joumal of Advanced Nursing, 1990,15, 447-455

The Betty Neuman Systems Model applied

to practice: a client with multiple sclerosis
Janet B Knight, BScN MScN RN
Assistant Professor, School of Nursing University of Ottawa, Ottawa, Canada

Accepted for publicahon 8 March 1989

KNIGHT J B (1990) Journal of Advanced Nursmg 1 5 , 447-455

The Betty Neuman Systems Model applied to practice: a client with
multiple sclerosis
The importance of nursing theones and models for the growth and development
of the profession of nursing is widely acknowledged The vanety of nursing
phenomena and situations demands some flexibility m the choice of specific
conceptualizations to be used This paper demonstrates the goodness of fit of the
Betty Neuman Systems Model to the care of clients with multiple sclerosis An
adapted assessment tool, based on Neuman's tool, but more useful m the acute
care medical setting, is used to gather data related to a woman with recently
diagnosed multiple sclerosis A nursing care plan illustrating the use of Neuman's
model IS generated, implemented and evaluated The Neuman Model is
demonstrated to be useful and effective m the implementation of the nursing
process in this case

INTRODUCTION dictates (McGee 1984) This paper desaibes some salient

features of nursing clients with multiple sclerosis (MS),
The 1980s have been charactenzed by the acceptance of demonstrates the goodness-of-fit of the Betty Neuman
the significance of theones and models for nursmg (Fawcett Systems Model (Neuman 1982) to the care of these clients,
1989, Meleis 1985) Such conceptualizahon help to clearly and specifically illustrates the application of this model to a
define the domain of nursing by differenhating it from the case study of a client with MS A modified assessment tool,
domain of mediane and other health care disaplmes They based on Neuman's tool, is utilized and is shown to apply
provide coherent and systematic frameworks which can to acute care medical patients
guide and direct nursmg assessment, plannmg and inter-
vention The language of models and theones, the
definihons of terms and the desaiptions of concepts, pro- SALIENT FEATURES OF MULTIPLE
vide grounds for communication among nurses and are SCLEROSIS
essential for nursmg research (Fawcett 1989, Jacox Multiple sclerosis is a generally non-fatal, chronic and often
1974) The conceptual-theoretical system of knowledge — progressive disease of the central nervous system which
represented by models and theones — is a vehicle of occurs pnmanly between the ages of 20 2md 40 years The
professionalism (Gruending 1985), espeaally for those uncertainty related to the course of the disease and the
professional attnbutes of accountability and autonomy actual or potential disruption of various motor, sensory or
(Fuller 1978, McKay 1969) cognitive funchons, can have complex and unpredictable
The enormous vanety of nursing phenomena and the affects on every aspect of a person's life The nurse caring
situahons in which they occur demand some flexibihty in for the client with MS must have a guide or framework for
the choice of nursmg theones or models as the situation carrying out the nursing process m situations with com-
plex and interactive vanables In MS, as m many chronic
Correspondence lanetB Kmght School of Nursing University of Ottawa 451 Smyth
Road Ottawa Oatano M1H8M5 Canada
unpredictable condihons, the meanings or mterpretahons

447
JB Knight

Primary 1
NURSING Secondary \ levels of prevention HEALTH
Tertiary f

Optimal
well ness

Reaction dependent on

' v strength of core and

Nines'
'v, amount and timing of
stressors
STRESSORS PERSON Reaction <\' intra-, inter- and extra-
personal factors
Related to Composite of
five variables 'v/ interrelationships of
•^ intra - \
f personal factors the five variables
V in environment
~ extra- ^ -^ psychological
~ sociocultural
Death
"" spiritual
-^ developmental

Figure 1 A conceptualizahon of the Betty Neuman Systems Model

that the client gives to the disease and its many physical client vanables accommodate the complexity and unpre-
and psychosoaal effects, are of cntical importance in dictability of situations encountered by the MS client The
relahon to the client's adjustment (Brooks & Matson 1982, model's major focus on perception is extremely helpful for
Duval 1984) Clients with chronic disease should ideally dealing with vanous clients' feelings, athtudes and beliefs
manage their own lives and should be co-aeators with that may affect the course of the disease and the appropn-
nurses and others of plans to help them maintam, regam, or ateness of management goals and modalihes The three
attain optimum functioning (McEwen et al 1983) A nurs- levels of prevention m this model — pnmary, secondary
ing framework that is suitable for workmg with clients with and terhary — certainly fit the vanous settmgs m which
MS must accommodate for the importance of percephon the client may encounter a nurse The model's non-reliance
and be compatible with the collaborahve approach on the medical model or the concept of illness is another
between the client and caregiver reason for its adoption m the case of a client with MS
MS IS a disease with the possibility of remissions and The followmg section presents a bnef summary of the
exacerbations and an overall deaease m functional ability major concepts and assumphons of the model The model
as time progresses A useful nursmg framework should IS then appbed to a case study of a young woman with MS
accommodate for the need to prevent complicahons, treat
acute problems and rehabilitate the client Fmally, there is
THE NEUMAN SYSTEMS MODEL
so far no proven medical treatment to halt or slow the
progress of this disease This condihon requires manage- This sechon descnbes the Neuman (1982) Model m terms
ment of speafic responses of the client to improve his of the four meta-paradigms of nursmg (Fawcett 1989) per-
functioning in daily life An avoidance of the 'sick role' for son, environment, health, and nursing For a diagrammatic
these clients is essential A nursmg framework which is not conceptualizahon of Neuman's model see Figure 1
dependent on the medical model or the concept of illness is
essential for working with MS clients
Person
Neuman (1982) views the client (an mdividual or coUechve
THE FIT OF THE NEUMAN MODEL
entity) as an open system The mdividuai dient is adyivanuc
The Betty Neuman Systems Model is ideally suited for composite of the mterrelahonship of five vanables physio-
guidmg nursing prachce m relation to the client with MS logic, psychologic, soaoculhiral, spintual, and develop-
The model's open-system charactenstics, its mcorporahon mental (C^>ers et al 1985) To meet personal needs, the
of the tune vanable, and its consideration of five major client mteracts with the environment and affects it and

448

Figure 2 The conception of the person in Betty Neuman's
Systems Model (based on Neuman 1982)
IS affected by it Each individual has charactenstics or
responses that fall within a common range and sets of
strengths or speafic responses that set him apart as unique
The system of the client can be portrayed figuratively
(Figure 2) by a core of basic structure and energy resources
surrounded by three hypothehcal concentnc circles rep-
resentmg boundanes (Neuman 1982) The closest bound-
ary, the lines of resistance, protects the core and consists of
internal defensive processes such as the immune response
and physiological hemeostatic mechanisms The next
boundary is the normal line of defence, or dynamic equilib-
num, and represents what the person has become over
hme It includes such aspects as intelligence, attitudes, and
problem solvmg and coping abibties The outennost
boundary is the flexible Ime of defence, a protective buffer
for the normal Ime of defence It has an accordion-like
action wbch changes m a relahvely short time dependent
on such factors as amount of sleep, level of nutrition, and
the quality and quanhty of stress
A person is constantly subject to stressors from withm
his own system and from the environment which can cause
disequilibnum, situational or maturahonal cnses, disease or
death (Neuman 1982) Reachon to stressors is determmed
in part by natural and teamed resistance which is mani-
fested by the strength of the core and the vanous lines
Factors which influence the reaction to stressors are mtra-,
inter- or extra-personal m nature The quabty and quantity
of an individual's reaction to stressors is determined by the
lnterrelahonships of the five vanables Of cnhcal import-
ance IS the person's percephon of a stressor smce it can
affect the person's resistance and response to the stressor
Betty Neuman Systems Model
The number, timing and mtensity of stressors also affect a
person's resistance to a stressor
Environment
Neuman states that the environment is 'that viable arena
which has relevance to the life span of an organism'
(Neuman 1982) She also views it as all factors affecting or
affected by a person Neuman contends that there is an
internal and external environment, a pomt which confuses
many as she does not clearly delineate the boundanes
between person and environment Although not stahng it
explicitly, Neuman (1974,1982) suggests that the environ-
ment IS the source of stressors and provides resources for
managing these stressors Stressors are such things as
miao-orgamsms, a ruptured aneurysm, radiation, excess-
ive noise, and interpersonal conflict Resources are entities
such as a functioning immunological system, good coping
sblls, education, strong family support, and a community
health centre Stressors can be classified as either benefiaal
or noxious, depending on their nature, timing, degree and
potential for either ultimate posihve or negative change in
the person Neuman places more emphasis on stressors
than any other aspect of the environment, as is highlighted
m Figure 1
Health
Neuman (1982) states that health or wellness — she uses
the terms synonymously — is the condition in which the
flexible line of defence has prevented penetration of the
normal line of defence and all parts and subparts are in
harmony (steady-state) with the whole of the person
Optimum wellness occurs when all needs are met Con-
versely, illness — or vanance from wellness, as she terms
it — IS a state of insufficiency or mstabibty, a state in which
disrupting needs are yet to be satisfied and the normal Ime
of defence is penetrated (Neuman 1982) Neuman implies,
without explicitly stating, that health, in the broad sense, is
a continuum with wellness at one end and extreme van-
ances from welbess (and ulhmately death) at the other end
Neuman (1982) uses the term reconstituhon to descnbe
the events which occur followmg the impact of a stressor
In the process of reconstruction, a person can progress
beyond his normal Ime of defence to a higher than usual
state of wellness or below his usual state of wellness
Nursing
Nursmg is defmed by Neuman as a 'unique profession that
IS concemed with all vanables affecting an mdividual's re-
sponses to stressors' (Neuman 1974) The mam concem of
449
; B Knight

Table 1 Summary of Betty Neuman's nursing process steps identified Based on the time frame associated with the
stressor impact on the person, Neuman has developed three
A Nursmg diagnosis levels of prevention Pnmary prevention is selected when a
J Data base and assessment stressor is suspected but no reaction has taken place Inter-
— identification, classification and evaluation of venhon strategies mclude education, desensitizahon
interactions among five client variables agamst nsks, avoidance of hazards, and strengthening
— identification of stressors and resources m the resistance to nsks Secondary prevention is appropnate
lntra- inter- and extra-personal areas when a reaction to a stressor has already occurred At this
— identification and differentiation of client and level the caregiver pnontizes the client's needs and cames
caregiver perceptions out actions aimed at stabilizing the system by conserving
— attempt to resolve perceptual differences client energy or purposefully manipulatmg stressors or
2 Actual or potential vanances from wellness
reaction to stressors Tertiary prevention is used after some
(These are what most other theonsts caU 'nursing diag-
mterventions at the secondary level prevention have been
noses' )
instituted and some degree of reconstitution has occurred
B Nursing goals
J Expected outcomes, l e specific desirable behavioural re- Tertiary level mterventions include increasing motivation,
sponses to deal with the actual or potential variances modifying maladaptive behaviour, orienting to reality, or
from wellness (decided by client and caregiver in re-education
collaboration)
2 Planned mteroenttorts, i e specific actions of client, care-
giver or others to effect expected outcomes APPLICATION OF THE NEUMAN MODEL
C Nursing outcomes
1 Actual interventions, l e interventions actually earned Client profile
out
2 Evaluation and goal reformulation Miss T IS a 22-year-old third-year university student who
— analysis of specific client responses IS engaged to be mamed but plans to finish her degree m
— determination of attainment of expected outcomes physical educahon first She has been m excellent health
— if incomplete attainment, determination of cause of until recently She was hospitalized for investigation of the
non-attainment third episode m a penod of 5 months of weakness and
— goal reformulation as needed
numbness m her legs Dunng her admission neurological
assessment, it was noted that she had decreased motor co-
ordmahon on her nght side, slight lack of equibbnum, some
nursmg is the total person and the goal of nursmg is to mild weakness m both legs, and nystagmus She reported
maintain, regain or attam client system stabihty Neuman 'seeing double', some numbness of her nght legs, and some
suggests that this stability or maximum level of wellness unnary urgency and frequency She displayed signs of mild
can be attained 'by purposeful mterventions aimed at anxiety She reported that she had been to the doctor
reduction of stress factors and adverse condihons which several times m the past 2 years because of dizziness,
either affect or could afiFect optimal functionmg m a given excessive fahgue and several minor musculoskeletal com-
client situation' (Neuman 1982) plaints About 6 months ago her physician suggested that
there was nothing organically wrong and that she was
expenencmg a stress reaction Counselling was advised but
Nursmg process , she did not follow through with the doctor's suggestion
Neuman's (1982) process contains three basic part's
At the start of this case study. Miss T has been m the
nursing diagnosis, nursmg goals, and nursing outcomes
hospital for 8 days and had had blood, unne and cerebro-
Neuman stresses the importance of identifying cbent and
spmal fluid tests, skull and spmal X-rays, computenzed axial
caregiver perceptions and coUaboratmg between client and
tomography and magnetic resonance imaging scans, an
caregiver at all stages of the process Table I summanzes
electroencephalogram, and visual and auditory evoked
Neuman's nursing process steps
potentials All of the investigations were normal except for
her cerebrospmal fluid tests which revealed elevated total
Levels of prevention protein, elevated gamma globulin and oligodonal bands
Neuman (1982) states that intervenhon can begm at any The neurologist mformed her that these results were
point at which the stressor is suspected or detected and highly suggeshve of MS

450
 Betty Neuman Systems Model

Assessment tool System review

Neurological
The following tool was used to gather data about Miss T
Gastrointestinal
by the nurse Based on Neuman's (1982) tool, it has been
Respiratory
adapted by the author and her colleagues to more readily
Gemto-unnary
fit an acute care medical setting There are two areas of
Musculoskeletal
change Section A, the intake summary, has been expanded
Cardiovascular
to mclude data about diagnosis, admission and discharge,
Dermatological
medication and other pertinent facts Section Dla, the
Endocrme-reproductive
physiological section of mtra-personal factors, has been
Functional status
expanded to mclude a system review and a two item func-
Activities of daily living
tional review These additions constitute a minor adap-
Rest and sleep
tation of Neuman's instrument and m no way affect the
b. Psychological
application of the model itself
c. Sociocultural
d. Developmental
Intake summary e. Spiritual
Name 2 Interpersonal factors
Age Resources, relationships of family, fnends, caregivers
Mantal status 3 Extrapersonal factors
Medical diagnosis Resources, relahonships with other groups, insti-
Date of admission to hospital tutions, fmimcial, employment
Date of discharge from hospital
Date of assessment
£ Formulation of actual or potential variances from wellness
Other pertinent facts
(nurstng diagnoses)
Medications

Assessment findings
Stressors (as perceived by client)
What do you consider your major problem, stress area A Intake summary
or areas of concem? 1 Name MissT
How do present circumstances differ from your usual 2 Age Female
pattern of living? 3 Mantal status Single
Have you ever expenenced a similar problem? If so, 4 Medical diagnosis Probable MS
what was the problem and how did you handle it? 5 Date of admission to hospital 15 February
Were you successful? 6 Date of discharge (still hospitalized)
What do you anticipate for yourself m the future as a 7 Date of assessment(s) 15-23 February
consequence of your present situation? 8 Other pertinent facts
What are you doing and what can you do to help 9 Medictions Multivitamms and birth control pills
yourself?
What do you expect caregivers, family, friends or B Client's perception of stressors
others to do for you? Miss T 's major concem was the meaning that the diag-
nosis of MS has m relahon to her plans for finishing her
C Stressors (as perceived by the nurse) degree, a career in physical education, mamage, and a
The same six questions, as above, should be answered, but family Her immediate area of stress was how she was
from the standpoint of how the nurse evaluates the cbent, going to make up classes and assignments She had always
the cbent's major problem, pattem of bvmg, present and been very physically active cmd was proud that she was
past copmg strategies, and expectahons for the future and strong, physically fit and as 'healthy as a horse' She had a
of others recurrent mental image of the only person she knows with
MS, an mcontment, partially blind wheelchair-bound man
D Summary of impressions She declared I'm not going to give into this' I will be better
1 Intrapersonal factors if I just get back to my usual regime of physical achvity and
a. Physiological my well balanced diet' She expected the neurologist to

451
JB Knight
discuss aspects of neuropathology and possible treatment
with her She thought the nurses could help her by answer-
ing some questions about MS, 'but the nurses seem so
busy, I hate to bother them' She said 'My parents are really
upset by this I've got to put on a brave face' and 'My fiance
IS such a support for me, I don't know what I would do
without him'
C Nurse's perceptions of stressors
Miss T 's major stressor was the profound threat that this
recent altered functioning and diagnosis of probable MS
has had to her image of herself as physically fit, strong and
possessing mastery over the functionmg of her body A
secondary, but important stressor was the threat to present
and future roles as student, career woman, wife and mother
The stressor of the inflammatory process m her nervous
system was important but, beyond the use of cortico-
steroids, there is no known direct way to influence this
process, more than temporanly
She had never had a similar cnsis before and her coping
style at the time of the case study was a combination of
information seebng, mtellectualizmg, and some denial of
the seriousness of the diagnosis and her need for emotional
support She constantly asked several different nurses the
same questions Fier affect vaned between cheerfulness and
seeming unconcern and some withdrawal and agitation
She was sleeping poorly, but resisted attempts by the
nurses to discuss her concems She was very anxious to get
back to her apartment so she would have more control over
her life She relied almost exclusively on her fiance for
emotional support and seemed to expect very little of any
of the health professionals, fnends or her parents Although
Miss T 's strengths of intelligence, knowledge (related to
diet, exercise and fitness), and self-reliance would certainly
be assets in dealing with the stressors, it appeared that if
she did not acknowledge her need for emotional support
and exploration of her feelmgs with appropnate resource
people, she might not be able to handle the cnsis
D Summary of impressions (only significant fmdings are
noted here)
1 Intrapersonal factors
a. Physiological
System review
Neurological — left eye laggmg on abduchon,
reports intermittent diplopia, honzontal nystagmus
with with slight nght and left lateral gaze, inability to
tandem walk, falls to nght dunng Rhomberg test,
slight slowness and clumsiness of nght arm dunng
rapidly altemahng movements, difficulty with moving
nght heel down left shm, slight weakness in hip flexors
Gastrointestinal — none
452
Respiratory — respiratory rate 28, frequent sighing,
non-smoker
Genito-unnary — reports unnary frequency mteimit-
tently over past year
Musculoskeletal — well-developed muscles and
except for above noted abnormalihes exhibits above
average strength m most muscle groups of arms and
legs
Cardiovascular — apical rate 92
Dermatological — none
Endocnne-reproduchve — on birth control pills for
3 years, yearly normal pap smears
Functional status
Activihes of daily living — reports intermittent mild
to severe fatigue over 3 years, worse in past year, has
had to cut out extracumcular sports (volleyball and
tennis) this term Managing with effort to meet her
academic requirements Difficulty in domg her share of
household chores
Rest and sleep — unable to rest and sleep adequately
in hospital environment, walks around ward and hospi-
tal dunng day, has difificulty sithng still or resting,
sleeps 6-7 hours at night with frequent wakmg, refuses
oxazepam ordered as sedative
b. Psychological
Mood labile (see stressors as perceived by nurse),
would not talk m any depth about her feelmgs about
the diagnosis, was unhappy that she could not main-
tain her usual diet (high fibre, low animal fat, avoidance
of refined carbohydrates) m the hospital, spent a lot of
hme with her fiance and was frequently seen quietly
crying while in discussion with him
c. Soaocultural
Is a member of mainstream white anglosaxon cultural
group, strong belief system which values education,
self-reliance, workmg hard, and physical strength and
fitness, values women having equal status with men m
all areas
d. Developmental
Has been successfully engaged in meetmg devel-
opmental needs appropnate to a young adult, l e
prepanng for a career and mamage
e. Spintual
Considers herself a Chnshan, but has not regularly
attended church since she left home for university,
stated she talks to her fiance and others about
religious and ethical beliefs but does not feel
comfortable with organized religion
2 Interpersonal factors
Miss T IS an only child Her parents are healthy and
live 50 miles away She feels respect and affection for
 Betty Neuman Systems Model

her parents, but considers herself to be largely mdepen- nurse negotiated some short-term goals The followmg
dent of them She and her fiance are close and mutually section outlmes the expected outcomes and planned inter-
supportive They have lived together for a year and ventions that compnsed nursmg goals to address each of
have several fnends m common, mostly other couples the four nursing diagnoses
She has two close women fnends, but her contact with
them has decreased since her engagement a year ago
7 Related to diagnosis 1
Her fiance has stated to several nurses that smce Miss
A
Expected outcomes
T 's hospitalization he has felt a lot of stress, has had
1
Miss T will verbalize an acceptance of the idea that she
headaches and abdominal pam, and has had difficulty
may have to redefine the parameters of her highly
in keeping up with his graduate school work m bio-
valued self-concepts of strength, fitness, autonomy
medical engineenng Miss T has not relied on nursing
(within 4 days)
or medical staff for more than straight-forward
2 Miss T will verbalize a contmued motivation, within
discussion of 'facts' related to diagnostic tests and to
the limitations of her strength and energy, to maintam
MS
activities which will maintam her present high level of
3 Extrapersonal factors
fitness and general strength (ongomg)
Miss T IS on a scholarship which provides for tuition,
B Planned interventions (combined pnmary and
books, supplies and a partial housing allowance She
secondary level prevention)
uses student loans and summer employment to pro-
1 Daily sessions (of at least 30 mmutes) with the nurse in
vide money for housing, clothes, food and other
a quiet pnvate room to explore Miss T's feelings
expenses Medical insurance is covered by student fees
about the diagnosis, her symptoms, the meanings the
at her university so hospitalization and doctors' visits
disease has for her and possible modifications of her
are covered The university has an excellent student
expectations and activities
health service which includes provision for counsel-
2 Reinforcement by the nurses of Miss T 's appropnate
ling There is a large and achve MS Soaety m Miss T 's
use of the nursmg staff for emotional support and ex-
community which holds nurse-led self-help groups for
plorations of feelings and attitudes
the newly diagnosed
3 Explorahon of acceptabihty to Miss T of a referral to
the MS Society — to talk to another person with MS
E Actual or potential variances from wellness (nurstng on the telephone, m person, or as a member of a group
diagnoses) for the newly diagnosed
1 Disturbance m self-concept due to mild decrease in
muscle strength, co-ordination and overall stamina,
and to recent medical diagnosis of MS 2 Related to diagnosis 2
2 Potential for meffechve coping with and adjustment to A Expected outcomes
diagnosis of MS and altered physical functionmg due 1 Miss T will continue to discuss openly that there is
to (i) fear of dependence, loss of autonomy, lack of a good possibility of ineffective coping with the
fulfilment of academic occupational and personal/ diagnosis and altered functioning if she does not deal
soaal goals, and (ii) her exhausting the emotional with her fear of loss of her autonomy and lack of fulfil-
resources of her fiance ment of academic, occupational and personal goals
3 Knowledge defiat related to lack of expenence and (ongoing)
facts related to MS, mdudmg its signs and symptoms, 2 Miss T will list other potential resources to supply
prognosis, course, role of athtudes and emotions, emohonal support and temporary assistance with
management and resources domeshc chores (shopping, cooking, cleaning) and
4 Mild alteration in mobility, coordination and stamina academic requirements upon her discharge from the
hospital (3 days)
due to MS
3 Miss T will identify alternate short-term adjustments
to her course load and extra-cumcular activities (3
Short-term nursing goals days)
The nurse shared her diagnoses with Miss T and in general B Planned interventions (pnmary level prevenhon)
Miss T accepted them, although she did not feel comfort- 1 Daily sessions (concurrent with 1 B 1 above) to
able with 'the potential for meffechve copmg' despite discuss fears, alternative resources and short-term
being willing to explore the possibility Miss T and the copmg strategies

453
JB Knight
2 Referral to community health nurse upon discharge to
follow-up on discussion of fears, resources and copmg
strategies
3 If required, baison by nurse or Miss T with academic
counsellor to explore feasibibty of adjustment of
academic requirements
3 Related to diagnosis 3
A
1 MISS T can explain the very basic facts about the
pathology of MS, the basis of her own symptoms, the
highly vanable course of the disease, the importance of
attention to emotional health, and any other areas
about which she expresses cunosity (by discharge)
2 Miss T verbalizes and demonstrates copmg strategies
for management of her present problems with fatigue,
decreased muscle strength, slight mcoordmation and
intermittent diplopia (4 days or by discharge)
3 Miss T can list reliable and questionable resources for
more information about MS and its management
B Planned mterventions (combined pnmary and
secondary level prevention)
1 Ongoing informal mstruchon and answenng Miss T 's
questions on MS and its management
2 Considenng Miss T 's readiness and appropnateness
of specific matenal, provision of information booklets
about MS
3 If acceptable referral to the MS Society as a source of
reliable information
4 Related to diagnosis 4
A Expected outcomes
1 Miss T will demonstrate and explam methods to
manage her
a decreased muscle strength (mostly nght leg),
b. slight mcoordmahon/lack of balance,
c fatigue, and
d. intermittent diplopia (By 3 days)
B Planned mtervenhons (examples of pnmary and
secondary level prevenhons)
1 The nurse will discuss and/or demonstrate manage-
ment strategies for
a. decreased muscle strength, e g (1) active exerase
withm limits of fatigue, with penodic rest penods,
(2) avoidance of very long and heavy penods of
exerase
b. slight lncoordmahon/lack of balance, e g (I)
avoidance of hazardous activities requinng good
coordmahoa (2) tub baths instead of showers, (3)
avoidance of quick tummg, (4) low heeled shoes
454
c. fatigue, e g (1) paang and timing of activities to
avoid overexerhon, (2) daily rest penods, (3)
sitting instead of standing when possible
d. diplopia, e g (1) patching of one eye, (2) avoidance
of eye muscle strain
Nursmg outcomes
The following is a summary of actual mtervenhons, evalu-
ahon and goal reformulation after 1 week
7 Related to diagnosis 1
Two nurses, Mrs B and Miss A , developed a close thera-
peutic relahonship with Miss T She became much more
honest about her feelmgs, crying openly at times and
expressing some anger that such a thmg should happen to
her She expressed some gnef that she may have to adjust
her self-concept to incorporate the new fact of 'probable
MS' She verbalized that perhaps she will have to focus
now on 'other ways of being strong' She is cautiously
ophmistic that she can manage not to push herself too
much when she is discharged She met a 30-year-old
woman, Mrs Z (another patient), who has had MS for 5
years and funchons very well They have had many long
discussions and Miss T appears to have been very
encouraged by this woman's example (Expected outcomes
met)
2 Related to diagnosis 2
Miss T stated she realizes how difficult her illness has been
for her fiance She is womed that he may not be able to
cope with all of the present and future problems Seemg his
distress has made her feel more fnghtened and upset She
realizes her difficulty m sharmg her feelings with people
other than her fiance She fears her overdependence on him
may backfire onto her if she does not seek other sources of
help MrsZ has reinforced to Miss T how important it was
to her to talk about her anger, fear and sadness with people
outside her family and especially with other people with
MS Mrs Z was discharged and she and Miss T have
talked on the phone and plan to see each other when Miss
T IS discharged
Miss T and her fiance have decided that when she is
discharged he will do major shopping and some cleaning
and that they will share cookmg responsibibties It may be
necessary to have a cleanmg agency in once every 2 weeks
She wants to have some extended discussions with a pro-
fessional after discharge to discuss important concems
related to her career, mamage and family plans, and will call
the student counselling service at the university She is still
quite womed about catching up with her academic work.

but carmot at this time envision what adjustments could
be made The referral to the community health nurse has
been made and Miss T is happy to have this follow
through
(Comment expected outcomes 1 and 2 met The third,
related to identifying adjustments to her academic and
extracumcular activities, cannot be dealt with now)
3 Related to dtagnosts 3 and diagnosis 4
MISS T seems to have a good basic understanding of MS
and her knowledge of anatomy and physiology have
helped her grasp the pathological basis for her own signs
and symptoms She has read some very basic pamphlets on
MS but states she just cannot read too much more now
'Some of it IS too depressing' She understands that MS is
highly vanable m its course and that it is impossible to
make any predictions about an individual's prognosis
She wanted to discuss more about how she felt about the
disease and what she could do to manage the specific
difficulties she was expenencmg She readily accepted the
proposed strategies for dealing with her speafic problems
Her diplopia and fatigue appeared improved, her other
problems persisted but were adequately managed by the
proposed mterventions Miss T knows about the MS
Society and would like to receive some literature from
them She is not sure she wants any direct contact with the
people m the Society at this time (Expected outcomes
met)
Miss T 's nurses and the discharge plannmg nurse are
workmg on longer term goals that relate to Miss T's
adjustment to havmg a senous illness with an uncertam
future
CONCLUSION
The Betty Neuman Systems Model (Neuman 1982) has
been applied to the case of a young woman recently diag-
nosed as havmg MS Miss T has expenenced several
stressors the process which initiates inflammation in the
white matter of the central nervous system, the resulting
host of minor but disturbing dysfunctions which interfere
with her daily bfe, a diagnosis of senous disease, and a
threat to her self-concept, her body image and to her
present and future roles Miss T 's flexible lme of defence
Betty Neuman Systems Model
has not been able to prevent the penetration of her normal
bne of defence
An adapted tool suitable for use m acute care medical
settings was applied Through its use, careful assessment
and evaluahon of Miss T 's and the caregiver's perceptions
of the vanous stressors and resources for coping were made
and diagnoses and goals were formulated Interventions at
the primary and secondary levels of prevention were
planned and implemented In general these mterventions
aimed to prevent further stressor invasions, to mamtam or
strengthen Miss T 's resources, to educate her about new
copmg strategies, resources and information about her dis-
ease, and to conserve her energy Finally, the outcomes of
the plan were evaluated and found to be largely congruent
with the expected outcomes
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