needs´ and ³a healthy state of mind and body´ in herdescription of nursing as a comprehensive service.

SOCIETY AND ENVIRONMENT

y Society is included in ³planning for optimum health on local, state, national, and international levels´. However, as she further delineated her ideas, the focus of nursing service is clearly the individual.

y The environment is the home or community from which patient comes.

A B D E L L A H ¶ S W O R K A N D C H A R A C T E R I S T I C S O F A T H E O R Y

Characteristic 1

y Abdellah¶s theory has interrelated the concepts of health, nursing problems, and problem solving as she attempts to create a differentway of viewing nursing phenomenon

y Nursing is the use of problem solving approach with key nursing problems related to health needs of people.

Characteristic 2

y Problem solving is an activity that is inherently logical in nature.

Characteristic 3

y Framework focus on nursing practice and individuals.

Characteristic 4



y The role of client within the framework.

Characteristic 5

y The results of testing such hypothesis would contribute to the general body of nursing knowledge

Characteristic 6

y Abdellah¶s problem solving approach can easily be used by practitioners to guide various activities within their practice that deals withclients who have specific needs and specific nursing problems.

Characteristic 7

y Although consistency with other theories exist, many questions remain unanswered

U S E O F 2 1 P R O B L E M S I N T H E N U R S I N G P R O C E S S

ASSESSMENT PHASE

y

Nursing problems provide guidelines for the collection of data.y A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected.

y The overt or covert nature of the problems necessitates a direct or indirect approach, respectively.

NURSING DIAGNOSIS

y The results of data collection would determine the client¶s specific overt or covert problems.

y These specific problems would be grouped under one or more of the broader nursing problems.

y This step is consistent with that involved in nursing diagnosis

PLANNING PHASE

y The statements of nursing problems most closely resemble goal statements. Once the problem has been diagnosed, the nursinggoals have been established.

IMPLEMENTATION

y Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined.

EVALUATION

y The most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals

C O N C E P T O F P R O G R E S S I V E P A T I E N T C A R E

y PPC is defined as better patient care through the organization of hospital facilities, services and staff around the changing medical

and nursing needs of the patient

y PPC is tailoring of hospital services to meet patients needs

y PPC is caring for the right patient in the right bed with the right services at the right time

y PPC is systematic classification of patients based on their medical needs

ELEMENTS OF PPC



INTENSIVE CARE

y Critically and seriously ill patients requiring highly skilled nursing care, close and frequent if not constant, nursing observation are

assigned to the ICU. One patient in an ICU requires at least three nurses to observe him in 24 hrs

y Intermediate care Patients assigned to this unit are both the moderately ill and those for whom the treatment can only be palliative

y Self care Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit

y Long term care unit This unit will provide services to certain patients now cared for in the general hospital, in nursing homes, or in

their own homes and who would benefit by care in a hospital environment to achieve its maximum potentialy Home care This programme makes it possible to extend needed services to the patient after he leaves the hospital and returns to his

home in the community

BENEFITS OF PPC

PATIENT

y better attention

y better adjustment

y minimized problems

y life saving care

y constant medical and nursing care

PHYSICIAN

y assuring best nursing care

y drugs and equipments at hand

y orders carried out effectively

y better clinical an team service

HOSPITAL

y effective and efficient use of staff

y improved public image

NURSING PERSONNEL

y individual skills can be used

y more time with patient

y helping pt. and family to solve problems

y job satisfaction

y in-service education

COMMUNITY

y continuity with hospital services

y minimize the need of hospitalization

IMPLICATIONS OF PPC FOR NURSING EDUCATION

y Many nurse educators feel that the PPC hospital where all five phases of care are available can provide clinical experience in which

the nurse can learn to solve basic nursing problems in meeting patients¶ needs.

y The three month assignment of professional nurses may no longer be realistic in such a setting.



y Organization of hospital and community services based on patients needs

y In the intensive care unit, the critically ill patients are concentrated regardless of diagnosis.

y These patients are under the constant audio-visual observation of the nurse, with life saving techniques and equipment immediately

available

y In the intermediate care unit are concentrated patients requiring a moderate amount of nursing care, not of an emergency nature, who

are ambulatory for short periods, and who are beginning to participate in he planning of their own care

y The self-care unit provides for patients who are physically self-sufficient and require diagnostic and convalescent care in hotel-type

accommodations. This unit serves as a link between the hospital and the home.y In the long-term care unit are concentrated patients requiring prolonged care. The grouping of such patients will permit staffing

patterns that are less costly

y Home care, the fifth element of progressive patient care, extends hospital services into the home to assist the physician in the care of

his patients

USEFULNESS

y The patient centered approach was constructed to be useful to nursing practice, with impetus for it being nursing education.

y Abdellah¶s publications on nursing education began with her dissertation; her interest in education for nurses continues into the

present.

y Abdellah has also published on nursing, nursing research, and public policy related to nursing in several international publications.

She has been a strong advocate for improving nursing practice through nursing research

VALUE IN EXTENDING NURSING SCIENCE

y It helped to bring structure and organization to what was often a disorganized collection of lectures and experiences.

y She categorized nursing problems based on the individual¶s needs and developed developed a typology of nursing treatment and

nursing skills..

NURSING RESEARCH

y She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced

practice in nursing and nursing research.

LIMITATIONS

y Very strong nursing centered orientation

y Little emphasis on what the client is to achieve

y Her framework is inconsistent with the concept of holism

Potential problems might be overlooked

C O N C L U S I O N S

y Using Abdellah¶s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived

is the use of the problem solving approach with key nursing problems related to health needs of people.

y From this framework, 21 nursing problems were developed

y Abdellah¶s theory provides a basis for determining and organizing nursing care. The problems also provide a basis for organizing

appropriate nursing strategies.

y It is anticipated that by solving the nursing problems, the client would be moved toward health. The nurse¶s philosophical frame of

reference would determine whether this theory and the 21 nursing problems could be implemented in practice.



O r l a n d o ' s N u r s i n g P r o c e s s T h e o r y

This page was last updated on February 11, 2011

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RODUCTION

y Ida Jean Orlando, was born in 1926.

y

Ida J. Orlando was one of the first nursing theorists to write about the nursingprocess based on her own research. ( Faust C, 2002) .

y Nursing diploma from New York Medical College

y BS in public health nursing from St. John's University, NY,

y MA in mental health nursing from Columbia University, New York.

y Associate Professor at Yale School of Nursing and Director of the Graduate

Program in Mental Health Psychiatric Nursing.

y Aat Yale she was project investigator of a National Institute of Mental Health

grant entitled: Integration of Mental Health Concepts in a Basic Nursing

Curriculum.

y It was from this research that she developed her theory which was published in

her 1961 book, The Dynamic Nurse-Patient Relationship.

y She furthered the development of her theory when at McLean Hospital in

Belmont, MA as Director of a Research Project: Two Systems of Nursing in a

Psychiatric Hospital.

y The results of this research are contained in her 1972 book titled: The Discipline

and Teaching of Nursing Processes

y Orlando held various positions in the Boston area, was a board member of

Harvard Community Health Plan, and served as both a national and international

consultant.

y Orlando's theory was developed in the late 1950s from observations she

recorded between a nurse and patient.

RODUCTION TO THEORY

y The role of the nurse is to find out and meet the patient's immediate need for

help.

y The patient's presenting behavior may be a plea for help, however, the help

needed may not be what it appears to be.

y Therefore, nurses need to use their perception, thoughts about the perception, or

the feeling engendered from their thoughts to explore with patients the meaning

of their behavior.

y This process helps nurse find out the nature of the distress and what help the

patient needs.

JOR DIMENSIONS OF THE THEORY

y Distressis the experience of a patient whose need has not been met.

y Nursing role is to discover and meet the patient¶s immediate need for help.

o Patient¶s behavior may not represent the true need.

o The nurse validates his/her understanding of the need with the patient.



y Nursing actions directly or indirectly provide for the patient¶s immediate need.

y An outcome is a change in the behavior of the patient indicating either a relief

from distress or an unmet need.

o Observable verbally and nonverbally.

y Function of professional nursing - organizing principle

y Presenting behavior - problematic situation

y Immediate reaction - internal response

y Nursing process discipline ± investigationy Improvement - resolution

NCTIONS OF PROFESSIONAL NURSING

RGANIZING PRINCIPLE

y Finding out and meeting the patients immediate needs for help

sing«.is responsive to individuals who suffer or anticipate a sense of helplessness, it

ocused on the process of care in an immediate experience, it is concerned with

viding direct assistance to individuals in whatever setting they are found for the purpose

voiding, relieving, diminishing or curing the individuals sense of helplessness

y The purpose of nursing is to supply the help a patient requires for his needs to be

met

rsing thought - Does the patient have an immediate need for help or not?

y If the patient has an immediate need for help and the nurse finds out and meets

that need ,the function of professional nursing is achieved

ESENTING BEHAVIOR ± PROBLEMATIC SITUATION

y To find out the immediate need for help the nurse must first recognize the

situation as problematic

y The presenting behavior of the patient, regardless of the form in which it

appears, may represent a plea for help

y The presenting behavior of the patient, the stimulus, causes an automatic

internal response in the nurse, and the nurses behavior causes a response in the

patient

MEDIATE REACTION ±INTERNAL RESPONSE

y Person perceives with any one of his five sense organs an object or objects

y The perceptions stimulate automatic thought

y Each thought stimulates an automatic feeling

y Then the person acts

y The first three items taken together are defined as the person¶s immediate

reaction

y Reflects how the nurse experiences her or his participation in the nurse patient



situation

RSING PROCESS DISCIPLINE - INVESTIGATION

y Any observation shared and explored with the patient is immediately useful in

ascertaining and meeting his need or finding out that he is not in need at that

time

y

The nurse does not assume that any aspect of her reaction to the patient iscorrect, helpful or appropriate until she checks the validity of it in exploration with

the patient

y The nurse initiates a process of exploration to ascertain how the patient is

affected by what she says or does

y Automatic reactions are not effective because the nurses action is decided upon

for reasons other than the meaning of the patients behavior or the patients

immediate need for help

y When the nurse does not explore with the patient her reaction it seems

reasonably certain that clear communication between them stops

PROVEMENT - RESOLUTION

y It is not the nurses activity that is evaluated but rather its result : whether the

activity serves to help the patient communicate her or his need for help and how

it is met

y In each contact the nurse repeats a process of learning how to help the individual

patient.

y Her own individuality and that of the patient requires that she go through this

each time she is called upon to render service to those who need her.

SUMPTIONS

y When patients cannot cope with their needs without help, they become

distressed with feelings of helplessness

y Nursing , in its professional character , does add to the distress of the patient

y Patients are unique and individual in their responses

y Nursing offers mothering and nursing analogous to an adult mothering and

nurturing of a child

y Nursing deals with people, environment and health

y Patient need help in communicating needs, they are uncomfortable and

ambivalent about dependency needs

y Human beings are able to be secretive or explicit about their needs, perceptions,

thoughts and feelings

y The nurse ± patient situation is dynamic, actions and reactions are influenced by

both nurse and patient

y Human beings attach meanings to situations and actions that are not apparent to

others

y Patients entry into nursing care is through medicine

y The patient cannot state the nature and meaning of his distress for his need

without the nurses help or without her first having established a helpful



relationship with him

y Any observation shared and observed with the patient is immediately useful in

ascertaining and meeting his need or finding out that he is not in need at that

time

y Nurses are concerned with needs that patients cannot meet on their own

MAIN CONCEPTS

1. Nursing ± is responsive to individuals who suffer or anticipate a sense of

helplessness

2. Process of care in an immediate experience«.. for avoiding, relieving,

diminishing or curing the individuals sense of helplessness. Finding out meeting

the patients immediate need for help

3. Goal of nursing ± increased sense of well being, increase in ability, adequacy in

better care of self and improvement in patients behavior

4. Health ± sense of adequacy or well being . Fulfilled needs. Sense of comfort

5. Environment ± not defined directly but implicitly in the immediate context for a

patient

6. Human being ± developmental beings with needs, individuals have their own

subjective perceptions and feelings that may not be observable directly

7. Nursing client ± patients who are under medical care and who cannot deal with

their needs or who cannot carry out medical treatment alone

8. Nursing problem ± distress due to unmet needs due to physical limitations,

adverse reactions to the setting or experiences which prevent the patient from

communicating his needs

9. Nursing process ± the interaction of 1)the behavior of the patient, 2) the

reaction of the nurse and 3)the nursing actions which are assigned for the

patients benefit

10. Nurse ± patient relations ± central in theory and not differentiated from nursing

therapeutics or nursing process

11. Nursing therapeutics ± Direct function : initiates a process of helping the patient

express the specific meaning of his behavior in order to ascertain his distress

and helps the patient explore the distress in order to ascertain the help he

requires so that his distress may be relieved.

12. Indirect function ± calling for help of others , whatever help the patient may

require for his need to be met

13. Nursing therapeutics - Disciplined and professional activities ± automatic

activities plus matching of verbal and nonverbal responses, validation of

perceptions, matching of thoughts and feelings with action

14. Automatic activities ± perception by five senses, automatic thoughts, automatic

feeling, action

EORY ANALYSIS

RADIGMATIC ORIGINS

y Paplau¶s focus of interpersonal relationships in nursing

y Paplau acknowledged the influence of Harry Stack Sullivan on the development



of her ideas

y Symbolic interactionism ± Chicago school

y Use of field methodology

y John Dewey¶s theory of inquiry

LANDO'S WORK AND CHARACTERISTICS OF A THEORY

y

Theories can interrelate concepts in such a way in such a way as to create adifferent way of looking at a particular phenomenon

y Theories must be logical in nature

y Theories should be relatively simple yet generalizable

y Theories can be the bases for hypotheses that can be tested

y Theories contribute to and assist in increasing the general body of knowledge

within the discipline through the research implemented to validate them

y Theories can be utililized by practitioners to guide and improve their practice

y Theories must be consistent with other validated theories, laws, and principles

but will leave open unanswered questions that need to be investigated

ERNAL DIMENSIONS

y Analyzed 2000 nurse ± patient interactions to identify the properties, dimensions

and goals of interactions

y Use of field approach

y Focus on describing psychosocial aspects of nurse - patient interaction

y Used a mixture of operational and problematic methods of theory development

y Focus on how to deliver care not on what care to be given

y Nursing process theory of low to medium level abstraction

RENGTHS

y Use of her theory assures that patient will be treated as individuals and that they

will have active and constant input into their own care

y Prevents inaccurate diagnosis or ineffective plans because the nurse has to

constantly explore her reactions with the patient

y Assertion of nursing¶s independence as a profession and her belief that this

independence must be based on a sound theoretical frame work

y Guides the nurse to evaluate her care in terms of objectively observable patient

outcomes

y Make evaluation a less time consuming and more deliberate function, the results

of which would be documented in patients charts

y Nursing can pursue Orlando's work for retesting and further developing her work

EORY CRITIQUE

y Lack of operational definitions for concepts ± limits development of research

hypothesis

y Theory is more congruent in guiding nurse ± patient interactions for assessing

needs and in providing nursing therapeutics deemed necessary to patient care



y Focus on short term care, particularly aware and conscious individuals and on

the virtual absence of reference group or family members

ITATIONS

y Highly interactive nature Orlando's theory makes it hard to include the highly

technical and physical care that nurses give in certain settings

y

Her theory struggles with the authority derived from the function of professionand that of the employing institution¶s commitment to the public

TERNAL COMPONENTS

y Value of nursing shifted from task oriented to patient oriented nursing process

y Theory is culturally bound

y Misinterpretation of continuous validation as lack of knowledge and expertise

y The uniqueness of individuals assumed by the theory could counteract automatic

responses of nurses

e in Clinical Practice

y Nursing care plan

y Case studies

y Progressive patient care settings

rsing process

y Assessment

y Diagnosis

y Planning

y Implementation

y Evaluation

MMARY

y Theorist ± IDA JEAN ORLANDO

y Development of theory

y Dimensions of theory

y Assumptions

y Concepts

y Theory analysis

y Characteristics of a theory

y Paradigmatic origins

y Strengths and limitations

y Internal and external components

y Comparison with nursing process

y Theory testing and uses of theory



NCLUSION TO THEORY

y Orlando's Deliberative Nursing Process Theory focuses on the interaction

between the nurse and patient, perception validation, and the use of the nursing

process to produce positive outcomes or patient improvement. Orlando's key

focus was to define the function of nursing. (Faust C., 2002)

y Orlando's theory remains one the of the most effective practice theories

available.y The use of her theory keeps the nurse's focus on the patient.

y The strength of the theory is that it is clear, concise, and easy to use.

y While providing the overall framework for nursing, the use of her theory does not

exclude nurses from using other theories while caring for the patient.



The Helping Art of Clinical Nursing

E r n e s t i n e W i e d e n b a c h

Last updated on February 11, 2011

INTRODUCTION

y Ernestine Wiedenbach was born in August 18, 1900, in Hamburg, Germany.

y Wiedenbach's conceptual model of nursing is called ' The Helping Art of Clinical

Nursing".

y Education:

o B.A. from Wellesley College in 1922

o R.N. from Johns Hopkins School of Nursing in 1925

o M.A. from Teachers College, Columbia University in 1934

o Certificate in nurse-midwifery from the Maternity Center Association

School for Nurse-Midwives in New York in 1946..

y Career:

o

Wiedenbach joined the Yale faculty in 1952 as an instructor inmaternity nursing.

o Assistant professor of obstetric nursing in 1954 and an associate

professor in 1956.

o She wrote F amily-Centered Maternity Nursing in 1958.

o She was influenced by Ida Orlando in her works on the framework.

y She died on March 8, 1998.

CONCEPTS AND DEFINITIONS

y Wiedenbach defined key terms commonly used in nursing practice.

The patient

y "Any individual who is recieving help of some kind, be it care, instruction or

advice from a member of the health profession or from a worker in the field of

health."

y The patient is any person who has entered the healthcare system and is

receiving help of some kind, such as care, teaching, or advice.

y The patient need not be ill since someone receiving health-related education

would qualify as a patient.

A need-for-help

y A need-for-help is defined as "any measure desired by the patient that has the

potential to restore or extend the ability to cope with various life situations that

affect health and wellness.

y It is crucial to nursing profession that a need-for-help be based on the individual

perception of his own situation.



Nurse

y The nurse is functioning human being.

y The nurse no only acts, but thinks and feels as well.

Knowledge

y

Knowledge encompasses all that has been percieved and grasped by the

human mind.

y Knowledge may be :

o factual

o speculative or

o practical

Judgment

y Clinical Judgment represents the nurse¶s likeliness to make sound decisions.

y Sound decisions are based on differentiating fact from assumption and relating

them to cause and effect.

y Sound Judgment is the result of disciplined functioning of mind and emotions,

and improves with expanded knowledge and increased clarity of professional

purpose.

Nursing Skills

y Nursing Skills are carried out to achieve a specific patient-centered purpose

rather than completion of the skill itself being the end goal.

y Skills are made up of a variety of actions, and characterized by harmony of

movement, precision, and effective use of self.

Person

y Each Person (whether nurse or patient), is endowed with a unique potential to

develop self-sustaining resources.

y People generally tend towards independence and fulf illment of responsibilities.

y Self-awareness and self-acceptance are essential to personal integrity and self-

worth.

y Whatever an individual does at any given moment represents the best available

judgment for that person at the time.

KEY ELEMENTS

y Wiedenbach proposes 4 main elements to clinical nursing.

o a philosophy

o a purpose

o a practice and

o the art.



The Philosophy

y The nurses' philosophy is their attitude and belief about life and how that

effected reality for them.

y Wiedenbach believed that there were 3 essential components associated with a

nursing philosophy:

o Reverence for life

o Respect for the dignity, worth, autonomy and individuality of eachhuman being and

o resolution to act on personally and professionally held beliefs.

The Purpose

y Nurses purpose is that which the nurse wants to accomplish through what she

does.

y It is all of the activities directed towards the overall good of the patient.

The Practice

y Practice are those observable nursing actions that are affected by beliefs and

feelings about meeting the patient¶s need for help.

The Art

y The Art of nursing includes

o understanding patients needs and concerns

o developing goals and actions intended to enhance patients ability and

o directing the activities related to the medical plan to improve the

patients condition.

y The nurses also focuses on prevention of complications related to reoccurrence

or development of new concerns.

PRESCRIPTIVE THEORY

Wiedenbach's prescriptive theory is based on three factors:

y The central purpose which the practitioner recognizes as essential to the

particular discipline.

y The prescription for the fullfillment of central purpose.

y The realities in the immediate situation that influence the central purpose.



Diagram

CONCLUSION

y Nursing is the practice of identification of a patient¶s need for help through

o observation of presenting behaviors and symptoms

o exploration of the meaning of those symptoms with the patient

o determining the cause(s) of discomfort, and

o determining the patient¶s ability to resolve the discomfort or if the

patient has a need for help from the nurse or other healthcare

professionals.

y Nursing primarily consists of identifying a patient¶s need for help.

Documents

Edward Paul M. Noveda