2. • A casual visitor to a hospital or other health care
setting might think that little has changed for nurses
over the past decade. The majority of nurses still
wear a traditional and recognizable uniform, and are
to be found in areas where care is provided or advice
offered to patients, their relatives and their friends.
However, behind this seemingly unchanged exterior,
much has altered. In particular, nurses are now
educated through a different system of training. They
are educated to a higher academic level, and the
work they do and the way in which they do it have, in
many areas of health care, changed considerably.
Aggleton P & Chalmers H, 2000
3. Introduction
Nursing Science is an identifiable discrete
body of knowledge comprising paradigms,
frameworks and theories. The integration
of nursing theories into practice
demonstrates an evolutionary pathway for
introducing a paradigm shift in the
essence of the science of nursing .
4. • Theories have been developed in nursing
to explain phenomena important to clinical
practice. For eg,we have a theory of
health promotion behaviour (Pender &Pender &
Pender,1996Pender,1996) and a theory of mother
infant attachment(Walker,1992Walker,1992). Although
we use these theories to guide our
practice, in many cases we have not
tested them to determine whether or not
the nursing actions proposed actually
have the effects claimed.
5. • The conceptual models and the nursingThe conceptual models and the nursing
theories that provide the basis for clinicaltheories that provide the basis for clinical
practice arepractice are
• Johnson’s Behavioral System Model,Johnson’s Behavioral System Model,
• King’s General Systems framework,King’s General Systems framework,
• Levine’s Conservation Model,Levine’s Conservation Model,
• Neuman’s Systems Model,Neuman’s Systems Model,
• Orem’s Self-Care Framework,Orem’s Self-Care Framework,
• Rogers’ Science of Unitary Human Beings,Rogers’ Science of Unitary Human Beings,
• Roy’s Adaptation Model,Roy’s Adaptation Model,
6. • Leininger’s Theory of Culture Care DiversityLeininger’s Theory of Culture Care Diversity
and Universality,and Universality,
• Newman’s Theory of Health as ExpandingNewman’s Theory of Health as Expanding
Consciousness,Consciousness,
• Parse’s Theory of Human Becoming,Parse’s Theory of Human Becoming,
• Orlando’s Theory of the Deliberative NursingOrlando’s Theory of the Deliberative Nursing
Process,Process,
• Wiedenbach’s Clinical Nursing: A HelpingWiedenbach’s Clinical Nursing: A Helping
Art, Henderson’s Nature of Nursing,Art, Henderson’s Nature of Nursing,
• Travelbee’s Interpersonal Aspects ofTravelbee’s Interpersonal Aspects of
Nursing,Nursing,
• Peplau’s Theory of Interpersonal Relations,Peplau’s Theory of Interpersonal Relations,
• Watson’s Theory of Human Caring, and soWatson’s Theory of Human Caring, and so
forth).forth).
7. I = integration and synthesis of nursing knowledge through cognitive ,
psychomotor and affective domain
8.
9. Nursing in its journey to attain
professional status incorporates
several concurrent changes in the
discipline by
• combining research based practice
• upgraded educational requirements
• theory based models .
10. Why we need to apply nursing
theories ?
Using theory helps to guide nursing
practice. It
helps to organise data
understand and analyse patient data
make appropriate decisions related to
nursing interventions.
11. Application of Orem’s theory to
nursing practice
• Orem presents her self –care deficit theory
of nursing which is composed of three
interrelated theories
• Theory of self care
• Theory of Self care deficit
• Theory of Nursing Systems
12. Orem’s Model
Self- CareSelf- Care
Self –careSelf –care
agencyagency
TherapeuticTherapeutic
Self careSelf care
demanddemand
NursingNursing
AgencyAgency
RR RR
RR RR
RR
<
DeficitDeficit
conditioningfactors
conditioningfactors
13. Orem’s professional- technological
operations of nursing practice
• Step 1: Nursing Diagnosis and
prescription that is, determining why
nursing is needed
• Step 2: Designing the nursing system and
planning for delivery of care
• Step 3: The production and management
of nursing systems, also labelled planning
and controlling
14. Assessment Phase
The nurse collects data in six areas:
1. The person’s health status
2. The physician’s and nurses perspective of the
person’s health
3. The person’s perspective of his health status
4. The health goals within the context of life history,
lifestyle, and health status
5. The person’s requirements for self care
6. The person’s capacity to perform self care
15. Application using case study
Basic ConditioningBasic Conditioning
FactorsFactors
48 yrs female,5’2”
82 kg, Italian
Widowed for 6
months after 25 yrs
of happy marriage
Catholic
University faculty
Universal Self
care
Smokes 1.5
packs/day
Frequently eats
fast food; high fat
diet; drinks 2 litres
of water
Largest meal of
the day is late
evening
No difficulties with
elimination,No
regular exercise,
DevelopmentalDevelopmental
Self careSelf care
Loss of husband
Loss of social
activity
Finds work as
university faculty
fulfilling
Works 12 hours a
day
Well groomed
16. Application using case study
Health DeviationsHealth Deviations
Family History:
F-heart attack, age
50
M-died of stroke, age
53 , cholesterol 260
mg; other lab values
WNL.
Lacks knowledge of
risk factors and
cardio vascular
functioning, B/P
142/88, P 92, R 26
Medical ProblemMedical Problem
And PlanAnd Plan
Diagnoses of
obesity with
potential for
cardiac disease
and low motivation
for weight loss
Prescription to:
Monitor
cholesterol levels
Decrease
cholesterol and fat
intake
Self care deficitsSelf care deficits
Difference between
healthy life style
and Ms M’s
Knowledge base
and life style which
increases her risk
of heart attack or
stroke
17. Application using case study
Health Deviations
Potential for cardiac
disease related to
obesity, smoking,
elevated cholesterol,
lack of exercise , and
family history
Medical Problem
And Plan
Increase exercise
Decrease or stop
smoking
Re-evaluate and if
needed prescribe
medication to
lower cholesterol
Self care deficits
18. Application using case study
Nursing Diagnosis
Potential for impaired
cardio vascular
functioning related to
lack of knowledge
about relationship
between current life
style and risk of heart
attack or stroke
Outcome & Plan
Outcome:
↓ cholesterol
Healthier life style
with regular
exercise,↓smoking
,& balanced
nutrition
Nursing Goals &
Objectives:
Goal: To decrease
risk for cardiac
impairement
Implementation
Jointly develop
contract related to:
1. Cholesterol
reduction
Ms M will keep a 3-
day food diary
Ms M will learn about
cholesterol & its
effects on cardio
vascular functioning
Ms M will learn about
low fat foods
19. Application using case study
Nursing Diagnosis
Potential for
impaired cardio
vascular
functioning
related to lack of
knowledge about
relationship
between current
life style and risk
of heart attack or
stroke
Outcome & Plan
Objectives: Ms M
will state that high
cholesterol levels
increase her risk for
cardiac impairement
Ms M will recognise
the relationship
between smoking
and cardio vascular
risk
Implementation
Ms. M will obtain
cholesterol and its effect
on cardiovascular
functioning
Jointly analyse food
diary and decide how to
decrease cholesterol /
fat intake to reduce M’s
Weight
Jointly determine food
items that are rich in
cholesterol and fat and
how receipes to be
adapted
20. Application using case study
Nursing
Diagnosis
Potential for
impaired cardio
vascular
functioning
related to lack
of knowledge
about
relationship
between
current life
style and risk
of heart attack
or stroke
Outcome & Plan
Design of Nursing
System:
Supportive
Educative
Methods Of
Helping:
Guidance,support
, teaching and
provision of a
developmental
environment
Implementation
Ms. M’s accomplishments will
be reinforced
Ms M’s will seek advice from
her physician re: medication
to reduce cholesterol
2. Reduction of smoking
Ms M will identify when she
smokes and what initiates the
desire for a cigarrete
Ms M will plan ways to
replace smoking with other
activities( exercising,chewing
gum
21. Application using case study
Nursing
Diagnosis
Potential for
impaired
cardio
vascular
functioning
related to lack
of knowledge
about
relationship
between
current life
style and risk
of heart attack
or stroke
Outcome & Plan
Design of
Nursing System:
Supportive
Educative
Methods Of
Helping:
Guidance
support,
teaching and
provision of a
developmental
environment
Evaluation
Does Ms M understand that with
her present life style, her risk of
heart attack or stroke is high?
Did Ms M. Select low
cholesterol , low fat foods?
Did Ms M’s Self care deficit
decrease
Is M’s Cholesterol lower?
Did Ms M Lose weight?
Has Ms M ↓ number of
cigarretes smoked daily
Was the supportive educative
system effective
22. Application of Imogene King’s Theory
PerceptionPerception
JudgementJudgement
Action Reaction Interaction TransactionAction Reaction Interaction Transaction
JudgementJudgement
PerceptionPerception
23. The basic assumption of the theory of GoalThe basic assumption of the theory of Goal
Attainment-Attainment-
• nurses and clients communicate informationnurses and clients communicate information
• set goals mutuallyset goals mutually
• act to attain those goalsact to attain those goals
24. AssessmentAssessment NursingNursing
DiagnosisDiagnosis
Mutual goalMutual goal
settingsetting
InterventionsInterventions EvaluationsEvaluations
Assessment
occurs during the
interaction of the
nurse and clients.
The concepts
identified are the
• perception,
communication
and interaction of
nurse and client
• Growth & Devp
• Knowledge of
self & role
• Amount of stress
• Factors
influencing
Clients perception
StatementStatement
thatthat
recognizesrecognizes
thethe
distresses,distresses,
difficulties ordifficulties or
worriesworries
identified byidentified by
the client andthe client and
nursenurse
DecisionDecision
making aboutmaking about
goals andgoals and
agreeing toagreeing to
means tomeans to
attain goalsattain goals
Activities thatActivities that
seek to meetseek to meet
goals. Thegoals. The
conceptconcept
involved is theinvolved is the
making ofmaking of
transactionstransactions
Goals areGoals are
attained orattained or
not.not.
EvaluationEvaluation
not onlynot only
speaks ofspeaks of
goalgoal
attainmentattainment
but alsobut also
effectivenesseffectiveness
of nursingof nursing
carecare
25. AssessmentAssessment
Nurses Perception:
Mrs X is well groomed pregnant female who appears to be
comfortable in the examination room and makes a eye
contact with the nurse. As they interact nurse finds that she
is 25 years old, married , about six months pregnant, gained
4 kgs of weight so far during the pregnancy( G&D)
X’s perception:
Views herself as healthy( self), recently moved to a new area
Works as a teacher plans to continue work after baby is
born. She keeps in contact with her family regularly. She
asks question about labour process and how she might
identify good paediatrician. She reports her nausea is
subsided and feels that her pregnancy is progressing
normally without any complications
The nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
26. Nursing DiagnosisNursing Diagnosis
Knowledge deficit about health care resources,
child birth related to recent move to a new locality
Mutual goal setting
To be a healthy mother and to have a successful
pregnancy and delivery of a healthy baby
The nurse is meeting Mrs X for the first time in antenatal OPDThe nurse is meeting Mrs X for the first time in antenatal OPD
27. Interventions in terms of transactions
Establishing and keeping a schedule of regular
prenatal visits
Providing information about community resources and
health care facilities
Conducting regular child birth education
EvaluationEvaluation
Verbalization of understanding the availability of
resources
Successful experience with pregnancy and birth of a
healthy new born baby . Successful initial experience
of breast feeding
28. Application of Roy’s Adaptation Theory toApplication of Roy’s Adaptation Theory to
Nursing PracticeNursing Practice
Case study:
Mr Raj is received from surgery after a major
abdominal operation. Before surgery his baseline
vital signs were:heart rate 80 beats per minute;BP
120/80mm of Hg and resp rate 16 per minute. After
45 minutes in post op recovery his vital signs are:
HR 150 beats per minute; BP 90/60mm of Hg; Resp
rate 32 per minute. { Increased regulator output is
signaled by sympahathetic nervous system
stimulation of the heart in response to decreased
blood pressure} The nurse decides that Mr Raj is
showing an ineffective response
29. Assessment of stimuli
• Focal Stimuli: Decrease in arterial blood
pressure (exact cause is unknown)
• Contextual Stimuli: Age 45 yrs, No food or
drink for 12 hours, IV infusion of 5% dextrose
with lactated ringer’s solution at 100 cc per
hour. 200cc of IV fluids infused during
surgery,20cc of urine excreted during the
first 45 minutes in recovery,1.5 hours of
general anaesthesia, estimated blood loss of
500ml during surgery no operative site
bleeding
• Residual Stimuli: include history of renal
infections
30. • Nursing Diagnosis:
Fluid Volume deficit related to blood loss,
decreased intake
• Goal:
To maintain adequate circulatory volume as
evidenced by BP within normal range±20mm
of Hg within 15 minutes, Urine output
>30ml/hour,mental alertness, rapid nail
blanching, pulse and respiration within normal
limits
31. Nursing InterventionsNursing Interventions
I.V fluids 300cc per hour.
Foot end elevation
Oxygen 40% by mask
Verbal and tactile stimulation
Administration of Vasopressor medication
Continous BP and Vital signs monitoring
EvaluationEvaluation
A constant evaluation of the effectiveness of
nursing care is made and patients response
is evaluated
32. • Application of Betty Neuman’s Model
• Case Study:
Janice is a 34-year-old married woman who
has three elementary school-aged children.
She moved to the Lower Mainland, from
the Interior, six months ago because her
husband was transferred by his employer.
Janice is currently on medical leave from
her job as a teacher's assistant. She was
referred to an outpatient psychiatric group
therapy program in order to gain
assistance in dealing with depression and
anxiety.
33. • Janice states she was feeling "reasonably
well" until February of last year when her
husband informed her of the likelihood of
his being transferred. She says she had
developed many friends in the Interior in
the five years they had lived there, and
she has made few friends since moving to
the Lower Mainland. Janice's extended
family lives in Ontario, as does her
husband's family.
34. • Janice says they moved to the Lower Mainland last August, two
weeks before school started. The children, aged six, eight and
ten years, were upset with the move because they were leaving
their friends behind. Janice feels guilty about this.
Another stressor for her is her new job, which she started last
September. She was assigned to work with a child diagnosed
with attention deficit hyperactivity disorder (ADHD). Janice did
not agree with the management style of the teacher when
dealing with this child, and she found it difficult to be assertive
in dealing with this teacher. Janice says she started
experiencing anxiety attacks and insomnia in early December.
35. • The idea of Christmas approaching, which she had always enjoyed,The idea of Christmas approaching, which she had always enjoyed,
now seemed overwhelming, "I wasn't doing well and I had no one tonow seemed overwhelming, "I wasn't doing well and I had no one to
talk to". The time away from work at Christmas break was helpful, andtalk to". The time away from work at Christmas break was helpful, and
she went back to work in January of this year. By the second week ofshe went back to work in January of this year. By the second week of
her work return, she wasn't coping well.her work return, she wasn't coping well.
• Janice saw her physician who suggested she take a medical leave. SheJanice saw her physician who suggested she take a medical leave. She
also ordered her Prozac 20 mg OD, which she says she takes at HS,also ordered her Prozac 20 mg OD, which she says she takes at HS,
and Xanax 0.5mg PRN up to QID. Additionally, she was referred forand Xanax 0.5mg PRN up to QID. Additionally, she was referred for
outpatient group therapy. After six weeks on medication, her mood hasoutpatient group therapy. After six weeks on medication, her mood has
improved. Xanax, which she uses BID, "takes the edge off" her anxiety.improved. Xanax, which she uses BID, "takes the edge off" her anxiety.
Insomnia remains a problem.Insomnia remains a problem.
36. • Janice says that she grew up an only child with an
"alcoholic" father and an "anxious" mother. She says she
married at age twenty years because she couldn't stand
being at home, and she didn't want to live alone.
Despite this, she says her marriage is good which she
qualifies with, "he doesn't run around or anything. He
works hard to provide for us, not like his dad who ran off
with another woman".
Janice's goals for group therapy are to learn ways to
handle her anxiety without medication, and to learn ways
to minimize her depression.
37. In applying Neuman's model to Janice's
situation, the initial assessment is carried out to
assess prediposing factors and stressors.
• Intrapersonal stressor : depression , insomnia,
guilt feeling
• Interpersonal stressor: social withdrawal and her
lack of her usual supports. Her disturbed sleep
leaves her feeling irritable in dealing with her
children, Conflict with the teacher.
• Extrapersonal stressor : Shift to a new place and
lack of social support.
38. • In Neuman's model, the nursing diagnosis
describes the whole client situation (Neuman,
1995). The nursing diagnosis could be described
as 'multiple stressors in too short a time frame
penetrated Janice's normal line of defense,
causing an energy drain and a variance from
wellness.
• Subsequently, system integrity was not
maintained and Janice developed symptoms of
anxiety, depression and insomnia'.
• Diagnosis statement : Ineffective coping
• : Anxiety
• :Sleep pattern disturbance
39. Goals
In Neuman's model, goals are set in collaboration
with the client.
• Janice stated her goals were to learn ways to
handle her anxiety without medication and to
learn ways to minimize her chances of becoming
depressed again.
{ These are reasonable goals in an outpatient
group therapy program. These goals are
relevant because they were determined by the
client and were deemed by the nurse to be
manageable goals in this practice setting.}
40. Neuman's interventions are carried out at three levels: primary,
secondary and tertiary prevention.
In Janice's situation,In Janice's situation, Secondary prevention:Secondary prevention:
• assess her sleep pattern.(Janice reveals she takes Prozac at HS.)assess her sleep pattern.(Janice reveals she takes Prozac at HS.)
• Advising her to take Prozac in the morning,( as Prozac frequentlyAdvising her to take Prozac in the morning,( as Prozac frequently
causes insomnia,)causes insomnia,)
• Encouraging Janice to talk about ways to handle her anxietyEncouraging Janice to talk about ways to handle her anxiety
II
Tertiary prevention :Tertiary prevention :
• exploring anxiety triggers.exploring anxiety triggers.
• Her depression would also be explored and she could expect to gainHer depression would also be explored and she could expect to gain
insight about waysinsight about ways
• to minimize the occurrence of future depressive episodes.to minimize the occurrence of future depressive episodes.
Tertiary prevention focus is to return the person to WellnessTertiary prevention focus is to return the person to Wellness
41. The final stage of Neuman's model is nursing
outcomes, or reassessment.
• Perceived progress towards her goals and she
would receive feedback from the nurse.
• Perhaps she still has insomnia after Prozac is
changed to morning administration. This
information leads the nurse back to assessment.
• Changes in intrapersonal, interpersonal and
extrapersonal factors would be noted because
change determines the success of the nursing
interventions.
42. Fig-1: Conceptual Framework on Postpartum Depressive symptoms, Family Support and Functional Status based on
Mercer’s Maternal role attainment Theory
* Variables under study
+ Positive influence
- Negative influence
Negative life
events
Stressful event
in pregnancy*
Pregnancy
risk
Pregnancy
related
problems*
Parity
Residual risk
factors
Age*
Socio
economic
status*
Substance
abuse*
Premenstrual
syndrome*
Previous or
family history
of depression*
Child care
risk
Child care
stress
Type of
delivery*
Feeding
pattern*
Frequency of
feed*
Sleep pattern*
Satisfaction
with gender of
the child*
Family
support
Informational
support*
Emotional
support*
Instrumental
support*
Esteem
support*
Self
esteem
Health
status
Sense
of
mastery
Anxiety
Depression*
Improved
functiona
l status*
_
_
_ _
__
+
+
+
43. Conclusion
We have seen that these models continue
to use the nursing process as the core for
decision making in determining if nursing
care to clients is meeting the expected
outcomes as established by the clinical
pathways. Applying these theorist views is
a challenge and it provides opportunity for
meaningful nursing practice
