Introduction To Nursing Theories

Introduction to Nursing Theories
This page was last updated on January 31, 2012

INTRODUCTION
Nursing theory is the term given to the body of knowledge that is used to support nursing practice.
A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived
from nursing models or from other disciplines and project a purposive, systematic view of phenomena by
designing specific inter-relationships among concepts for the purposes of describing, explaining,
predicting, and /or prescribing.
Each discipline has a unique focus for knowledge development that directs its inquiry and distinguishes it
from other fields of study.(Smith & Liehr, 2008).
Theory-guided, evidence-based practice is the hallmark of any professional discipline.
Nursing is a professional discipline (Donaldson & Crowley, 1978).
Almost 90% of all Nursing theories are generated in the last 20 years.
Nursing models are conceptual models, constructed of theories and concepts
A paradigm is a model that explains the linkages of science, philosophy, and theory accepted and applied
by the discipline.
Nursing theory is a framework designed to organize knowledge and explain phenomena in nursing, at a
more concrete and specific level.
M E TAPAR AD I G M S I N NURS I NG
Person
Recipient of care, including physical, spiritual, psychological, and sociocultural components.

Individual, family, or community
Environment
All internal and external conditions, circumstances, and influences affecting the person
Health
Degree of wellness or illness experienced by the person
Nursing
Actions, characteristics and attributes of person giving care.
COMPONENTS OF A THEORY
DEFINITIONS
Theory
a set of related statements that describes or explains phenomena in a systematic way.
a formulated hypothesis or, loosely speaking, any hypothesis or opinion not based upon actual
knowledge.
a provisional statement or set of explanatory propositions that purports to account for or characterize
some phenomenon.
the doctrine or the principles underlying an art as distinguished from the practice of that particular art.
Concept
a mental idea of a phenomenon

Concepts are the building blocks (the primary elements) of a theory.
Construct
a phenomena that cannot be observed and must be inferred

Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given
theory are its constructs.
Proposition
a statement of relationship between concepts
Conceptual model
made up of concepts and propositions
Different Frameworks will emphasize different variables and outcomes and their interrelatedness.
( Bordage, 2009)
Models may draw on a number of theories to help understand a particular problem in a certain setting or
They epresent ways of thinking about a problem or ways of representing how complex things work the
way that they do.
context. They are not always as specified as theory.

Variables
Variables are the operational forms of constructs. They define the way a construct is to be measured in a
specific situation.
Match variables to constructs when identifying what needs to be assessed during evaluation of a theorydriven program.
Middle range theory
a testable theory that contains a limited number of variables, and is limited in scope as well, yet is of
sufficient generality to be useful with a variety of clinical research questions.
NURSING PHILOSOPHIES
Theory
Florence Nightingales Legacy of
caring
Key Points
Focuses on nursing and the patient environment relationship.
Helping process meets needs through the art of individualizing care.
Nurses should identify patients need-for help by:
Ernestine Wiedenbach: The helping

art of clinical nursing
Virginia Hendersons Definition of

Nursing
Faye G.Abedellahs Typology of

twenty one Nursing problems
Lydia E. Hall :Care, Cure, Core
model
Jean Watsons Philosophy and
Science of caring
Patricia Benners Novice to Expert
Observation
Understanding client behaviour
Identifying cause of discomfort
Determining if clients can resolve problems or have a need

for help
Patients require help towards achieving independence.
Derived a definition of nursing
Identified 14 basic human needs on which nursing care is based.
Patients problems determine nursing care
Nursing care is person directed towards self love.
Caring is a universal, social phenomenon that is only effective when

practiced interpersonally considering humanistic aspects and caring.
Caring is central to the essence of nursing.
Described systematically five stages of skill acquisition in nursing

practice novice, advanced beginner, competent, proficient and
expert.
CONCEPTUAL MODELS AND GRAND THEORIES

Dorothea E. Orems Self care deficit
Selfcare maintains wholeness.
theory in nursing
Three Theories:
Theory of Self-Care
Theory of Self-Care Deficit
Theory of Nursing Systems
Myra Estrin Levines: The

conservation model
Martha E.Rogers: Science of

unitary human beings
Dorothy E.Johnsons Behavioural

system model
Sister Callista: Roys Adaptation

model
Betty Neumans : Health care

systems model
Nursing Care:
Wholly compensatory (doing for the patient)
Partly compensatory (helping the patient do for himself or

herself)
Supportive- educative (Helping patient to learn self care

and emphasizing on the importance of nurses role
Proposed that the nurses use the principles of conservation of:
Client Energy
Personal integrity
Structural integrity
Social integrity
A conceptual model with three nursing theories
Conservation
Redundancy
Therapeutic intention
Person and environment are energy fields that evolve

negentropically
Nursing is a basic scientific discipline
Nursing is using knowledge for human betterment.
The unique focus of nursing is on the unitary or irreducible human

being and the environment (both are energy fields) rather than
health and illness
Individuals maintain stability and balance through adjustments and

adaptation to the forces that impinges them.
Individual as a behavioural system is composed of seven

subsystems: the subsystems of attachment, or the affiliative,
dependency, achievement, aggressive, ingestive-eliminative and
sexual.
Disturbances in these causes nursing problems.
Stimuli disrupt an adaptive system
The individual is a biopsychosocial adaptive system within an

environment.
The individual and the environment provide three classes of stimulithe focal, residual and contextual.
Through two adaptive mechanisms, regulator and cognator, an

individual demonstrates adaptive responses or ineffective responses
requiring nursing interventions
Neumans model includes intrapersonal, interpersonal and

extrapersonal stressors.
Imogene Kings Goal attainment

theory
Nancy Roper, WW.Logan and

A.J.Tierney A model for nursing
based on a model of living
Hildegard E. Peplau:
Psychodynamic Nursing Theory
Nursing is concerned with the whole person.
Nursing actions (Primary, Secondary, and Tertiary levels of

prevention) focuses on the variables affecting the clients response
to stressors.
Transactions provide a frame of reference toward goal setting.
Major concepts (interaction, perception, communication, transaction,

role, stress, growth and development)
Perceptions, Judgments and actions of the patient and the nurse

lead to reaction, interaction, and transaction (process of nursing).
Individuality in living.
A conceptual model of nursing from which theory of goal attainment

is derived.
Living is an amalgam of activities of living (ALs).
Most individuals experience significant life events which can affect

ALs causing actual and potential problems.
This affects dependence independence continuum which is bidirectional.
Nursing helps to maintain the individuality of person by preventing

potential problems, solving actual problems and helping to cope.
Interpersonal process is maturing force for personality.
Stressed the importance of nurses ability to understand own

behaviour to help others identify perceived difficulties.
The four phases of nurse-patient relationships are:
Ida Jean Orlandos Nursing Process

Theory
1. Orientation
2. Identification
3. Exploitations
4. Resolution
The six nursing roles are:
1. Stranger
2. Resource person
3. Teacher
4. Leader
5. Surrogate
6. Counselor
Interpersonal process alleviates distress.
Nurses must stay connected to patients and assure that patients get
what they need, focused on patients verbal and non verbal
expressions of need and nurses reactions to patients behaviour to
alleviate distress.
Elements of nursing situation:

1.
Patient
2.
Nurse reactions
3.
Nursing actions
Therapeutic human relationships.
Nursing is accomplished through human to human relationships that

began with the original encounter and then progressed through
stages of emerging identities.
Growth and development of children and motherinfant

relationships
Individual characteristics of each member influence the parent

infant system and adaptive behaviour modifies those characteristics
to meet the needs of the system.
Ramona T.Mercers :Maternal Role

Attainment
A complex theory to explain the factors impacting the development

of maternal role over time.
Katharine Kolcabas Theory of

comfort
Comfort is desirable holistic outcome of care.
Health care needs are needs (physical, psycho spiritual, social and
environmental needs) for comfort, arising from stressful health care
situations that cannot be met by recipients traditional support
system.
Comfort measures include those nursing interventions designed to

address the specific comfort needs.
Caring is universal and varies transculturally.
Major concepts include care, caring, culture, cultural values and

cultural variations
Caring serves to ameliorate or improve human conditions and life

base.
Care is the essence and the dominant, distinctive and unifying

feature of nursing
Indivisible beings and environment co-create health.
A theory of nursing derived from Rogers conceptual model.
Clients are open, mutual and in constant interaction with

environment.
The nurse assists the client in interaction with the environment and
co creating health
Promoting optimum health supersedes disease prevention.
Identifies cognitive, perceptual factors in clients which are modified

by demographical and biological characteristics, interpersonal
influences, situational and behavioural factors that help predict in
health promoting behaviour
Joyce Travelbees Human To Human

Relationship Model
Kathryn E. Barnards Parent Child

Interaction Model
Madeleine Leiningers Transcultural

nursing, culture-care theory
Rosemarie Rizzo Parses :Theory of

human becoming
Nola J.Penders :The Health

promotion; model
CONCLUSION
The conceptual and theoretical nursing models help to provide knowledge to improve practice, guide
research and curriculum and identify the goals of nursing practice.
Nursing knowledge is the inclusive total of the philosophies, theories, research, and practice wisdom of
the discipline.As a professional discipline this knowledge is important for guiding practice.(Smith & Liehr,
2008).
REFERENCES
1.
2.
Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113120.
Smith, M. J., & Liehr, P. R. (2008). Middle range theory for nursing. New York: Springer Publishing.
3.
George B. Julia , Nursing Theories- The base for professional Nursing Practice, 3rd ed. Norwalk,
Appleton & Lange.
4.
Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams&
wilkins.
5.
Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia,
Lippincott.
6.
Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.
7.
Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing Concepts Process & Practice 3rd ed.
London Mosby Year Book.
8.
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002
9.
Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.
Application of Theory in Nursing Process

Introduction
Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable
fact or event) that is explanatory & predictive in nature.
Theories are composed of concepts, definitions, models, propositions & are based on assumptions.
They are derived through two principal methods; deductive reasoning and inductive reasoning.
Objectives
to assess the patient condition by the various methods explained by the nursing theory
to demonstrate an effective communication and interaction with the patient.
to select a theory for the application according to the need of the patient
to identify the needs of the patient
to apply the theory to solve the identified problems of the patient
to evaluate the extent to which the process was fruitful.
Definition
Nursing theory is an organized and systematic articulation of a set of statements related to questions in
the discipline of nursing.
"A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived
from nursing models or from other disciplines and project a purposive, systematic view of phenomena by
designing specific inter-relationships among concepts for the purposes of describing, explaining,
predicting, and /or prescribing."
C h a r a c t e r i s t i c s o f a U s e f u l T h e o r y [Robert T. Croyle (2005)]

A useful theory makes assumptions about a behavior, health problem, target population, or environment that are:
Logical
Consistent with everyday observations
Similar to those used in previous successful programs and
Supported by past research in the same area or related ideas.
Importance of nursing theories
Nursing theory aims to describe, predict and explain the phenomenon of nursing
It should provide the foundations of nursing practice, help to generate further knowledge and indicate in
which direction nursing should develop in the future. Theory is important because it helps us to decide
what we know and what we need to know
It helps to distinguish what should form the basis of practice by explicitly describing nursing. The benefits
of having a defined body of theory in nursing include better patient care, enhanced professional status for
nurses, improved communication between nurses, and guidance for research and education
The main exponent of nursing caring cannot be measured, it is vital to have the theory to analyze and
explain what nurses do
As medicine tries to make a move towards adopting a more multidisciplinary approach to health care,
nursing continues to strive to establish a unique body of knowledge
This can be seen as an attempt by the nursing profession to maintain its professional boundaries
Evolution of Nursing Theories & Application
The history of professional nursing begins with Florence nightingale.
Following that came the curriculum era which addressed the questions about what the nursing students
Later in last century nursing began with a strong emphasis on practice.
should study in order to achieve the required standard of nursing.
As more and more nurses began to pursue higher degrees in nursing, there emerged the research era.
Later graduate education and masters education was given much importance.
The development of the theory era was a natural outgrowth of the research era.
With an increased number of researches it became obvious that the research without theory produced
isolated information; however research and theory produced the nursing sciences.
Within the contemporary phase there is an emphasis on theory use and theory based nursing practice
and lead to the continued development of the theories.
Characteristics of theories
Theories are
Interrelating concepts in such a way as to create a different way of looking at a particular phenomenon.
Logical in nature.
Generalizable.
Bases for hypotheses that can be tested.
Increasing the general body of knowledge within the discipline through the research implemented to
validate them.
Used by the practitioners to guide and improve their practice.
Consistent with other validated theories, laws, and principles but will leave open unanswered questions
that need to be investigated.
Purposes of theory in practice
Assist nurses to describe, explain, and predict everyday experiences.
Provide a rationale for collecting reliable and valid data about the health status of clients, which are
Serve to guide assessment, intervention, and evaluation of nursing care.
essential for effective decision making and implementation.
Help to establish criteria to measure the quality of nursing care
Help build a common nursing terminology to use in communicating with other health professionals. Ideas
are developed and words defined.
Enhance autonomy (independence and self-governance) of nursing by defining its own independent
functions.
PURPOSES OF NURSING THEORIES
In Practice:
Provide a rationale for collecting reliable and valid data about the health status of clients, which are
Serve to guide assessment, interventions, and evaluation of nursing care.
essential for effective decision making and implementation.
Help to describe criteria to measure the quality of nursing care.
Help build a common nursing terminology to use in communicating with other health professionals.
Ideas are developed and words are defined.
Enhance autonomy (independence and self-governance) of nursing through defining its own independent
functions.
In Education:
Provide a general focus for curriculum design

Guide curricular decision making.
In Research:
Offer a framework for generating knowledge and new ideas.
Offer a systematic approach to identify questions for study; select variables, interpret findings, and
Assist in discovering knowledge gaps in the specific field of study.
validate nursing interventions.
Approaches to developing nursing theory
Borrowing conceptual frameworks from other disciplines.
Inductively looking at nursing practice to discover theories/concepts to explain phenomena.
Deductively looking for the compatibility of a general nursing theory with nursing practice.
Questions from practicing Nurse about using Nursing theory
Practice
Does this theory reflect nursing practice as I know it?
Can this theory be considered in relation to a wide range of nursing situation?
Personal Interests, Abilities and Experiences
What will it be like to think about nursing theory in nursing practice?
Will it support what I believe to be excellent nursing practice?
Will my work with nursing theory be worth the effort?
Conclusion
If theory is expected to benefit practice, it must be developed co- operatively with people who practice
nursing.
People who do research and develop theories think differently about theory when they perceive the
reality of practice.
Theories do not provide the same type of procedural guidelines for practice as do situation- specific
principles and procedures or rules.
Procedural rules or principles help to standardize nursing practice and can also be useful in achieving
minimum goals of quality of care.
Theory is ought to improve the nursing practice.
One of the most common ways theory has been organized in practice is in the nursing process of
analyzing assessment data.
References
1.
Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby
Publications; 2002.
2.
3.
George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed. New Jersey :Prentice
Hall;2002.
4.
Croyle RT. Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition).
U.S. Department of Health and Human Services, National Institutes of Health, 2005. Available at
www.thecommunityguide.org.
Undertanding the Works of Nursing Theorists

Theories of Nursing
Theory is "an internally consistent group of relational statements (concepts, definitions and propositions)
that present a systematic view about a phenomenon and which is useful for description, explanation,
prediction and control".
Theories provide a framework for selecting and organizing information:
What to ask
What to observe
What to focus on
What to think about
Nursing theory is an organized and systematic articulation of a set of statements related to questions in
the discipline of nursing.
Uses of Nursing Theory
Define relationships among the variables of a given field of inquiry
Allow the prediction of the consequences of care
Allow the prediction of a range of patient responses
Guide research, practice and communication
Levels of Theory
There are four levels of theory
Metatheory
Middle Range Theory
Practice Theory
Grand Theory
Types of Theory
In nursing there are four types of theories:
Needs
Outcome
Humanistic
Interaction
Value of theory
Enhances understanding and explanation for events
Makes to think differently about a problem or a situation
Helps to try new approaches or altering behavior.
Influence our behavior.
We can gain a new perspective of events
Basis for challenge of its speculative tenets or propositions
Challenges subsequent discovery of new ideas or knowledge that might explain and predict events not
yet understood
In practice
Provide a rationale for collecting reliable and valid data about the health status of clients.
Help to establish criteria to measure the quality of nursing care
Help build a common nursing terminology.
Enhance autonomy of nursing by defining its own independent functions.
Serve to guide assessment, intervention, and evaluation of nursing care.
In education
Provide a general focus for curriculum design.

Guide curricular decision making
In research
Offer a framework for generating knowledge and new ideas.
Offer a systematic approach to identify questions for study, select variables, interpret findings, and
Assist in discovering knowledge gaps in specific field of study.
validate nursing interventions.

Theory development
Theory development within nursing occurs in the context of practice.

Two activities contribute significantly to the overall process of developing theory in nursing.
Concept analysis and
Practical validation of theory.

Concept analysis
Identify and verify abstract concepts
Application of theory in practice
Nursing process operation of analysis of assessment data.
Used as scientific rationale supporting judgments in nursing care plans.
"what events in practice can be linked with abstract concept x"
Concepts
Concepts may be
1.
readily observable, or concrete - thermometer, rash, and lesion;
2.
indirectly observable, or inferential - pain and temperature; or
3.
non-observable, or abstract - equilibrium, adaptation, stress, and powerlessness
nursing theories address and specify relationships among four major abstract concepts referred to as the
metaparadigm of nursing.
Four concepts are considered to be central to nursing:

o
Person or client, the recipient of nursing care (includes individuals, families, groups, and
communities).
Environment, the internal and external surroundings that affect the client. This includes people
in the physical environment, such as families, friends, and significant others.
Health, the degree of wellness or well-being that the client experiences.
Nursing, the attributes, characteristics, and actions of the nurse providing care on behalf of, or
in conjunction with, the client.
References
1.
Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical practice.6th edition.
Philadelphia. Mosby publications. 1996.
2.
Black M. Joice, Hawks hokanson Jane. Medical Surgical Nursing: Clinical Management for positive
outcomes. St Lois, Missouri. 2005.
3.
4.
Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby, Philadelphia, 2002.
Application of Theory of Goal Attainment

OBJECTIVES
to assess the patient condition by the various methods explained by the nursing theory
to demonstrate an effective communication and interaction with the patient.
to select a theory for the application according to the need of the patient
to apply the theory to solve the identified problems of the patient
to evaluate the extent to which the process was fruitful
INTRODUCTION
Kings theory offers insight into nurses interactions with individuals and groups within the environment.
It highlights the importance of clients participation in decision that influences care and focuses on both
the process of nurse-client interaction and the outcomes of care.
Mr.Sy (74 years) was admitted in L3 ward of ...Hospital, for a herniorrhaphy on ... for his left indirect
inguinal hernia and was expecting discharge from hospital... the theory of goal attainment was used in his
nursing process.
NURSING PROCESS
Assessment
King indicates that assessment occur during interaction. The nurse brings special knowledge and skills
whereas client brings knowledge of self and perception of problems of concern, to this interaction.
During assessment nurse collects data regarding client (his/her growth & development, perception of self
and current health status, roles etc.)
Perception is the base for collection and interpretation of data.
Communication is required to verify accuracy of perception, for interaction and transaction.
The first process in nursing process is nurse meets the patient and communicates
and interacts with him. Assessment is conducted by gathering data about the patient
based on relevant concepts.
Mr. Sy is 74yrs married, got admitted in L3 ward of ...Hospital on 27/03/08 with a
diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh
done on 30/03/08. The following areas were addressed to for gathering data.
Patient says I have undergone surgery for hernia.
The wound is getting healed, I have no other problem
I have pain in the area of surgery when moving Im
What is the patients
taking medicines for hypertension for the last 7 years
perception of the situation?
from here I have vision problem to my left eye. I had
undergone a surgery for my right eye about 10 years
back.
Patient underwent herniorahaphy operation on 30th
Application of Orem's Self-Care Deficit theory

This page was last updated on October 17, 2011
OBJECTIVES
to assess the patient condition by the various methods

explained by the nursing theory
to demonstrate an effective communication and interaction

with the patient.
to select a theory for the application according to the need of

the patient
to apply the theory to solve the identified problems of the

patient
to evaluate the extent to which the process was fruitful.
P AT I E N T P R O F I L E
Areas
Name
Age
Sex
Education
Occupation
Marital status
Religion
Diagnosis
Theory applied
Patient details
Mrs. X
56 years
Female
No formal education
House hold
Married
Hindu
Rheumatoid arthritis
Orems theory of self care deficit.
OREMS THEORY OF SELF CARE DEFICIT
The self care deficit theory proposed by Orem is a

combination of three theories, i.e. theory of self care, theory
of self care deficit and the theory of nursing systems.
In the theory of self care, she explains self care as the

activities carried out by the individual to maintain their own
health.
The self care agency is the acquired ability to perform the

self care and this will be affected by the basic conditioning
factors such as age, gender, health care system, family
system etc.
Therapeutic self-care demand is the totality of the self care

measures required.
The self care is carried out to fulfill the self-care requisites.
There are mainly 3 types of self care requisites such as

universal, developmental and health deviation self care
requisites.
Whenever there is an inadequacy of any of these self care

requisite, the person will be in need of self care or will have
a deficit in self care.
The deficit is identified by the nurse through the thorough

assessment of the patient.
Once the need is identified, the nurse has to select required

nursing systems to provide care: wholly compensatory, partly
compensatory or supportive and educative system.
The care will be provided according to the degree of deficit

the patient is presenting with.
Once the care is provided, the nursing activities and the use
of the nursing systems are to be evaluated to get an idea
about whether the mutually planned goals are met or not.
Thus the theory could be successfully applied into the

nursing practice.
For Mrs. X.
She came to the hospital with complaints of pain over all the
joints, stiffness which is more in the morning and reduces by
the activities.
She has these complaints since 5 years and has taken

treatment from local hospital.
The symptoms were not reducing and came to --MC, Hospital

for further management.
Patient w as able to do the ADL by herself but the way she

performed and the posture she used was making her prone to
develop the complications of the disease.
She also was malnourished and was not having awareness

about the deficiencies and effects.
D ATA COLLE CTI ON ACC OR DI N G TO ORE M S THE ORY OF S ELF CARE

DEFICIT
1. BAS I C CONDI TI ONI NG FAC TORS
Age
Gender
56 year
Female
Health state
Disability due to health condition,

therapeutic self care demand
Development state
Sociocultural orientation
Ego integrity vs despair

No formal education, Indian, Hindu
Health care system

Family system
Institutional health care

Married, husband working
Patterns of living
Environment
At home with partner

Rural area, items for ADL not in easy
reach, no special precautions to
prevent injuries
resources
Husband, daughter, sisters son
2. UNIVERSAL SELF-CARE REQUISITES

Breaths without difficulty, no pallor cyanosis
Air
Water
Fluid intake is sufficient. Edema present over

ankles.
Turgor normal for the age
Food
Hb 9.6gm%, BMI = 14.Food intake is not

adequate or the diet is not nutritious.
Elimination
Activity/ rest
Voids and eliminates bowel without difficulty.

Frequent rest is required due to pain.
Pain not completely relieved,
Activity level ha s come down.
Deformity of the joint secondary to the disease
process and use of the joints.
Social interaction
Communicates well with neighbors and calls

the daughter by phone Need for medical care
is communicated to the daughter.
Need instruction on care of joints and
prevention of falls. Need instruction on
improvement of nutritional status. Prefer to
walk bare foot.
Has good relation with daughter
Prevention of hazards
Promotion of normalcy
3. DEV E LOP ME NTAL SE LF-C ARE RE QUIS I TES

Maintenance of
developmental
environment
Prevention/ management
of the conditions
threatening the normal
development
Able to feed self , Difficult to perform the

dressing, toileting etc
Feels that the problems are due to her own
behaviours and discusses the problems with
husband and daughter.
4. HE ALTH DEV I ATI ON SE LF C AR E RE QUI SI TES

Adherence to medical
regimen
Reports the problems to the physician when

in the hospital. Cooperates with the
medication, Not much aware about the use

and side effects of medicines
Awareness of potential
problem associated with
the regimen
Not aware about the actual disease process.
Not compliant with the diet and prevention of

hazards. Not aware about the side effects of
the medications
Modification of self image Has adapted to limitation in mobility.
to incorporates changes in
health status
The adoption of new ways for activities leads
to deformities and progression of the
disease.
Adjustment of lifestyle to Adjusted with the deformities.
accommodate changes in Pain tolerance not achieved
the health status and
medical regimen.
5. MEDICAL PROBLEM AND PLAN

Physicians perspective of the condition: Diagnosed with
rheumatoid arthritis and is on the following medications:
T. Valus SR OD
T. Tramazac 50 mg OD
T. Recofix Forte BD
T. Shelcal BD
Syp. Heamup 2tsp TID
T. Pan 40 mg OD
Medical Diagnosis: Rheumatoid arthritis

Medical Treatment: Medication and physical therapy.
AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF SELFCARE DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING
DIAGNOSIS.
Air
Food
Elimination
Activity/ Rest
Solitude/ Interaction
Prevention of hazards
Water
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.
modify self image
Adjust life style to accommodate health status changes and

MR
NURSING CARE PLAN ACCORDING TO OREMS THEORY OF SELF CARE

DEFICIT
Nursing
diagnosis
(diagnostic
operations)
Outcome and plan

(Prescriptive
operations)
Implementation
(control
operations)
Evaluation
(regulatory
operations)
Based on self
care deficits
Outcome
Nursing goal and
objectives
Design of nursing
system
Appropriate method of
helping
Nurse- patient
actions to
- Promote patient
as self care agent
- Meet self care
needs
- Decrease the self
care deficit.
1. Effectiveness of
the nurse patient
action to
-Promote patient
as self care agent
- Meet self care
needs
- Decrease the
self care deficit.
2. Effectiveness of
the selected
nursing system to
meet the needs.
Thus in the patient Mrs. X the areas that need assistance were
Air
Food
Elimination
Activity/ Rest(2)
Solitude/ Interaction
Prevention of hazards(2)
Water
Maintain a developmental environment.
Prevent or manage the developmental threats
Maintenance of health status
Awareness and management of the disease process.
Adherence to the medical regimen
Awareness of potential problem.
modify self image
Adjust life style to accommodate health status changes and

medical regimen
APPLYING THE OREMS THEORY OF SELF-CARE DEFICIT, A NURSING

CARE PLAN FOR MRS. X COULD BE PREPARED AS FOLLOWS
A. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: FOOD
ADE Q U AC Y OF S E LF C ARE AG E N CY: I N ADE Q U ATE
NURSING DIAGNOSIS
Inability to maintain the ideal nutrition related to inadequate

intake and knowledge deficit
OUTCOMES AND PLAN

a. Outcome:
Improved nutrition
Maintenance of a balanced diet with adequate iron
supplementation.
b. Nursing Goals and objectives

Goal: to achieve optimal levels of nutrition.
Objectives: Mrs. X will:
state the importance of maintaining a balanced diet.

List the food items rich in iron , that are available in the
locality.
c. Design of the nursing system:
supportive educative
d. Method of helping:
guidance
Teaching
Providing developmental environment
support
I M P L E M E N T AT I O N
Mutually planned and identified the objectives and the patient

were made to understand about the required changes in the
behaviour to have the requisites met.
E VALU ATI ON
Mrs. X understood the importance of maintaining an optimum

nutrition.
She told that she will select the iron rich diet for her food.
She listed the foods that are rich in iron and that are locally
available.
The self care deficit in terms of food will be decreased with

the initiation of the nutritional intake.
The supportive educative system was useful for Mrs. X
---------------------------------------------------------------------B. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: ACTIVITY

NURSING DIAGNOSIS
Self-care deficit: dressing, toileting related to restricted

joint movement, secondary to the inflammatory process in the
joints.
OUTCOMES AND PLAN
a. Outcome:
improved self-care
maintain the ability to perform the toileting and dressing with
modification as required.

Goal: to achieve optimal levels of ability for self care.
perform the dressing activities within limitations

utilize the alternative measures available for improving the
toileting
perform the other activities of daily living with minimal

assistance.
c. Design of the nursing system: Partly compensatory

d. Method of helping:
1. Guidance:
Assess the various hindering factors for self care and how to
tackle them.
2. Support:
Provide all the articles needed for self care, near to the
patient and ask the family members also to give the articles
near to her.
Provide passive exercises and make to perform active

exercises so as to promote the mobility of the joint.
Make the patient use commodes or stools to perform toileting

and insist on avoidance of squatting position
Provide assistance whenever needed for the self care

activities
Provide encouragement and positive reinforcement for minor

improvement in the activity level.
Initiate the pain relieving measures always before the patient
go for any of the activities of daily living
Make the patient to use loose fitting clothes which will be

easy to wear and remove.
3. Teaching:
Teach the family members the limitation in the activity level

the patient has and the cooperation required
4. Promoting a developmental environment:
Teach the family and help them to practice how to help the
patient according to her needs
Mutually planned and identified the objectives and the patient

was made to understand about the required changes in the
behaviour to have the requisites met.
E VALU ATI ON
Patient was performing some of the activities and she

practiced toileting using a commode in the hospital.
She verbalized an improved comfort and self care ability.
She performed the dressing activities with minimal assistance
Patient verbalized that she will perform the activities as

instructed to get her ADL done.
The partly compensatory system was useful for Mrs. X
---------------------------------------------------------------------C. THERAPEUTIC SELF CARE DEMAND:
DE FI CI E NT AR E A: PAI N
CONTROL
ADEQUACY OF SELF CARE AGENCY:
I NADE QU ATE
NURSING DIAGNOSIS
Ineffective pain control related to lack of utilization of pain

relief measures
OUTCOMES AND PLAN

a. Outcome:
improved pain self control

achieve and maintain a reduction in the pain.

Goal: to achieve reduction in the pain.
describe
the total plan of pharmacological and non
pharmacological pain relief
demonstrate a reduction in the pain behaviours
verbalize a reduction in the pain scale score from 7 4
c. Design of the nursing system: supportive educative

d. method of helping:
Guidance:
Explore the past experience of pain and methods used to

manage them.
Ask the client to report the intensity, location, severity,

associated and aggravating factors.
Support:
Provide rest to the joints and avoid excessive manipulations
Encourage exercises to the joints by immersing in the warm
provide hot and cold application to have better mobility.
water.
Administer T. Ultracet and Tab Diclofecac as prescribed.
Provide diversion and psychological support to the patient
Teaching:
Teach the non pharmacological method to the patient once
the pain is a little reduced.

Providing the developmental environment:
Discuss with the patient the necessity to maintain a pain

diary with all information regarding episodes of pain and
refer to that periodically
Enquire from the health team, the need for opioid analgesics
or other analgesics and get a prescription for the patient.
----------------------------------------------------------------------------E VALU ATI ON
Patient still has pain over the joints and she agreed that she
will use the measures for pain relief that is told to her.
The pain scale score was 6 after the measures were provided
to the patient.
She demonstrated slight reduction in the pain behaviours.
-------------------------------------------------------------D. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA:

PREVENTION OF HAZARDS.
I NADE QU ATE
NURSING DIAGNOSIS
Potential for fall and fractures related to rheumatoid

arthritis.
OUTCOMES AND PLAN

a. Outcome:
Absence of falls and injury to the patient
Goal: prevent the falls and injury and to maintain a good body
mechanics.
remain free from injury as evidenced by:
Explaining the methods to prevent the injury.
absence of signs and symptoms of fall or injury

Support
Never leave the client alone in the unit

Assess the patients gait, activities and the mental status for
any confusion or disorientation
Encourage the patient to use supportive devices as required.
Provide a safe environment in the hospital by avoiding sharp

objects or wooden objects on the way and slippery floor.
Involve the family members in providing and maintaining a

safe environment in the home
Involve the family members to provide support
to the patient
whenever necessary
Plan a balanced diet for the patient with a mutual interaction
-----------------------------------------------------------------E VALU ATI ON
Patient remained free from injury as evidenced by absence of

signs and symptoms.
Patient explained the various measures that they will take to

prevent the injury.
-----------------------------------------------------------------E. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA:

PREVENTION OF HAZARDS.
I NADE QU ATE
NURSING DIAGNOSIS:
Potential for impaired skin integrity related to edema

secondary to renal cysts.
OUTCOMES AND PLAN:

a. Outcome:
Maintenance of normal skin integrity.
b. nursing Goals and objectives

Goal: Maintain the skin integrity and take measures to prevent skin
impairment.
maintain a normal skin integrity
identify the measures to relieve edema.
list the measures to prevent the loss of skin integrity

Support:
Assess the skin regularly for any excoriation or loss of

integrity or colour changes. Keep the skin clean always
Avoid stress or pressure over the area of edema by providing

extra cushions or padding
Monitor the lab values as well as the patient for any signs
and symptoms of renal failure.
Encourage the patient to use slippers while walking and that

should not be tight fitting.
Assess the edema for its degree, pitting or non pitting and
continue the assessment daily.
Provide a leg end elevated position or elevation of the leg on

a pillow if no cardiac abnormalities are identified.
Explain the patient the need for taking care of the edematous
parts
Explain the patient to report the symptoms like decreased

urine output, palpitations, increased edema etc. to the health
team
------------------------------------------------------------------E VALU ATI ON
Patient remained free from impaired skin integrity
She identified the measures to relieve edema.
The supportive educative system was useful for Mrs. x
She listed the measures to prevent the loss of skin integrity
----------------------------------------------------------------F. THE RAP E UTI C SE LF CARE DE M AND : DE FI CIE NT AR E A: AWAR E NE S S

OF THE DISEASE PROCESS AND MANAGEMENT
NURSING DIAGNOSIS
Potential for complications related to rheumatoid arthritis

secondary to knowledge deficit.
OUTCOMES AND PLAN

a. Outcome:
Absence of complications and improved awareness about the

disease process.
b. nursing Goals and objectives
Goal: Improve the knowledge of the patient about the disease

process and the complications.
verbalize the various complication and their preventions

verbalize the changes occurring with the disease process and
the treatment available
describe the actions and side effects of the medications

which she is using
c. Design of the nursing system:
supportive educative
d. Methods of helping:
Guidance
Promoting a developmental environment
Teaching
------------------------------------------------------------E VALU ATI ON
Patient got adequate information regarding the disease

She verbalized what she understood about the disease and its
management.
Patient has cleared her doubts regarding the medication

actions and the side effect
E VALU ATI ON OF THE AP P LI CATI ON OF SE LF CARE DE FI CI T THE ORY

The theory of self-care deficit when applied could identify the self
care requisites of Mrs. X from various aspects. This was helpful to
provide care in a comprehensive manner. Patient was very
cooperative. the application of this theory revealed how well the

supportive and educative and partly compensatory system could be
used for solving the problems in a patient with rheumatoid
arthritis.
REFERENCES
1.
Alligood M R, Tomey A M. Nursing Theory: Utilization

&Application .3rd ed. Missouri: Elsevier Mosby Publications;
2002.
2.
Tomey AM, Alligood. MR. Nursing theorists and their w ork.

(5th ed.).
3.
Mosby,
Philadelphia, 2002
George JB .Nursing Theories: The Base for Professional

Nursing Practice .5th ed. New Jersey :Prentice Hall;2002.
A P P L I C ATI O N O F S U C H M A N S S T AG E S O F I L L N E S S
MODEL
Introduction
Man is a social being.
Social conditions and not only promote the possibility of illness and disability, they also enhance prospect
Social factors play important role in health.
for disease prevention and health maintenance.
Health life style and the avoidance of high-risk behaviour, advance the individuals potential for a longer
and healthier life.
The recognition of the fact that the health of an individual is more than biological phenomena has brought
in to the forefront the significance of behavioural dimension of health.
Mr. AS, a 73 years old, Muslim, male patient admitted in ---ward of ---Hospital with a diagnosis of prostate cancer.
Data regarding psychosocial aspects of his life and illness were collected through interview. He was cooperative
and interactive with me for most part. But later he was found to be reluctant to talk ...as he was frequently
expressing his financial troubles which could not be helped by anyone related to him
Cancer Prostate
Prostate cancer is the fifth most common type of cancer in men and its incidence rises with advancing years. It
occurs in 1 in 10 in the men living to the age of 70 years. Early clinical features are indistinguishable from those of
BPH and the gland may feel normal on digital examination. The PSA may be elevated (>4 ng/ml). As the tumour
grows locally it may produce bladder neck obstruction, obstruct the ureters and rapidly lead to renal impairment. In
late disease rectal examination shows the prostate to be large, hard and irregular. Rectal ultrasound may show the
spread of the cancer and this should also be used for directing needle or aspiration biopsy. Prostatic biopsy is
important in giving prognostic information- prognosis being poorer with poorly differentiated tumours.
Therapy depends on staging. Early disease is treated with local radiotherapy and more advanced disease by
orchidectomy and hormone therapy with oestrogen. It has been suggested that all men over the age of 50 years
should be screened by rectal examination, transrectal ultrasound and PSA measurement.
General information
Name
Age
: 73 years
Gender
: Male
Marital status
: Married
Place
: ---/ ----
Hosp. No.
: ------
Date of admission
: 1-4-08
Ward/Unit
: --------
Education
: No formal education
: Mr. AS
Culture & life-style
Religion
: Islam, Muslim, believes in 'Durgas', and has gone there too.
Food habits
: four time in a day & Non-vegetarian once in a day
Socioeconomic condition
Lower socioeconomic status
Fisher man for 12 years
He was a beedi worker for 10 years
went to gulf and worked there for 4 years
Cook for 35 years
His son is in Gulf country, but earns only Rs.5000/month
His residence is about 80 km away from ----,
to and fro journey costs rs.50/ person
Occupation
Role in the family
Head of the family, earning member, and father

These role are affected due the illness everything is disturbed at home
Social Support Network
Patient has poor social support network
His daughter visited him twice in the hospital, no other person visited him or enquired him about his
There is no one to support him financially for treatment of his illness
illness after coming in the hospital

Patient complaints (on the first meeting)
Pain at the genital area (on catheterization)
No taste for anything he eats
No money in hand to pay the hospital bill
No sleep at night
Urine tube needs to be removed
Identification of patient needs
Collection, observing/ performing Interpretation and analysis

activities relating to caring
Needs arising from present illness I have pain at genital region

Patients main complaints are pain,
and the consequent response to
I have problem of passing urine irritation at the site of urinary catheter,
cope with
without control, that is why tube is
and sleep disturbance
inserted
I want to get this urine tube
removed
Who will pay my hospital bill of
Rs.50,000?
Patient complains that he is not
getting adequate sleep during night
He sleeps during daytime
He was a cook, working most of his

life in night time for marriage parties
Currently, he is hospitalised for
cancer, prostate and is receiving
radiotherapy for the last one month
Basic physical needs
He is advised not to take bath till

the end of radiotherapy to avoid skin
excoriation at the site
He maintains adequate
cleanliness
He visits toilet with assistance
from his wife
He is catheterized for the last 2
months
He says is a practicing Muslim

He is taking bath means it interferes
with his religious practices
He is advised not to take bath
because he may wet the irradiation
area, but the cultural issues are not
addressed.
Needs related to life style
He is a non-vegetarian
But he not getting any non-veg
food in the hospital
His life style related needs

hindered in this hospital environment
Needs related to habits
Individuals knowledge and

experience of illness
Patients Knowledge of Present

illness
Patient explains his illness:
I have pain and urine block for
the last 6 months
My illness is serious
I have diabetes for the last one
year
I underwent a surgery for urinary
block and pain in ----- 4 months
back
What the patient wants to know
about the illness?
will this illness get cured
I have come here because, doctors
in ---- told me my illness can be
cured only in this Hospital
Experience of illness
Knowledge of formal and

alternative therapies
He does not take tea or coffee
As he has any regular habits of

He does not smoke or take drinks taking tea or coffee or drinking alcohol
What has been his past experience

with illness?
Past Illness History
Earlier I went to many local folk
doctors, they only made all these
illness
I have sugar illness for the last
one year
The doctor in Kundapura told
me to check sugar, so I know I have
sugar problem
I have not had any major illness
in my life other than this
Family History
No major illness in his

knowledge
Whether patient has accepted his
illness
I dont have any habits,

drinking, smoking or taking even
coffee since childhood. I dont know
why I got this illness
He has adequate information
about formal and folk medicines
I have gone to them, but no
benefits
Knowledge at present and future Patient says he has one month

course of action.
duration of x-ray treatment
What is the treatment plan
nobody tells me what is my
Patient has understanding of the

illness as his illness is serious.
Patient underwent orchidectomy and
TURP in -------- 4 months back and later
referred to a tertiary care hospital for
further management
Patient wants to know whether his
illness will get cured.
He says he has no money to spend
her.
But his expenses are met by his
daughter and one brother
Patient has consulted many folk

doctors for minor illness and never
satisfied with them.
He had minor troubles with urinary

frequency for about 4 years
So he consulted some folk people

for some remedies
But never satisfied
Patient has accepted the illness as

some thing which he does not deserve.
He puts it on fate
He had tried alternative medicines and
found to have no benefit in his illness
Patient has only partial knowledge of

his illness and treatment plans
He is illiterate, but nobody has
Does the person knows about it illness

Im taking medicines regularly
explained him about his treatment plans
Coping with the illness and its

outcome (Patient and family)
What will we do?

We have to suffer everything
He looks depressed and tries to
avoid visitors
I dont have money pay here, I
dont know what to do
Patient is not showing adaptive

responses
He has depressive cognitions
He has financial problems
Analyse the individuals and

familys views on
health team
doctors
nurses
Doctor People come and asks

how you are? (he explains
sarcastically), nothing else
They do not want to know about
my pain
sometimes, nurses come asks
about me
Doctor has told something to my
daughter
He is not satisfied with the

psychological attention given to him by
nurse or doctor
His wife too has the same opinion
Doctor has explained about the illness
to his daughter about the diagnosis and
prognosis
Distinguish between the

Patient: they are not asking me
meanings of the patient, doctor, anything
nurse
Doctor: he will not understand
anything, it is explained to his
daughter
Nurse: doctor has explained
everything to him, we cannot tell
anything to the patient
Patient wants to know about his illness,

and course of treatment, but doctor is
preoccupied with the patients
educational status.
Observe the patient, doctor and What patient says has reason.
nurse interaction
Doctor has advised him RT for 1
month, so he feels there is nothing
more to talk to the patient than
enquiring any problems
Nurse is largely functionally
oriented and interact with patient
only in such occasions
The mutual interaction among the

treating team and patient is missing in
this situation
Suchmans Stages of illness Model
Nursing staff is bothered whether they

may convey wrong message to the
patient.
There is a communication gap exists
among these people.
Application of Suchman's Model
Conclusion
Mr. AS has been suffering form Prostate cancer for the last 1 year. But his symptoms started about 4 years back.
For about 3 years he tried folk remedies based on the advice of other people. He approached medical advice when
his symptoms aggravated. He is currently undergoing radiotherapy for prostate cancer and medications for
diabetes and other symptoms. This case study helps to understand the psychosocial aspects of illness
development and application illness behaviour model in nursing practice.
References
1.
Guptha MC, Mahajan B. Text book of Social Medicine, 3rd Edn. JayPee, ND,2003
2.
Coe RM. Sociology of Medicine. McGraw-Hill Inc. New York, 1978.
Application of Betty Neuman's System Model

NURSING PROCESS
Assessment
Outcome identification and planning
Implementation
Evaluation
Nursing diagnosis
ASSESSMENT
PATIENT PROFILE
1. Name- Mr. AM
3. Sex-Male
4. Marital status-married
5. Referral source- Referred from ------- Medical College, -------
2. Age- 66 years
STRESSORS AS PERCEIVED BY CLIENT
(Information collected from the patient and his wife)
Patient was suffering from severe abdominal pain, nausea, vomiting, yellowish discolorations of eye,
palm, and urine, reduced appetite and gross weight loss(8kg with in 4 months)
Patient is been diagnosed to have Periampullary carcinoma one week back.
Patient underwent operative procedure i.e. WHIPPLES PROCEDURE- Pancreato duodenectomy on

27/3/08.
Psychologically disturbed about his disease condition- anticipating it as a life threatening condition.
Patient is in depressive mood and does not interacting.
Patient is disturbed by the thoughts that he became a burden to his children with so many serious
illnesses which made them to stay with him at hospital.
Patient has pitting type of edema over the ankle region, and it is more during the evening and will not be
relieved by elevation of the affected extremities.
He had developed BPH few months back (2008 January) and underwent surgery TURP on January 17.
Still he has mild difficulty in initiating the stream of urine.
Patient is a known case of Diabetes since last 28 years and for the last 4 years he is on Inj. H.Insulin (4U0-0). It is adding up his distress regarding his health.
Major stress area, or areas of health concern
Life style patterns
patient is a retired school teacher
living with his son and his family
active in church
participates in community group meeting i.e. local politics
has a supportive spouse and family
taking mixed diet
no habits of smoking or drinking
spends leisure time by reading news paper, watching TV, spending time with family members and
relatives
cares for wife and other family members
Have you experienced a similar problem?
The fatigue is similar to that of previous hospitalization (after the surgery of the BPH)
Was psychologically disturbed during the previous surgery i.e. TURP.
What helped then- family members psychological support helped him to over come the crisis situation
Severity of pain was some what similar in the previous time of surgery i.e. TURP.
Anticipation of the future
Concerns about the healthy and speedy recovery.
Anticipating about the demands of modified life style
Anticipating the needs of future follow up
Anticipation of changes in the lifestyle and food habits
What doing to help himself?
Talking to his friends and relatives
Instillation of positive thoughts i.e. planning about the activities to be resume after discharge, spending
time with grand children, going to the church, return back to the social interactions etc
Avoiding the negative thoughts i.e. diverts the attentions from the pain or difficulties, try to eliminate the
disturbing thoughts about the disease and surgery etc
Trying to accept the reality etc..
Reading the religious materials i.e. reading the Bible
What is expected of others?
Family members visiting the patient and spending some time with him will help to a great extent to relieve
his tension.
Convey a warm and accepting behaviour towards him.
Family members will help him to meet his own personal needs as much as possible.
Involve the patient also in taking decisions about his own care, treatment, follow up etc
STRESSORS AS PERCEIVED BY THE CARE GIVER.

Major stress areas
Persistent fatigue
History of BPH and its surgery
Persistence of urinary symptoms (difficulty in initiating the stream of urine) and edema of the lower
extremities
Persistent disease- chronic hypertensive since last 28 years
Depressive ideations and negative thoughts
Present circumstances differing from the usual pattern of living
Hospitalization
acute pain ( before the surgery patient had pain because of the underlying pathology and after the
surgery pain is present at the surgical site)
nausea and vomiting which was present before the surgery and is still persisting after the surgery also
Massive weight loss i.e.( 8 kg of body weight with in 4 months)
anticipatory anxiety concerns the recovery and prognosis of the disease
negative thoughts that he has become a burden to his children
Anticipatory anxiety concerning the restrictions after the surgery and the life style modifications which are
to be followed.
Clients past experience with the similar situations
Patient verbalized that the severity of pain, nausea, fatigue etc was similar to that of patients previous
surgery. Counter checked with the family members that what they observed.
Psychologically disturbed previously also before the surgery. (collected from the patient and counter
checked with the relatives)
Client perceived that the present disease condition is much more severe than the previous condition. He
thinks it is a serious form of cancer and the recovery is very poor. So patient is psychologically
depressed.
Future anticipations
Client is capable of handling the situation- will need support and encouragement to do so.
He also planned in his mind about the future follow up ie continuation of chemotherapy
He has the plans to go back home and to resume the activities which he was doing prior to the
hospitalization.
What client can do to help himself?
Patient is using his own coping strategies to adjust to the situations.
He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope.
He sets his major goal i.e. a healthy and speedy recovery.
Client's expectations of family, friends and caregivers
he sees the health care providers as a source pf information.
He tries to consider them as a significant members who can help to over come the stress
He seeks both psychological and physical support from the care givers, friends and family members
He sees the family members as helping hands and feels relaxed when they are with him.
He is spending time to read religious books and also spends time in talking with others
Evaluation/ summary of impressions-
There is no apparent discrepancies identified between patients perception and the care givers
perceptions.
INTRAPERSONAL FACTORS
1. Physical examination and investigations
Height- 162 cm
TPR- 37o C, 74 b/m, 14 breaths per min
Weight 42 kg
BP- 130/78 mm of Hg
Eye- vision is normal, on examination the appearance of eye is normal. Conjunctiva is pale in
appearance. Pupils reacting to the light.
Ear- appearance of ears normal. No wax deposition. Pinna is normal in appearance and hearing ability is
also normal.
Respiratory system- respiratory rate is normal, no abnormal sounds on auscultation. Respiratory rate is
16 breaths per min.
Cardiovascular system- heart rate is 76 per min. on auscultation no abnormalities detected. Edema is
present over the left ankle which is non pitting in nature.
GIT- patient has the complaints of reduced appetite, nausea; vomiting etc. food intake is very less.
Mouth- on examination is normal. Bowel sounds are reduced. Abdomen could not be palpated because
of the presence of the surgical incision. Bowel habits are not regular after the hospitalization
Extremities- range of motion of the extremities are normal. Edema is present over the left ankle which is
non pitting in nature. Because of weakness and fatigue he is not able to walk with out support
Integumentary system- extremities are mild yellowish in color. No cyanosis. Capillary refill is normal.
Genitor urinary system- patient has difficulty in initiating the urine stream. No complaints of painful
micturation or difficulty in passing urine.
Self acre activities- perform some of his activities, for getting up from the bed he needs some other
persons support. To walk also he needs a support. He do his personal care activities with the support
from the others
Immunizations- it is been told that he has taken the immunizations at the specific periods itself and he
also had taken hepatitis immunization around 8 years back
Sleep . He told that sleep is reduced because of the pain and other difficulties. Sleep is reduced after
the hospitalization because of the noisy environment.
Diet and nutrition- patient is taking mixed diet, but the food intake is less when compared to previous food
intake because of the nausea and vomiting. Usually he takes food three times a day.
Habits- patient does not have the habit of drinking or smoking.
Other complaints- patient has the complaints of pain fatigue, loss of appetite, dizziness, difficulty in
urination, etc...
2. Psycho- socio cultural
Anxious about his condition
Patient is a retired teacher and he is Christian by religion.
Studied up to BA
Married and has 4 children(2sons and 2 daughters)
Congenial home environment and good relationship with wife and children
Is active in the social activities at his native place and also actively involves in the religious activities too.
Good and congenial relationship with the neighbors
Has some good and close friend at his place and he actively interact with them. They also very
Depressive mood
supportive to him
Good social support system is present from the family as well as from the neighborhood
3. Developmental factors
Patient confidently says that he had been worked for 32 years as a teacher and he was a very good
teacher for students and was a good coworker for the friends.
He told that he could manage the official and house hold activities very well
He was very active after the retirement and once he go back also he will resume the activities
4. Spiritual belief system
Patient is Christian by religion
He has a personal Bible and he used to read it min of 2 times a day and also whenever he is worried or
tensed he used to pray or read Bible.
He has a good social support system present which helps him to keep his mind active.
He believes in got and used to go to church and also an active member in the religious activities.
INTERPERSONAL FACTORS
has supportive family and friends
good social support system is present
active in the agricultural works at home after the retirement
active in the religious activities.
Good interpersonal relationship with wife and the children
Good social adjustment present
good social interaction with others
EXTRAPERSONAL FACTORS
All the health care facilities are present at his place
His house at a village which is not much far from the city and the facilities are available at the place.
Financially they are stable and are able to meet the treatment expenses.
All communication facilities, travel and transport facilities etc are present at his own place.
Summary
Physiological- thin body built pallor of extremities, yellowish discoloration of the mucus membrane and
sclera of eye. Nausea, vomiting, reduced appetite, reduced urinary out put. Diagnosed to have
periampullary carcinoma.
Psycho socio cultural factors- patient is anxious abut his condition. Depressive mood. Not interacting
much with others. Good support system is present.
Developmental no developmental abnormalities. Appropriate to the age.
Spiritual- patients belief system has a positive contribution to his recovery and adjustment.
CLINICAL FEATURES
pain abdomen since 4 days
Complaints of vomiting
Fatigue
Reduced appetite
on and off fever
Yellowish discoloration of eye, palms and nails
Complaints of weight loss
Edema over the left leg
Discoloration of urine
Investigations
Hemoglobin(13-19g/dl)
Values
6.9
HCT (40-50%)
WBC (4000-11000
cells/cumm)
Neutrophil (40-75%)
21.9
12200
Lymphocyte (25-45%)
Monocyte (2-10%)
10.5
4.5
Eosinophil (0-10%)
Basophil (0-2%)
2.6
.2
Platelet (150000-400000
cells/cumm)
345000
ESR (0-10mm/hr)
RBS (60-150 mg/dl)
86
148
Pus C/S
USG
Urea (8-35mg/dl)
_
USG shows mild diffuse cell growth at the Ampulla of Vater which suggests peri
ampullary carcinoma of Grade I with out metastasis and gross spread.
28
Creatinine (0.6-1.6 mg/dl)

Sodium (130-143 mEq/L)
1.8
136
77.2
Potassium (3.5-5 mEq/L) 4

PT (patient)(11.4-15.6 sec) 12.3
APTT- patient (24- 32.4
sec)
26.4
Blood group
HIV
A+
Negative
HCV
HBsAg
Negative
Negative
Urine Protein (negative)

Urine WBC (0-5 cells/hpf)
Negative
Nil
RBC (nil )
Nil
Initial Treatment
Post operative period (immediate post op)
Patient got admitted to ---- Medical

college for 3 days and the symptoms not
relieved. So they asked for discharge and
came to ---this hospital. There he
was treated with:
Inj Tramazac IV SOS

IV fluids DNS
Treatment at this hospital...

Pre operative period
Tab Clovipas 75 mg 0-1-0
Tab Metalor XL 1-0-0
Inj H Insulin S/C 6-0-6U
Inj Tramazac 50 mg IV Q8H
Inj Emset 4 mg Q8H
Tab Pantodac 40 mg 1-0-0
Cap beneficiale 0-1-0
Syp Aristozyme 1-1-1
K bind I sachet TID
Inj Pethedine 1mg SOS
Inj Phenargan SOS
Inj Pantodac 40 mg IV OD
Inj Clexane 0.3 ml S/C OD
Inj Vorth P 40 mg IM Q12H
Inj calcium Gluconate 10 ml over

10 min
IV fluids DNS
Late post op period after 3 days of

surgery)
Inj H Insulin S/C 6-0-6U
Cap beneficiale 0-1-0
Tab Clovipas 75 mg 0-1-0
Tab Monotrate 1-0-1
Tab Metalor XL 1-0-0
Tab Pantodac 40 mg 1-0-0
Tab Monotrate 1-0-1
Other instructions
Surgical management
Patient underwent Whipples procedure

(pancreato duodenectomy)
NURSING PROCESS
I. NURSING DIAGNOSIS
Incentive
spirometry
Steam
inhalation
Eearly
ambulation
Diabetic diet
Acute pain related to the presence of surgical wound on abdomen secondary to periampullary carcinoma
Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and
verbalization.
Nursing Actions
Primary Prevention
secondary Prevention
Tertiary Prevention
Assess severity of pain by

using a pain scale
Check the surgical site for
any signs of infection or
complications
Support the areas with
extra pillow to allow the
normal alignment and to
prevent strain
Handle the area gently.
Avoid unnecessary
handling as this will affect
the healing process
lean the area around the
incision and do surgical
dressing at the site of
incision to prevent any form
of infections
Provide nonpharmacological measures
for pain relief such as
diversional activity which
diverts the patients mind.
Administer the pain
medications as per the
prescription by the pain
clinics to relieve the severity
of pain.
Teach the patient about the

relaxation techniques and
make him to do it
Encourage the patient to
divert his mind from pain
and to engage in
pleasurable activities like
taking with others
Do not allow the patient to
do strenuous activities. And
explain to the patient why
those activities are
contraindicated.
Involve the patient in
making decisions about his
own care and provide a
positive psychological
support
Provide the primary

preventive care when ever
necessary.
educate the client about the

importance of cleanliness
and encourage him to
maintain good personal
hygiene.
Involve the family members
in the care of patient
Encourage relatives to be
with the client in order
provide a psychological well
being to patient .
Educate the family
members about the pain
management measures.
Provide the primary and
secondary preventive
measures to the client
whenever necessary.
Keep the patients body

clean in order to avoid
infection
Evaluation patient verbalized that the pain got reduced and the pain scale score also was zero. His facial
expression also reveals that he got relief from pain.
II. NURSING DIAGNOSIS

Activity intolerance related to fatigue secondary to pain at the surgery site, and
dietary restrictions
Outcome/ goals: Client will develop appropriate levels of activity free from excess fatigue, as evidenced by
normal vital signs & verbalized understanding of the benefits of gradual increase in activity & exercise.
Nursing actions
Primary prevention
Adequately
oxygenate the client
Secondary prevention
Instruct the client

to avoid the
activities which
Tertiary prevention
Encourage the client

to do the mobility
Instruct the client to

avoid the activities
which causes
extreme fatigue
causes extreme
fatigue.
Provide the
necessary articles
near the patients bed
side.
Assist the patient in

early ambulation
Monitor clients
response to the
activities in order to
reduce discomforts.
Provide nutritious
diet to the client.
Avoid psychological
distress to the client.
Tell the family
members to be with
him.
Schedule rest
periods because it
helps to alleviate
fatigue
exercises
Advice the client to

perform exercises
to strengthen the
extremities&
promote activities
Tell the client to

avoid the activities
such as straining at
stool etc
Teach the client

about the
importance of
early ambulation
and assist the
patient in early
ambulation
Teach the mobility

exercises
appropriate for the
patient to improve
the circulation
Tell the family

members to provide
nutritious diet in a
frequent intervals
Teach the patient and

the family about the
importance of
psychological well
being in recovery.
Provide the primary

and secondary level
care if necessary.
Evaluation patient verbalized that his activity level improved. He is able to do some of his activities with
assistance. Fatigue relieved and patient looks much more active and interactive.
NURSING DIAGNOSIS-III
Impaired physical mobility related to presence of dressing, pain at the site of surgical incision
Outcomes/goals: Patient will have improved physical mobility as evidenced by walking with minimum support
and doing the activities in limit.
Nursing actions
Primary prevention
Provide active and

passive exercises
to
all
the
extremities
to
improve
the
muscle tone and
Secondary prevention
Provide positive
reinforcement for
even a small
improvement to
increase the
frequency of the
desired activity.
Tertiary prevention
Educate and
reeducate the
client and family
about the patients
care and recovery
Support the
strength.
Make the patient

to perform the
breathing
exercises which
will strengthen the
respiratory
muscle.
Massage the
upper and lower
extremities which
help to improve
the circulation.
Provide articles
near to the patient
and encourage
doing activities
within limits
which promote a
feeling of well
being.
Teach the mobility

exercises
appropriate for
the patient to
improve the
circulation and to
prevent
contractures
Mobilize the
patient and
encourage him to
do so whenever
possible
Motivate the
client to involve in
his own care
activities
Provide primary
preventive
measures
whenever
necessary
patient, and family

towards the
attainment of the
goals
Coordinate the
care activities
with the family
members and
other disciplines
like
physiotherapy.
Teach the
importance of
psychological well
being which
influence
indirectly the
physical recovery
Provide primary
preventive
measures
whenever
necessary
CONCLUSION
The Neumans system model when applied in nursing practice helped in identifying the interpersonal,
intrapersonal and extra personal stressors of Mr. AM from various aspects. This was helpful to provide care in a
comprehensive manner. The application of this theory revealed how well the primary, secondary and tertiary
prevention interventions could be used for solving the problems in the client.
REFERENCES
1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed.

Missouri: Elsevier Mosby Publications; 2002.
2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
3. George JB .Nursing Theories: The Base for Professional Nursing Practice,5thed.
New Jersey :Prentice Hall;2002.
Application of Roy's Adaptation Model (RAM)

Last updated on January 26, 2012
INTRODUCTION
Roy's Adaptation Model (RAM) was developed by Sr.Callista Roy.
Nursing is the science and practice that expands adaptive abilities and enhances person and
RAM is one of the widely applied nursing models in nursing practice, education and research.
environment transformation
Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes, thus
contributing to health, quality of life, and dying with dignity
This is done by assessing behavior and factors that influence adaptive abilities and by intervening to
expand those abilities and to enhance environmental interactions.
Mr.NR who was suffering with diabetes mellitus for past 10 years. He developed a diabetic foot ulcer and
had to undergo amputation. He was admitted in __ Hospital. Mr. NR was selected for application of RAM
in providing nursing care.
NURSING PROCESS
According to RAM, nursing process is a problem solving approach for gathering data, identifying the
capacities and needs of the human adaptive system, selecting and implementing approaches for nursing
care, and evaluation the outcome of care provided.
Assessment of Behavior
the first step of the nursing process which involves gathering data about the behavior of the person as an
adaptive system in each of the adaptive modes.
Assessment of Stimuli
the second step of the nursing process which involves the identification of internal and external stimuli
that are influencing the persons adaptive behaviors.
Stimuli are classified as:

1.
Focal- those most immediately confronting the person,
2.
Contextual-all other stimuli present that are affecting the situation and
3.
Residual- those stimuli whose effect on the situation are unclear.
Nursing Diagnosis
step three of the nursing process which involves the formulation of statements that interpret data about
the adaptation status of the person, including the behavior and most relevant stimuli
Goal Setting
the forth step of the nursing process which involves the establishment of clear statements of the
behavioral outcomes for nursing care.

Intervention
the fifth step of the nursing process which involves the determination of how best to assist the person in
attaining the established goals
Evaluation
the sixth and final step of the nursing process which involves judging the effectiveness of the nursing
intervention in relation to the behavior after the nursing intervention in comparison with the goal
established.
DE M OGR AP HI C DATA
Name
Age
Sex
IP number
Education
Occupation
Marital status
Religion
Informants
Date of admission
Mr. NR
53 years
Male
----Degree
Bank clerk
Married
Hindu
Patient and Wife
21/01/08
FIRST LEVEL ASSESSMENT

PHYSIOLOGIC-PHYSICAL MODE
Oxygenation
Stable process of ventilation and stable process of gas exchange. RR= 18Bpm.
Apex beat felt on left 5th inter-costal space mid-clavicular line.
Air entry equal bilaterally. No ronchi or crepitus. NVBS. S1& S2 heard.
No abnormal heart sounds.
Delayed capillary refill+. JVP0.
Apex beat felt- normal rhythm, depth and rate.
Dorsalis pedis pulsation of affected limp is not palpable.
All other pulsations are normal in rate, depth, tension with regular rhythm.
Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line.
S1& S2 heard.
Chest normal in shape. Chest expansion normal on either side.
No abnormal heart sounds. BP- Normotensive. .
Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.
Nutrition
He is on diabetic diet (1500kcal). Non vegetarian.
He has stable digestive process.
He has complaints of anorexia and not taking adequate food.
No abdominal distension. Soft on palpation. No tenderness.
No visible peristaltic movements.
Bowel sounds heard.
Percussion revealed dullness over hepatic area.
Oral mucosa is normal. No difficulty to swallow food
Recently his Weight reduced markedly (10 kg/ 6 month).
Elimination:
No signs of infections, no pain during micturation or defecation.
Stool is hard and he complaints of constipation.
Normal bladder pattern. Using urinal for micturation.
Activity and rest:
Taking adequate rest.
Not following any peculiar relaxation measure.
Like movies and reading. No regular pattern of exercise.
Walking from home to office during morning and evening.
Now, activity reduced due to amputated wound. Mobility impaired.
Walking with crutches.
Pain from joints present. No paralysis.
ROM is limited in the left leg due to wound.
No contractures present. No swelling over the joints.
Sleep pattern disturbed at night due unfamiliar surrounding.
Patient need assistance for doing the activities.
Protection:
Left lower fore foot is amputated.
No redness, discharge or other signs of infection.
Nomothermic.
Wound healing better now.
Walking with the use of left leg is not possible.
Using crutches.
Pain form knee and hip joint present while walking.
Dorsalis pedis pulsation, not present over the left leg. Right leg is normal in length and size.
Several papules present over the foot.
All peripheral pulses are present with normal rate, rhythm and depth over right leg.
Black discoloration present over the area.
Senses:
No pain sensation from the wound site. Relatively, reduced touch and pain sensation in the lower
periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses
are normal.
Fluids and electrolytes:
Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte values are with in
normal limit. No signs of acidosis or alkalosis. Blood glucose elevated.
Neurological function:
He is conscious and oriented.
Like to go home as early as possible.
Showing signs of stress.
Touch and pain sensation decreased in lower extremity. Thinking and memory is intact.
He is anxious about the disease condition.
Endocrine function
He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No
enlarged glands.
SELF CONCEPT MODE
Physical self:
He is anxious about changes in body image, but accepting treatment and coping with the situation. He
deprived of sexual activity after amputation.
Belongs to a Nuclear family. 5 members. Stays along with wife and three children. Good relationship with
the neighbours. Good interaction with the friends. Moderately active in local social activities
Personal self:
Self esteem disturbed because of financial burden and hospitalization. He believes in god and worshiping
Hindu culture.
ROLE PERFORMANCE MODE:
He was the earning member in the family. His role shift is not compensated. His son doesn'tt have any
work. His role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbors. Good interaction with the friends relatives. But he believes,
no one is capable of helping him at this moment. He says all are under financial constrains. He was
moderately active in local social activities
SECOND LEVEL ASSESSMENT

FOCAL STIMULUS
Non-healing wound after amputation of great and second toe of left leg- 4 week. A wound first found on
the junction between first and second toe-4 month back. The wound was non-healing and gradually
increased in size with pus collected over the area.
He first consulted in a local (---) hospital. From there, they referred to ---- medical college; where he was
admitted for 1 month and 4 days. During hospital stay great and second toe amputated. But surgical
wound turned to non- healing with pus and black colour. So the physician suggested for below knee
amputation. That made them to come to ---Hospital, ---. He underwent a plastic surgery 3 week before.
CONTEXTUAL STIMULI:
Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years, but switched to
insulin and using it for 8 years now. Not wearing foot wear in house and premises.
RESIDUAL STIMULI:
He had TB attack 10 year back, and took complete course of treatment. Previously, he admitted in
---Hospital for leg pain about 4 year back. . Mothers brother had DM. Mother had history of PTB. He is a
graduate in humanities, no special knowledge on health matters.
CONCLUSION
Mr.NR who was suffering with diabetes mellitus for past 10 years. Diabetic foot ulcer and recent amputation made
his life more stressful. Nursing care of this patient based on Roy's adaptation model provided had a dramatic
change in his condition. Wound started healing and he planned to discharge on 25th april. He studied how to use
crutches and mobilized at least twice in a day. Patients anxiety reduced to a great extends by proper explanation
and reassurance. He gained good knowledge on various aspect of diabetic foot ulcer for the future self care
activities.
NURSING CARE PLAN
ASSESS. OF
BEHAVIOUR
ASSESSMENT OF
STIMULI
NURSING
DIAGNOSIS
Ineffective
protection and
sense in physicalphysiological mode
Focal stimuli:
Non-healing wound
after amputation of
great and second toe
of left leg- 4 week
1. Impaired skin
integrity related to
fragility of the skin
secondary to
vascular
insufficiency
(No pain sensation

from the wound
site.)
Impaired activity in
physicalphysiological mode
Focal stimuli:
During hospital stay
great and second toe
amputated. But
surgical wound turned
to non- healing with
pus and black colour.
2. Impaired
physical mobility
related to
amputation of the
left forefoot and
presence of
unhealed wound
GOAL
INTERVENTION
EVALUATION
Long-term objective:
1. amputated area will
be completely healed
by 20/5/08
2.Skin will remain
intact with no ongoing
ulcerations.
Short-Term Objective:
i. Size of wound
decreases to 1x1 cm
within 24/4/08.
ii. No signs of
infection over the
wound within 1-wk
iii. Normal WBC
values within 1-wk
iv. Presence of healthy
granular tissues in the
wound site within 1-wk
- Maintain the wound

area clean as
contamination affects
the healing process.
- Follow sterile
technique while
providing cares to
prevent infection and
delay in healing.
- Perform wound
dressing with Betadine
which promote healing
and growth of new
tissue.
- Do not move the
affected area frequently
as it affects the
granulation tissue
formation.
- Monitor for signs
and symptoms of
infection or delay in
healing.
- Administer the
antibiotics and vitamin
C supplementation
which will promote the
healing process.
Short term goal:

Met: size of wound
decreased to less than
1x1 cms.
WBC values became
normal on 24/4/08
- Assess the level of

restriction of movement
- Provide active and
passive exercises to all
Patient will attain
the extremities to
maximum possible
physical mobility with in improve the muscle
tone and strength.
6 months.
- Make the patient to
Short term objective:
perform the ROM
exercises to lower
extremities which will
i. Correct use of
strengthen the muscle.
crutches with in
- Massage the upper
22/4/08
and lower extremities
ii.
walking with
which help to improve
minimum supportthe circulation.
22/4/08
- Provide articles near
to the patient and
encourage performing
iii.
He will be self
activities within limits
motivated in activities- which promote a feeling
20/4/08.
of well being.
- Provide positive
reinforcement for even
a small improvement to
increase the frequency
Long term Objective:
Long term goal:

Partially Met: skin
partially intact with no
ulcerations.
Continue plan
Reassess goal and
interventions
Unmet: not achieved
complete healing of
amputated area.
Continue plan
Reassess goal and
interventions
Short term goal:

Met: used crutches
correctly on 22/4/08.
he is self motivated in
doing minor excesses
Partially Met: walking
with minimum support.
Long term goal:
Unmet: not attained
maximum possible
physical mobilityContinue plan
Reassess goal and
interventions
of the desired activity.

- Measures for pain
relief should be taken
before the activities are
initiated as pain can
hinder with the activity.
Alteration in
Physical self in
Self-concept mode
(He is anxious
about changes in
body image)
Change in Role
performance mode.
(He was the earning
member in the
family. His role shift
is not compensate)
Contextual stimuli:
Known case DM for
past 10 years and on
treatment with insulin
for 8 years.
3. Anxiety related
to hospital
admission and
unknown Outcome
of the disease and
financial
constrains.
Residual stimuli: no
special knowledge in
health matters
Contextual stimuli:
Known case DM for
past 10 years and on
treatment with insulin
for 8 years.
4. deficient
knowledge
regarding the foot
care, wound care,
diabetic diet, and
need of follow up
care.
Residual stimuli: no
special knowledge in
health matters
------

The client will remain
free from anxiety
i.
demonstrating
appropriate range
effective coping in the
treatment
ii. Being able to rest
and
iii. Asking fewer
questions

Patient will acquire
adequate knowledge
regarding the t foot
care, wound care,
diabetic diet, and need
of follow up care and
practice in their day to
day life.
i.
Verbalization and
demonstration of foot
care.
ii. Strictly following
diabetic diet plan
iii. Demonstration of
wound care.
- Allow and
encourage the client
and family to ask
questions. Bring up
common concerns.
- Allow the client and
family to verbalize
anxiety.
- Stress that frequent
assessment are routine
and do not necessarily
imply a deteriorating
condition.
- Repeat information
as necessary because
of the reduced attention
span of the client and
family
- Provide comfortable
quiet environment for
the client and family
- Explain the
treatment measures to
the patient and their
benefits in a simple
understandable
language.
- Explain about the
home care. Include the
points like care of
wounds, nutrition,
activity etc.
Clear the doubts of the
patient as the patient
may present with some
matters of importance.
- Repeat the
information whenever
necessary to reinforce
learning.
Short term goal:

Met: demonstrated
appropriate range
effective coping with
treatment
He is able to rest
quietly.
Long term goal:
Unmet: client not
completely remained
free from anxiety due
to financial constrainsContinue plan
Reassess goal and
interventions
Short term goal:

Met: Verbalization and
demonstration of foot
care.
Strictly following
diabetic diet plan
Unmet: Demonstration
of wound care.
Long term goal:
Unmet: not completely
acquired and practiced
the required
knowledge. Continue
plan Reassess goal
and interventions
REFERENCE
1.
Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. St Louis: Mosby; 2005
2.
George BJ, Nursing Theories- The Base for Nursing Practice.3rd ed. Chapter 8. Lobo ML. Behavioral
System Model. St Louis: Mosby; 2005
3.
Alligood MR Nursing Theory Utilization and Application 5th ed. St Louis: Mosby; 2005
4.
Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006.
5.
Brunner LS, Suddharth DS. Text book of Medical Surgical Nursing. 6th ed. London: Mosby; 2002
6.
Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidsons principle and practices of medicine. 20th ed.
London: Churchill Livingstone Elsevier; 2006.
Application of Interpersonal Theory in Nursing

Practice
Introduction
Peplaus theory focuses on the interpersonal processes and therapeutic relationship that develops
between the nurse and client.
The interpersonal focus of Peplaus theory requires that the nurse attend to the interpersonal processes
that occur between the nurse and client.
Interpersonal process is maturing force for personality. Interpersonal processes include the nurse- client
relationship, communication, pattern integration and the roles of the nurse.
Psychodynamic nursing is being able to understand ones own behavior to help others identify felt
difficulties and to apply principles of human relations to the problems that arise at all levels of experience.
This theory stressed the importance of nurses ability to understand own behavior to help others identify
perceived difficulties.

1. Orientation:
During this phase, the individual has a felt need and seeks professional assistance.
The nurse helps the individual to recognize and understand his/ her problem and determine the need for
help.
2. Identification
The patient identifies with those who can help him/ her.
The nurse permits exploration of feelings to aid the patient in undergoing illness as an experience that
reorients feelings and strengthens positive forces in the personality and provides needed satisfaction.
3. Exploitation
During this phase, the patient attempts to derive full value from what he/ she are offered through the
relationship.
The nurse can project new goals to be achieved through personal effort and power shifts from the nurse
to the patient as the patient delays gratification to achieve the newly formed goals.
4. Resolution
The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient
frees himself from identification with the nurse.
Peplaus theory and nursing process
Peplau defines Nursing Process as a deliberate intellectual activity that guides the professional practice of nursing
in providing care in an orderly, systematic manner.
Peplau explains 4 phases such as:
Orientation: Nurse and patient come together as strangers; meeting initiated by patient who expresses a
felt need; work together to recognize, clarify and define facts related to need.
Identification: Patient participates in goal setting; has feeling of belonging and selectively responds to
those who can meet his or her needs.
Exploitation: Patient actively seeks and draws knowledge and expertise of those who can help.
Resolution: Occurs after other phases are completed successfully. This leads to termination of the
relationship.
In Nursing Process, the orientation phase parallels with assessment phase where both the patient and nurse are
strangers; meeting initiated by patient who expresses a felt need.
Conjointly, the nurse and patient work together, clarifies and gathers important information.
Based on this assessment the nursing diagnoses are formulated, outcome and goal set.
The interventions are planned, carried out and evaluation done based on mutually established expected
behaviours.
Peplaus theory application nursing process:
The nursing process for Mrs. JL based on Peplaus theory is as follows:
Mrs. JL
Diagnosis: Inter vertebral disc prolapse
27 years
Assessment
Nursing
Planning
Implementation
(Orientation
diagnosis (Identification phase) (Exploitation phase)
phase)
Mrs. JL is on pelvic Impaired
Goal setting was done Carried out plans
traction and she is physical
along with patient
mutually agreed upon.
restricted to bed.
mobility related
to the presence
of pelvic
The need for bed
rest and restriction traction.
Patient will have
was discussed.
improved physical
mobility as evidenced Provided active and
by participating in self
passive exercises to all
care within the limits. the extremities
Provide active and
passive exercises to
all the extremities to
improve the muscle
tone and strength.
Made the patient to

perform breathing
Evaluation
(Resolution
phase)
Mrs. JL was free to express
problems regarding difficulty
in mobilizing.
She expressed satisfaction

when able to move without
difficulty.
Make the patient to

exercises
perform the breathing
exercises which will
strengthen the
respiratory muscle.
Massaged the upper and
lower extremities
Massage the upper
Provided article within
and lower extremities the reach of the patient
which help to improve
the circulation.
Provide articles near to
Provided positive
the patient and
reinforcement to the
encourage doing
activities within limits. patient
Provide positive
reinforcement for even
a small improvement
to increase the
frequency of the
desired activity.
Assessment (Orientation Nursing

phase)
diagnosis
Planning
(Identification
phase)
Mrs. JL expresses pain in Pain related to Goal setting was

the low back region.
the degenerative done along with
changes in the patient
lumbar region.
Regarding pain, discussion
was made to assess the
severity and the type and
duration of pain. Also the
measures to reduce pain
were discussed.
Implementation
Evaluation
(Exploitation phase) (Resolution phase)
Carried out plans
mutually agreed
upon.
Mrs. JL was free to

express problems of pain.
Mrs. JL will have

reduction in pain as
evidenced by her
verbalisation of
Expressed that she got
reduction in pain
Provided non
slight relief from pain.
responses.
pharmacological
measures like
Provide nondiversion, massaging,
pharmacological
and pelvic traction.
measures for pain
relief such as
diversional activity Provided supine
position to the client
which diverts the
Supported the back
patients mind.
during position
change
Give the client a
neutral position
Used pillows to
support the back.
Always use back
support while turning
Administered Tab.
the patient that
reduces the strain on Hifenac P and Cap.
Myoril 4mg as
the back.
prescribed.
Support the areas
with extra pillow to
allow the normal
alignment and to
prevent strain.
Administer
Given pelvic traction

and explained the
need for traction
analgesics as
prescribed by the
physician.
Provide pelvic
traction to the patient
Assessment
Nursing
(Orientation phase) diagnosis
Mrs. JL expresses Self care deficit
that she need
related to the
assistance to get
presence of
down from bed.
pelvic traction.
Regarding self care
discussion was done
and discussed
regarding the
measures to solve
the problems.
Planning
(Identification phase)
Goal setting was done
along with patient
Implementation
Evaluation
(Exploitation phase)
(Resolution phase)
Carried out plans mutually Mrs. JL was free to
agreed upon.
express problems of self
care.
Client will achieve and

maintain self care
activities with assistance
of caregiver or within her
limits.
Keep all the articles
within the reach of the
patient.
She used to call for the

needs and all her needs
were met appropriately
Kept the articles within t

he reach of the client
She achieved and

maintained self care
activities within her limits
Provide a call bell to the

patient to call in any
emergency
Assessment
(Orientation
phase)
Frequently visit the

patient and enquire for
any needs.
Frequently visited the

patient and enquired for
any needs
Assist the patient in

doing her self care
activities.
Assisted the client in

doing her self care
activities
Remove the weight of

the traction as needed
by the patient.
Removed the weight as

and when needed.
Nursing diagnosis Planning

Implementation
(Identification phase) (Exploitation phase)
Mrs. JL is
Anxiety related to
enquiring about thehospital admission
disease condition, as evidenced by
its outcome and
verbalisation and
need for surgery client & family
appearing
Discussed with the withdrawn
client regarding the
disease process
and the findings in
the client
Evaluation
(Resolution phase)

Mrs. JL was free to
along with patient
mutually agreed upon. express problems of self
care.
Client will have
reduced feeling of
anxiety as evidenced
by
asking fewer questions
Taught the family

regarding the disease
Teach the family and
process in simple
client regarding the
Kannada
disease process.
Explain in simple
understandable
language of the client.
She asked her doubts

regarding the illness and
the diagnostic procedures
She verbalized that her
anxiety has reduced to
some extent.
Allow and encourage

the client and family to
ask questions. Allow
the client and family to
verbalize anxiety.
Allowed the client and

family members to ask
questions
She and her husband
expressed their anxiety
Stress that frequent

assessment are routine
and do not necessarily
imply a deteriorating
condition.
Allow the family
members to visit the
client frequently
Assessment
(Orientation
phase)
Nursing
diagnosis
Mrs. JL is enquiring Deficient

about the disease knowledge
condition, its
related to the
outcome and need treatment
for surgery
measures to be
continued even
Discussed with the after the
client regarding the discharge.
disease process
and the need for
follow up
Allowed the family

members to frequently
visit the client
Planning
Implementation
(Identification phase) (Exploitation phase)
Evaluation
(Resolution phase)

along with patient
mutually agreed upon.
Mrs. JL was free to express

problems of self care.
Patient will acquire

adequate knowledge
regarding the treatment
and home care.
She expressed acquisition

of knowledge regarding the
disease and the signs of
aggravation of illness
Explained treatment
Explain the treatment measures and the need
measures to the patient
for follow up
and their benefits
Explained regarding the
Explain to the client the
signs of aggravation of
signs of aggravation of disease
illness
Use simple and
understandable terms
Used simple and

understandable terms
for explaining
Clarified her doubts
Clarify all the doubts of

the patient of
importance.
Repeated the
Repeat the information
information
whenever necessary to
reinforce learning.
Summary
1. Orientation phase
Client is initially reluctant to talk due to pain.
Client expressed without movement and supine position gave her relief from pain.
Client is expressing that while standing she is having much pain.
2. Identification
The client participates and interdependent with the nurse
Expresses need for improving the mobility
Expresses need to know more about prognosis, discharge and home care and follow up.
Expresses the need for measure to get relief from pain
3. Exploitation
Client explains that she gets relief of pain when lying down supine.
Client mobilizes changes position and cooperates during position changes.
Cooperates and participates actively in performing exercises.
4. Resolution
Client expressed that pain has reduced a lot and she is able to tolerate it now
She also expressed that she would come for regular follow up after discharge.
She has agreed upon to continue the exercises at home
Evaluation of the theory of interpersonal relations by Peplau
With the help of the theory of interpersonal relations, the client's needs could be assessed.
It helped her to achieve them within her limits. This theory application helped in providing comprehensive
care to the client.
References
1.
Chinn PL, and Kramer MK. Theory and nursing- a systemic approach. 3rd edition. Philadelphia: Mosby
year book;1991.
2.
George JB. Nursing theories. 5th edition. New Jersey: Prentice hall; 2002.
3.
Alligood MR, Tomey AM. Nursing theory- utilization and application. 3rd edition. Missouri: Mosby Elsevier;
2006.
4.
Craven RF, Hirnle CJ. Fundamentals of nursing human health and function. 5th edition. Philadelphia:
Lippincott Williams and Wilkins; 2007.
5.
McQuiston CM and Webb AA. Foundations of nursing theory- Contributions of 12 key theorists. New
Delhi: Sage Publications; 1995.
Application of Interpersonal Theory in
Nursing Practice
Introduction
Peplaus theory focuses on the interpersonal processes and therapeutic

relationship that develops between the nurse and client.
The interpersonal focus of Peplaus theory requires that the nurse attend to the
interpersonal processes that occur between the nurse and client.
Interpersonal process is maturing force for personality. Interpersonal processes

include the nurse- client relationship, communication, pattern integration and the
roles of the nurse.
Psychodynamic nursing is being able to understand ones own behavior to help

others identify felt difficulties and to apply principles of human relations to the
problems that arise at all levels of experience.
This theory stressed the importance of nurses ability to understand own

behavior to help others identify perceived difficulties.

1. Orientation:
During this phase, the individual has a felt need and seeks professional
assistance.
The nurse helps the individual to recognize and understand his/ her problem
and determine the need for help.
2. Identification
The patient identifies with those who can help him/ her.
The nurse permits exploration of feelings to aid the patient in undergoing illness
as an experience that reorients feelings and strengthens positive forces in the
personality and provides needed satisfaction.
3. Exploitation
During this phase, the patient attempts to derive full value from what he/ she are
offered through the relationship.
The nurse can project new goals to be achieved through personal effort and
power shifts from the nurse to the patient as the patient delays gratification to
achieve the newly formed goals.
4. Resolution
The patient gradually puts aside old goals and adopts new goals. This is a
process in which the patient frees himself from identification with the nurse.
Peplaus theory and nursing process
Peplau defines Nursing Process as a deliberate intellectual activity that guides the
professional practice of nursing in providing care in an orderly, systematic manner.
Peplau explains 4 phases such as:
Orientation: Nurse and patient come together as strangers; meeting initiated by

patient who expresses a felt need; work together to recognize, clarify and
define facts related to need.
Identification: Patient participates in goal setting; has feeling of belonging and

selectively responds to those who can meet his or her needs.
Exploitation: Patient actively seeks and draws knowledge and expertise of

those who can help.
Resolution: Occurs after other phases are completed successfully. This leads
to termination of the relationship.
In Nursing Process, the orientation phase parallels with assessment phase where both
the patient and nurse are strangers; meeting initiated by patient who expresses a felt
need.
Conjointly, the nurse and patient work together, clarifies and gathers important
information.
Based on this assessment the nursing diagnoses are formulated, outcome and goal set.
The interventions are planned, carried out and evaluation done based on mutually
established expected behaviours.
Peplaus theory application nursing process:
The nursing process for Mrs. JL based on Peplaus theory is as follows:
Mrs. JL
Diagnosis: Inter vertebral disc prolapse
27 years
Assessment
(Orientation
phase)
Mrs. JL is on
pelvic traction
and she is
restricted to
bed.
Nursing
diagnosis
Impaired
physical
mobility
related to
the
presence of
pelvic
Planning
Implementation
Evaluation
(Identification
(Exploitation
(Resolution
phase)
phase)
phase)
Goal setting was Carried out plans Mrs. JL was free to
done along with mutually agreed
express problems
patient
upon.
regarding difficulty in
mobilizing.
The need for traction.

bed rest and
restriction was
discussed.
Patient will have

improved physical
mobility as
Provided active and She expressed
evidenced by
passive exercises satisfaction when able
participating in
to all the
to move without
self care within
extremities
difficulty.
the limits.
Provide active
and passive
exercises to all Made the patient to
the extremities to perform breathing
exercises
improve the
muscle tone and
strength.
Make the patient
to perform the
breathing
exercises which
will strengthen
the respiratory
muscle.
Massaged the
upper and lower
extremities
Provided article
within the reach of
the patient
Massage the
upper and lower
extremities which Provided positive
help to improve reinforcement to
the patient
the circulation.
Provide articles
near to the
patient and
encourage doing
activities within
limits.
Provide positive
reinforcement for
even a small
improvement to
increase the
frequency of the
desired activity.
Assessment
Nursing
(Orientation phase) diagnosis
Planning
Implementation Evaluation
(Identification (Exploitation
(Resolution
phase)
phase)
phase)
Mrs. JL expresses
Pain related Goal setting
Carried out
Mrs. JL was free to
pain in the low back to the
was done along plans mutually express problems of
region.
degenerative with patient
agreed upon.
pain.
changes in
the lumbar Mrs. JL will have
region.
reduction in pain
as evidenced by
Regarding pain,
her verbalisation
discussion was made
of reduction in
to assess the
Expressed that she
pain responses. Provided non
severity and the type
pharmacological got slight relief from
and duration of pain.
measures like pain.
Also the measures to
Provide nondiversion,
reduce pain were
pharmacological massaging, and
discussed.
measures for
pain relief such

as diversional
activity which
diverts the
patients mind.
pelvic traction.
Provided supine
position to the
client
Supported the
Give the client back during
a neutral
position change
position
Used pillows to
Always use backsupport the
support while
back.
turning the
patient that
Administered
reduces the
Tab. Hifenac P
strain on the
and Cap. Myoril
back.
4mg as
prescribed.
Support the
areas with extra Given pelvic
pillow to allow
traction and
the normal
explained the
alignment and to
need for traction
prevent strain.
Administer
analgesics as
prescribed by
the physician.
Provide pelvic
traction to the
patient
Assessment
(Orientation
phase)
Mrs. JL
expresses that
she need
assistance to
get down from
bed.
Nursing
diagnosis
Planning
(Identification
phase)
Goal setting was
done along with
patient
Implementation
(Exploitation
phase)
Carried out plans
mutually agreed
upon.
Self care
deficit
related to
the
presence of
Client will achieve
pelvic
and maintain self
traction.
care activities with
Regarding self
assistance of
care discussion
caregiver or within
was done and
her limits.
discussed
regarding the
Kept the articles
Keep all the
measures to
within t he reach of
articles
within
the
solve the
the client
reach of the
problems.
patient.
Provide a call bell
to the patient to
call in any
emergency
Frequently visited
the patient and
Frequently visit the enquired for any
patient and
enquire for any
Evaluation
(Resolution
phase)
Mrs. JL was free to
express problems of
self care.
She used to call for
the needs and all
her needs were met
appropriately
She achieved and
maintained self care
activities within her
limits
needs.
needs
Assist the patient Assisted the client in

in doing her self doing her self care
care activities.
activities
Remove the
Removed the weight
weight of the
as and when
traction as needed needed.
by the patient.
Assessment
(Orientation
phase)
Mrs. JL is
enquiring
about the
disease
condition, its
outcome and
need for
surgery
Nursing
diagnosis
Planning
(Identification
phase)
Anxiety related Goal setting was
to hospital
done along with
admission as patient
evidenced by
verbalisation
Client will have
and client &
reduced feeling of
family
anxiety as
appearing
evidenced by
withdrawn
asking fewer
Discussed with
questions
the client
regarding the
Teach the family
disease
and client
process and
regarding the
the findings in
disease process.
the client
Explain in simple
understandable
language of the
client.
Allow and
encourage the
client and family
to ask questions.
Allow the client
and family to
verbalize anxiety.
Implementation
(Exploitation
phase)
Carried out plans
mutually agreed
upon.
Evaluation
(Resolution
phase)
Mrs. JL was free to
express problems of
self care.
She asked her
doubts regarding the
illness and the
diagnostic
procedures
Taught the family

regarding the
She verbalized that
disease process in
simple Kannada her anxiety has
reduced to some
extent.
Allowed the client

and family
members to ask
questions
She and her
husband
expressed their
anxiety
Stress that
frequent
assessment are
routine and do not Allowed the family
necessarily imply members to
a deteriorating
frequently visit the
condition.
client
Allow the family
members to visit
the client
frequently
Assessment
(Orientation
phase)
Nursing
diagnosis
Planning
(Identification
phase)
Implementation
(Exploitation
phase)
Evaluation
(Resolution phase)
Mrs. JL is
enquiring
about the
disease
condition, its
outcome and
need for
surgery
Deficient
Goal setting was Carried out plans Mrs. JL was free to
knowledge done along with mutually agreed
express problems of
related to the patient
upon.
self care.
treatment
measures to Patient will acquire
She expressed
be continued
acquisition of
adequate
even after the knowledge
knowledge regarding
discharge.
the disease and the
regarding the
signs of aggravation
treatment and
Discussed with
of illness
Explained
home care.
the client
treatment
regarding the
measures and the
Explain the
disease
need for follow up
treatment
process and
measures to the
the need for
patient and their Explained
follow up
regarding the signs
benefits
of aggravation of
disease
Explain to the
client the signs of
Used simple and
aggravation of
understandable
illness
terms for
explaining
Use simple and
Clarified her
understandable
doubts
terms
Clarify all the
doubts of the
patient of
importance.
Repeated the
information
Repeat the
information
whenever
necessary to
reinforce learning.
Summary
1. Orientation phase
Client is initially reluctant to talk due to pain.
Client expressed without movement and supine position gave her relief from
Client is expressing that while standing she is having much pain.
pain.
2. Identification
The client participates and interdependent with the nurse
Expresses need for improving the mobility
Expresses need to know more about prognosis, discharge and home care and
Expresses the need for measure to get relief from pain
follow up.
3. Exploitation
Client explains that she gets relief of pain when lying down supine.
Client mobilizes changes position and cooperates during position changes.
Cooperates and participates actively in performing exercises.
4. Resolution
Client expressed that pain has reduced a lot and she is able to tolerate it now
She also expressed that she would come for regular follow up after discharge.
She has agreed upon to continue the exercises at home
Evaluation of the theory of interpersonal relations by Peplau
With the help of the theory of interpersonal relations, the client's needs could be
assessed.
It helped her to achieve them within her limits. This theory application helped in
providing comprehensive care to the client.
References
1.
Chinn PL, and Kramer MK. Theory and nursing- a systemic approach. 3rd
edition. Philadelphia: Mosby year book;1991.
2.
George JB. Nursing theories. 5th edition. New Jersey: Prentice hall; 2002.
3.
Alligood MR, Tomey AM. Nursing theory- utilization and application. 3rd edition.
Missouri: Mosby Elsevier; 2006.
4.
Craven RF, Hirnle CJ. Fundamentals of nursing human health and function.
5th edition. Philadelphia: Lippincott Williams and Wilkins; 2007.
5.
McQuiston CM and Webb AA. Foundations of nursing theory- Contributions of

12 key theorists. New Delhi: Sage Publications; 1995.

Introduction To Nursing Theories

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Introduction to Nursing Theories

This page was last updated on January 31, 2012

Theory-guided, evidence-based practice is the hallmark of any professional discipline.

Nursing is a professional discipline (Donaldson & Crowley, 1978).

Nursing models are conceptual models, constructed of theories and concepts

Recipient of care, including physical, spiritual, psychological, and sociocultural components.

Degree of wellness or illness experienced by the person

Actions, characteristics and attributes of person giving care.

a set of related statements that describes or explains phenomena in a systematic way.

a mental idea of a phenomenon

a phenomena that cannot be observed and must be inferred

a statement of relationship between concepts

made up of concepts and propositions

context. They are not always as specified as theory.

Middle range theory

Focuses on nursing and the patient environment relationship.

Helping process meets needs through the art of individualizing care.

Nurses should identify patients need-for help by:

Ernestine Wiedenbach: The helping

Virginia Hendersons Definition of

Faye G.Abedellahs Typology of

Patricia Benners Novice to Expert

Understanding client behaviour

Identifying cause of discomfort

Determining if clients can resolve problems or have a need

Patients require help towards achieving independence.

Derived a definition of nursing

Identified 14 basic human needs on which nursing care is based.

Patients problems determine nursing care

Nursing care is person directed towards self love.

Caring is a universal, social phenomenon that is only effective when

Caring is central to the essence of nursing.

Described systematically five stages of skill acquisition in nursing

CONCEPTUAL MODELS AND GRAND THEORIES

Theory of Self-Care Deficit

Theory of Nursing Systems

Myra Estrin Levines: The

Martha E.Rogers: Science of

Dorothy E.Johnsons Behavioural

Sister Callista: Roys Adaptation

Betty Neumans : Health care

Wholly compensatory (doing for the patient)

Partly compensatory (helping the patient do for himself or

Supportive- educative (Helping patient to learn self care

Proposed that the nurses use the principles of conservation of:

A conceptual model with three nursing theories

Person and environment are energy fields that evolve

Nursing is a basic scientific discipline

Nursing is using knowledge for human betterment.

The unique focus of nursing is on the unitary or irreducible human

Individuals maintain stability and balance through adjustments and

Individual as a behavioural system is composed of seven

Disturbances in these causes nursing problems.

Stimuli disrupt an adaptive system

The individual is a biopsychosocial adaptive system within an

Through two adaptive mechanisms, regulator and cognator, an

Neumans model includes intrapersonal, interpersonal and

Imogene Kings Goal attainment

Nancy Roper, WW.Logan and

Nursing is concerned with the whole person.

Nursing actions (Primary, Secondary, and Tertiary levels of

Transactions provide a frame of reference toward goal setting.

Major concepts (interaction, perception, communication, transaction,