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Theoretical Framework in Nursing Process - Nursing Theories Based on Human Needs

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Theoretical Framework in Nursing Process - Nursing Theories Based on Human Needs
Theoretical Framework for Nursing Practice – Module 4

A. As you read Henderson 's definition of nursing, what nursing functions and actions are applicable today? Explain.

Almost all basic independent nursing interventions have its basis on the fourteen nursing needs by Henderson. She described the role of the nurse as one of the following: substitutive, which is doing something for the patient; supplementary, which is helping the patient do something; or complimentary which is working with the patient to do something (http://nursing-theory.org). In essence, all patient needs across the dependent-independent continuum would need some sort of intervention from the nurse while the patient is under her care with the main end-goal of full independence by the time the patient is discharged. Among different types of patients, those admitted in the intensive care units, particularly those who are rated 3 to 7 out of 15 on the Glasgow Coma Scale require a mostly supplementary form of care. Simple activities of daily living are fully performed by the caregiver that includes, but not limited, to the following: maintaining patent airway by placing an oral protective airway and suctioning of secretions via oral or endotracheal tube (breathe normally); ensuring adequate nutrition by tube feeding either through NGT, PEG or intravenously (eat and drink adequately); frequent changing of soaked/ soiled diapers or underpads (depending on institution policies) or the insertion of a foley catheter as well as emptying of excess bodily fluids such as that from an ostomy appliance or a Jackson-Pratt drainage (eliminate body wastes); unless contraindicated, routine positioning and turning of the patient from side-to-side and flat on back for the prevention of bedsore formation and promotion of comfort or by employing postural drainage for mobilization of pulmonary secretions (move and maintain desirable body postures/protect the integument); ensuring ambient noise is minimized, providing dimmed but adequate lighting, maintaining room temperatures in check, and reducing patient manipulation during time of sleep (sleep and rest/maintain body temperature); routine hygienic measures such as daily bed baths and oral care, shaving of facial/body hair as necessary and regular change of linens and patient clothes/hospital gown (keep the body clean and well groomed/select suitable clothes); ensuring that side rails are up at all times, making sure that the bed is free from sharps or other objects that could be potentially harmful to the patient, following the 10 R’s and hospital protocols when administering medications (avoid dangers in the environment).

In other cases a client (may it be the patient or a relative) maybe fully capable but is simply unaware, incompetent, uneducated, confused, or perhaps is undergoing some stressful situation at present, that a nurse is needed to guide, coach, counsel or teach. This is where a nurse’s most often overlooked roles come in the form of patient/client education and compassionate care through sympathizing and empathizing. Numbers 9 up to 14 of Henderson’s components fall under this type of nursing function.

B. Select a patient in your practice setting or recall a patient when you were a student. Use Abdellah 's typology of 21 nursing problems to assess the patient. Make an NCP and identify outcome measures.

Patient A.M., a 55 year old male comes into the ER with complaints of a left sided chest pain that is 7/10 on the pain scale. Upon assessment, the patient is diaphoretic, his right hand clutching his chest and is short of breath. Upon interview, it was learned that started 6 hours ago as an epigastric pain and so he thought that he was just having a heart burn but has now gotten worse and is now accompanied with difficulty of breathing. He states he is on hypertensive and diabetes medications and has had a previous double-vessel bypass surgery in 2008. Upon arrival, his vital signs are as follows: BP=186/101, HR=101, O2 Sat=95%, RR=22, and Temp=37.4⁰C. The patient is given Isordil 5mg SL tab, Catapres 75mg SL tab, and is hooked on oxygen via nasal cannula at 2lpm. ECG shows slight ST elevation while the cardiac panel results are at borderline normal values. The patient is advised for admission to Telemetry unit for observation. At present, the patient states that his chest pain is as improved, now at 3/10 with the dyspnea resolved and his latest vital signs are as follows: BP=176/98, HR=92, RR=20. Though feeling better, patient verbalizes concerns over hospitalization due to his past experiences over four years ago. He states: “Nako, wag naman sanang maulit yung dati. Mahirap ma-ospital, mashadong magastos.”

|Assessment |Nursing Diagnosis |Planning |Intervention |Rationale |Evaluation |
|Objective cues: |Anxiety related to |Goal: The client will |Assist the client to reduce anxiety: |An anxious client has a narrowed |Client verbalized feeling |
|Diaphoresis |unpredictable nature of |relate increased |Provide reassurance and comfort. |perceptual field and a diminished |less worried about his |
|Elevated BP (186/101) |condition as evidenced by |psychological and |Convey understanding and empathy. Do |ability to learn. He or she may |hospitalization. |
|Ttachycardia (HR=101) |verbalization of concerns |physiologic comfort |not avoid questions. |experience symptoms caused by increased| |
|Dyspnea |over hospitalization. | |Encourage the client to verbalize any|muscle tension and disrupted sleep |Verbalized specific areas |
|Previous history of | |Indicators: |fears or concerns regarding MI and |patterns. Anxiety tends to feed on |of concern and particular |
|bypass surgery obtained | |Verbalize fears related to |its treatment. |itself, trapping the client in a spiral|fears regarding his |
|from records review | |the illness and |Identify and support effective coping|of increased anxiety, tension, |illness and |
|Subjective cues: | |hospitalization. |mechanisms. |emotional and physical pain. |hospitalization. |
|Verbalization of concern:| |Share concerns about the | | |Shared concerns of the |
|“Nako, wag naman sanang | |effects of illness on |Assess the patient’s anxiety level. | |perceived negative effects|
|maulit yung dati. Mahirap| |normal functioning, role |Plan teaching when level is low or |Some fears are based on inaccuracies. |of illness via verbal |
|ma-ospital, mashadong | |responsibilities and life |moderate. |Accurate information can relieve them. |feedback. |
|magastos.” | |style. | |A client with severe or panic anxiety |Client demonstrated |
| | |Use at least one relaxation| |does not retain learning. |deep-breathing exercises |
| | |technique. | |Verbalization allows sharing and |as a form of relaxation |
| | | |Encourage family or friends to |provides the nurse an opportunity to |technique. |
| | | |verbalize fear and concerns. |correct misconceptions. | |
| | | | |Praising effective coping can reinforce| |
| | | | |future positive coping responses. | |
| | | |Provide the client and family valid |These techniques enhance the client’s | |
| | | |reassurance; reinforce positive |sense of control over his or her body’s| |
| | | |coping behavior. |responses to stress. | |
| | | | | | |
| | | |Encourage the client to use | | |
| | | |relaxation techniques such as | | |
| | | |relaxation breathing or guided | | |
| | | |imagery. | | |
|Objective cues: |Pain related to cardiac |Goal: The client will |Instruct the client to immediately |Less pain medication generally is |Client reported a 50% |
|Diaphoresis |tissue ischemia or |report satisfactory control|report any pain episode. |required if administered early. Acute |decrease in pain score |
|Elevated BP (186/101) |inflammation as evidenced |of chest pain within the |Administer nitrates and oxygen or |intervention can prevent further |within five minutes of |
|Tachycardia (HR=101) |by pain score of 7/10. |appropriate timeframe. |analgesics, per physician order. |ischemia or injury. |giving intervention. |
|Dyspnea | |Indicators: |Document administration and degree of|Severe, persistent pain unrelieved by |Client return-demonstrated|
|Pain sore: 7/10 | |Report pain relief after |pain relief the client experiences. |analgesics may indicate impending or |the use of alternative |
|Subjective cues: | |pain relief measures. |Instruct the client to rest during a |extending infarction. |pain relieving measures. |
|Clutching of chest | |Demonstrate a relaxed mode.|pain episode. | |Client was observed to be |
| | | |Reduce environmental distractions as |Activity increases oxygen demand, which|in a calm, relaxed mode as|
| | | |much as possible. |can exacerbate cardiac pain. |manifested by lack of |
| | | |Obtain and evaluate a 12-lead ECG and|Environmental stimulation can increase |muscle tension and |
| | | |rhythm strip during pain episodes. If|heart rate and can exacerbate |guarding. |
| | | |immediately available, do so before |myocardial tissue hypoxia which causes | |
| | | |nitrates administration. Notify the |pain. | |
| | | |physician. |Cardiac monitoring may help | |
| | | |Explain and assist with alternative |differentiate variant angina from | |
| | | |pain relief measures. |extension of infarction. | |
| | | |Positioning | | |
| | | |Distraction (activities, breathing |These measures can help to prevent | |
| | | |exercises) |painful stimuli from reaching higher | |
| | | |Massage |brain centers by replacing the painful | |
| | | |Relaxation Techniques |stimuli by another painful stimulus. | |
| | | | |Relaxation reduces muscle tension, | |
| | | | |decreases heart rate, may improve | |
| | | | |stroke volume, and enhances the | |
| | | | |client’s sense of control over the | |
| | | | |pain. | |

In this particular problem, I have identified several nursing problems that are included in Abdellah’s typology:

1. To promote physical comfort – alleviation of pain through various methods that include dependent, independent as well as collaborative nursing interventions.

2. To promote optimal activity, rest and sleep – conserving oxygen consumption as the main goal in prevention of possible further coronary injury.

3. To promote safety through prevention of accident or injury – through the use of 10 R’s when administering medicines.

4. To maintain good body mechanics – improvement of dyspnea by proper patient positioning (high-back rest)

5. To facilitate the maintenance of a supply of oxygen to all body cells – and for the purpose of this discussion, the cardiac oxygen supply in particular. Promoting optimal supply by the use of oxygen support while decreasing the demand at the same time by promoting relaxation and comfort.

6. To recognize the physiological responses of the body to disease conditions – in this case, it would be an acute coronary syndrome and the corresponding physiologic responses that emerge out of it.

7. To identify and accept positive and negative expressions, feelings and reactions – as observed with the first nursing diagnosis which is anxiety related to the unpredictable nature of illness.

8. To identify and accept interrelatedness of emotions and organic illness – evident with the patients anxiety in relation to previous history of condition and the present problem.

9. To facilitate the maintenance of effective verbal and non-verbal communication – primarily initiated by the nurse and maintained all throughout the patient’s stay in the emergency room.

10. To create and maintain a therapeutic environment – important in achieving reduction of external stimuli needed for relaxation.

C. Apply the theory of Dorothea Orem in taking care of an elderly with chronic illness. Give the profile of the patient, history of present illness and the diagnosis. Make an NCP. Explain how the theory works and how you applied it in the situation.

|Assessment |Nursing Diagnosis |Planning |Intervention |Rationale |Evaluation |
|Objective cues: |Fluid volume excess |Goal: |Monitor and record accurate hourly |Accurate I&O is necessary for |Patient has displayed |
|Venous distension |related to compromised |Patient will show signs of |input and output of the patient. |determining renal function and fluid |appropriate urine output. |
|Generalized, grade 3, |regulatory mechanism |hemodynamic stability. | |replacement needs in order to prevent |Patient has maintained a |
|pitting edema |(renal failure) |Indicators: |Accurate daily weighing of the |renal overload. |stable body weight. |
|HR=110 (tachycardic) | |After 8 hours of nursing |patient using the same scale and with|Daily body weight is the best monitor |Patient had stable vital |
|BP=162/95 | |intervention, the patient |the same equipments or clothing if |of fluid status. A drastic increase in |signs throughout the |
|RR=24 (tachypneic) | |will display appropriate |possible. |weight in the span of 24 hours could |shift. |
|Patient reports of | |urinary output. | |mean that the patient is retaining more|Pitting edema was observed|
|fatigue, weakness and | |Patient will maintain a |Continuous monitoring and |fluid than is necessary and may be the |to improve from grade 3 to|
|body malaise | |stable body weight |re-assessment of patient’s face, |basis for early referral. |2+. |
|Subjective cues: | |Patient will have stable |skin, dependent areas and extent of |Edema primarily occurs in the dependent| |
|Verbalization of concern:| |vital signs |progression of edema. Ensure timely |tissues of the body (eg. Hands, feet, | |
|“Namamanas ako ang | |Signs of edema will |updates and appropriate referrals to |lumbosacral area). Patient can gain up | |
|nahihirapan akong | |improve. |the attending physician. |to 10lbs (4.5kg) of fluid before | |
|huminga.” | | | |pitting edema is detected. | |
| | | |Plan oral fluid replacement within |Helps avoid prolonged periods without | |
| | | |multiple restrictions based on the |fluids, minimizes boredom of limited | |
| | | |physicians orders. |choices and reduces sense of | |
| | | |Administer/restrict fluids as |deprivation and thirst. | |
| | | |indicated. |Fluid management is usually calculated | |
| | | | |to replace output from all sources | |
| | | |Administer medications as indicated. |(including estimated insensible losses)| |
| | | |(diuretics, antihypertensives etc.) |Given early in the oliguric phase of | |
| | | | |renal failure, in an effort to convert | |
| | | | |to non-oliguric phase, flush the | |
| | | | |tubular lumen of debris, reduce | |
| | | | |hyperkalemia and promote adequate urine| |
| | | | |volume. | |

Case scenario:

Patient R.S., an 82 year-old female, was admitted to the hospital with a chief complaint shortness of breath. Patient also reported generalized body weakness and fatigue for 2 days. She is known to have diabetes mellitus for past 13 years and hypertension for 1 year. According to her records, she is noted to have beginning episodes of oliguria. The patient developed bipedal edema 2 weeks ago although according to her, it has been more prominent during the last 5 days. Now it is observed that she has generalized, grade 3, pitting edema. On examination, patient’s vital signs are as follows: BP=162/95, HR=110, RR=24. When asked how she is doing, she responded by saying, “Eto, namamanas ako at nahiirapang uminga.” After a series of tests, the patient has now been diagnosed with Chronic Renal Failure.

Dorothea Orem’s theory is comprised of three related theories but for the purpose of this discussion, I would like to focus on her Theory of Self-Care Deficits. The theory of self-care deficit is focused on and limited to dealing with individual self-care deficits, rather than with the entire human being. It deals essentially with what Orem calls practical science of nursing (Meleis, 2012). In the case described and discussed above, the patient has already been dealing with hypertension and diabetes for a while now but with chronic renal failure adding on as a new health problem, the patient would certainly need assistance in dealing with this newly discovered deficit. The unfamiliarity with the illness would somewhat contribute to the “helplessness” of any individual inflicted with it thus it is the role of the nurse to intervene in all aspects pertaining to the care and management of such deficit. In the nursing care plan presented above, it was clear that the nurse’s focus was attending on the patient’s state of fluid excess (though not to be confused with health deficit) and how to manage it. Through accurate and continuous monitoring accompanied by the collaborative interventions of medication and regulated fluid administration, the patient is assisted with her own self-care. This type of assistive self-care is known as a partially compensatory system where in the patient is participative in the process of managing her own self-care deficit. This is done through encouragement of reporting for any progression of symptoms as well as taking an active part in restricting one’s fluid intake as well as monitoring one’s urine output. To summarize, Orem’s theory on self-care deficit is more applicable to nurses as professional than with the nurse as a caregiver outside of the institution. Its focus on the deficits (i.e. illness/disability) makes it more applicable on a structured setup.

D. Compare and contrast Abdellah 's 21 nursing problems with Henderson 's 14 activities for client assistance.

Virginia Henderson’s and Faye Abdellah’s nursing theory, in my own opinion, have a lot of commonalities in them and I am going as far as I could by saying that they may have borrowed concepts from each other. Henderson may have described hers as “needs” and Abdellah classified hers as “problems” but what’s readily obvious is that they are both basically presenting/defining/enumerating an individual’s requirement for sustaining life. Upon closer inspection, both of their respective requirements are essentially interchangeable. To our advantage, both made it very convenient for us end users to easily analyze their theories and put it into practical use. To make a clear-cut illustration on what I am trying to explain, I have presented both theories side-by-side and in such a way that the elements of both correspond with essentially same concepts. For example, the concept of Henderson for breathing, Abdellah made more elaborate by defining it as oxygenation – still, the two in actuality are trying to define the same concept.

|Henderson’s Theory of 14 Needs |Abdellah’s Typology of 21 Nursing Problems |
|Breathe normally |To facilitate the maintenance of a supply of oxygen to all body |
| |cells |
|Eat and drink adequately |To facilitate the maintenance of nutrition of all body cells |
| |To facilitate the maintenance of fluid and electrolyte balance |
| |To facilitate the maintenance of regulatory mechanisms and |
| |functions |
| |To facilitate the maintenance of sensory function. |
|Eliminate body wastes. |To facilitate the maintenance of elimination |
|Move and maintain desirable postures. |To maintain good body mechanics and prevent and correct |
| |deformity |
|Sleep and rest. |To promote optimal activity: exercise, rest and sleep |
|Select suitable clothes-dress and undress. |To maintain good hygiene and physical comfort |
|Maintain body temperature within normal range by adjusting |To create and / or maintain a therapeutic environment |
|clothing and modifying environment | |
|Keep the body clean and well groomed and protect the integument | |
|Avoid dangers in the environment and avoid injuring others. |To promote safety through the prevention of accidents, injury, |
| |or other trauma and through the prevention of the spread of |
| |infection |
|Communicate with others in expressing emotions, needs, fears, or |To identify and accept positive and negative expressions, |
|opinions. |feelings, and reactions |
| |To identify and accept the interrelatedness of emotions and |
| |organic illness |
| |To facilitate the maintenance of effective verbal and non verbal|
| |communication |
| |To promote the development of productive interpersonal |
| |relationships |
|Worship according to one’s faith. |To facilitate progress toward achievement of personal spiritual |
| |goals |
|Learn, discover, or satisfy the curiosity that leads to normal |To use community resources as an aid in resolving problems |
|development and health and use the available health facilities. |arising from illness |
| |To understand the role of social problems as influencing factors|
| |in the case of illness |
| |To recognize the physiological responses of the body to disease |
| |conditions |
| |To facilitate awareness of self as an individual with varying |
| |physical , emotional, and developmental needs |
|Work in such a way that there is a sense of accomplishment. |To accept the optimum possible goals in the light of |
|Play or participate in various forms of recreation. |limitations, physical and emotional. |

Regardless on the differences on the definition of each of their respective theories, one emerging theme still stands out: the significance of the relationship of the person with his or her environment (may it be physical, social, cultural, spiritual) creates an impact on the type of nursing care that same person would require. And with all of these in mind, I would conclude that any deviation from any of these requirements anywhere, and at any point in time, a corresponding nursing intervention would be appropriate and would be relevant.

References:

http://nursing-theory.org/nursing-theorists/Virginia-Henderson.php, retrieved March 31, 2012

Lynda Juall Carpenito-Moyet (2009), Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems, 5th Edition, Wolters Kluwer Health / Lippincott Williams and Wilkins, 530 Walnut Street, Philadelphia, PA 19106, p.103-105

Meleis, Afaf Ibrahim PhD, FAAN (2012), Theoretical Nursing: Development and Progress, Fifth Edition, Lippincott Williams and Wilkins, Philadelphia, p.216-218

References: http://nursing-theory.org/nursing-theorists/Virginia-Henderson.php, retrieved March 31, 2012 Lynda Juall Carpenito-Moyet (2009), Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems, 5th Edition, Wolters Kluwer Health / Lippincott Williams and Wilkins, 530 Walnut Street, Philadelphia, PA 19106, p.103-105 Meleis, Afaf Ibrahim PhD, FAAN (2012), Theoretical Nursing: Development and Progress, Fifth Edition, Lippincott Williams and Wilkins, Philadelphia, p.216-218

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