Nursing Theory: Case Study

Mike Cowell

NSG 403

National University

Case Study
 Kim is a 35 year old who was admitted to the oncology unit for evaluation after palpating a

lump in her right breast. She also observed dimpling around the nipple, a unusual drainage from

the breast and was experiencing moderate pain. A mammography and biopsy were performed

and revealed stage III breast cancer. Kim’s right breast tumor is 7 cm, there is fixed lymph node

involvement in the axillary and there is no metastasis present . Kim was found to have

infiltrating ductal carcinoma of the right breast. Soon after the diagnosis was made Kim

underwent a total mastectomy to her right breast.

Kim’s past medical history shows that physical examinations by her primary physician were

infrequent, and she also denies ever performing self breast examinations. She stated that she only

noticed the lump after the other sign and symptoms were observed. She is 5 feet, 8 inches tall

and weighs 110 lbs. Her usual weight is around 130 lbs. She has smoked 1 pack of cigarettes a

day for 12 years. She is gravida 3, para 3. Her first pregnancy was at age 22, her second at age

25, and her last at age 28. Since her last pregnancy she has been regularly taking oral

contraceptives. Kim finished the 10th grade, but dropped out of high school to work. She has

been married for 15 years, and currently lives with her husband and three children in her mother-

in-law’s home. She doesn’t appear to be happy about the living arrangements and states that the

house is unsanitary. She is a stay-at-home mother, and her husband is currently unemployed. She

describes her husband as emotionally distant and emotionally and physically abusive at times.

Kim is stable after surgery and doing well except for being unable to fully empty her

urinary bladder. She has 2 JP tubes in place for drainage. She is complaining of constant

postoperative pain that she rates as a 7/10 on the numerical pain scale, and is also experiencing

nausea and emisis. She is on a clear liquid diet, but cannot keep anything down. When she is

discharged home, it will be necessary for her to perform intermittent self-catheterization and also

to empty and record her JP drainage. Her current medications are (1) a prophylactic antibiotic
(2) an analgesic PRN for pain and (3)an antiemetic PRN for nausea. In addition to these

medications she will be receiving chemotherapy on an outpatient basis.

Kim is extremely tearful and upset. She expresses serious concern over her future and the

future of her three children. She is upset about her relationship with her husband and the current

living arrangements of her family. Kim states that she believes this cancer is a punishment for

her past life.

King’s Conceptual System and Theory of Goal Attainment

Imogene King believed that "the goal of nursing is health: it's

promotion, maintenance, and/or restoration; the care of the sick or injured;

and the care of the dying" (Khowaja, 2006). She also proposed that the

universal concepts of nursing discipline are social systems, health,

interpersonal relationships, and perception (Khowaja, 2006). King’s model

uses the nursing process, critical thinking, communication, and interaction

to achieve patient goals. King's nursing model is composed of two parts:

(1)conceptual systems (2)theory of goal attainment.

The conceptual system is "based on the assumption that human beings

are the focus of nursing" (Alligood & Tomey, 2006, p.183). King proposed

three separate systems that define the conceptual system: personal,

interpersonal, and social. King believed these systems "demonstrate the

interactions of human beings in their social world" (King, 2007). In the

conceptual model the personal, interpersonal, and social systems “should

operate as a whole to achieve maximum benefit for the patient. When all

members of the conceptual systems communicate, interact, transact, and

use critical thinking for decision-making, they design an integrated clinical

pathway”(Khowaja, 2006). She concluded that “nurses must have the

knowledge and skill to observe and interpret behavior and intervene in the

behavioral realm to assist individuals and groups cope with health, illness,

and crisis (Alligood & Tomey, 2006, p.183).

The personal system represents the individual. "Each individual is an

open, total, unique system in constant interaction with the environment"

(Alligood & Tomey, 2006, p.183). In order to understand the person, the

nurse must consider the individuals concepts of perception, self, growth and

development, time, and personal space ( Killeen & King, 2007). The nurse

must understand perception in order to utilize the nursing process in

achievement of goals. “Perception gives meaning to one’s experiences,

represents one’s image of reality, and influences one’s behavior” (Killeen &

King, 2007).

The interpersonal system consist of two or more individuals. King's

nursing process occurs in this system between the nurse and patient.

“Nursing acts are directed toward health and can be observed as a process

of interaction between nurses and patients in specific situations’ (Killeen &

King, 2007).Interpersonal concepts important in this system to help

understand interactions between the nurse and patient are: communication,

interactions, role, stress, stressors, and transaction (Alligood & Tomey,

2006, p.185).

The social system is comprised of a large group of individuals with a

common goal or interest (Alligood & Tomey, 2006, p. 185). Organization,
authority, power, status, and decision making are concepts useful in
understanding interactions within a social system (Alligood & Tomey,2006,
p. 185). King’s view was that interactions with social systems impact
individuals throughout their entire lives. Examples of social systems are
hospital settings, work environments, religious groups ( Alligood & Tomey,
2006, p.185). Critical thinking is an important component of King’s
theory. She knew that only when nurses utilized critical thinking would they
understand how to care for their patients. “ King explicitly links critical
thinking to the mental acts of judgement that are implicit in perception,
communication, and interactions that lead to transaction and the concept of
decision making” (Alligood & Tomey, 2006, p.188). She believed that critical
thinking and actions taken by the nurse have a direct influence on patient
outcomes. She noted that it is also important to use critical thinking to
monitor patient outcomes, and to prevent negative outcomes from
reoccurring.
King's theory of goal attainment "addresses nursing as a process of

human interaction" (Alligood & Tomey, 2006, 186). “This theory “presents a

standard where nurses purposefully interact with patients, mutually

establish goals, and agree to means to achieve goals” (Killeen & King,

2007). King believed that this theory utilized the nursing process based on

nurse and patient interactions. She theorized that goal attainment can only

be achieved through patient and nurse interactions (Khowaja, 2006). "The

nurse and patient form an interpersonal system in which each affects the

other and in which both are affected by situational factors in the

environment" (Alligood & Tomey, 2006, p.186). King's theory of goal

attainment, in practice, is a nursing process, or a system of interrelated

concepts. King’s nursing process, or goal attainment theory, is as follows:

(1) the perception of the nurse and patient (2) communication of nurse-

patient (3) interaction of nurse-patient (4) decision-making about goals by

nurse-patient (5) agreement of means to attain goals (6) transactions made

between nurse-patient (7) goals met, and if not, why not (King, 2007).
"Goals cannot be mutually achieved unless the nurse and the patient share

their perceptions, feelings, values, and conclusions" (Alligood & Tomey,

2006, p.191). With today's multidisciplinary health care teams, the theory of

goal attainment, "facilitates mutual goal-setting with patients based on each

member of the team's specific knowledge and functions" (Killeen & King,

2007).

Applying King’s Model to Case Study

Using King’s conceptual systems and theory of goal attainment in the

care of Kim, it is important to first understand the nursing process. The first

step in the nursing process would be for the nurse and Kim and meet each

other and interact (Alligood & Tomey, 2006, p.189). An assessment is done

by observing data about Kim based on pertinent concepts. The nurse would

utilize critical thinking to understand Kim’s situation. The nurse would

conclude that Kim is fearful and upset about her health, unsure about the

future and her prognosis, and unhappy with her marriage relationship. This

initial meeting is important to understand what all of this information means

to the patients health and for the nurse to come to conclusions about Kim’s

situation

The second step in the nursing process is to determine and plan goals

(Alligood & Tomey, 2006, p.190). In this step it is up to the nurse to use

critical thinking to understand what goals are going to benefit Kim. It is

important to understand what goals the patient wants to work towards and

to understand the ways teamwork can achieve these goals.

 The third step in the nursing process is transactions. “Transactions occur

as a result of perceiving the other persons and the situation, making

judgements about those perceptions, and taking some action in response”

(Alligood & Tomey, 2006, p.190). It is important for the nurse to consider if

the goals are mutually agreeable between patient and nurse. The nurse

must consider and use critical thinking to understand how, why, and when

actions are being carried out (Alligood & Tomey, 2006).

The fourth step in the nursing process is the theory of goal attainment,

or in some cases the revision of goals. In this step, the nurse must decide

whether actions taken are helping the patient achieve desired goals. It is

important to consider if the nursing actions are working, or not working, and

what needs to be changed in order to achieve goals (Alligood & Tomey,

2006, p.190).. The nurse might have to revise goals based on the patients

response to nursing actions. It is important to communicate with the patient

in order to get feedback and to agree on goals.

In terms of the conceptual systems, Kim is and individual in interaction

with other systems, and these interactions have an effect on her health and

behavior. Kim’s cancer, hospitalization, and outpatient treatment plan have

put stress into her life. The nurse and Kim would utilize the nursing process

to “interact , communicate, engage in mutual goal setting, and make

decisions about the means to achieve goals” (Alligood & Tomey, 2006,

p.193). In Kim’s case a goal may be to reduce anxiety and stress associated

with her diagnosis.

 The interpersonal system is formed between Kim and nurse. “The

transactions process begins with perception, judgements, mental actions,

and reactions of both individuals” (Alligood & Tomey, 2006, p.193). The

nurse would utilize her perceptions of Kim in order to gather and interpret

information. Kim’s perceptions are influence by her present situation, her

past, and thoughts about the future. Communication with Kim is important

in order for the nurse to describe her personal perceptions and to explain

what perceptions she has observed in Kim. Once the nurse recognizes and

describes perceptions, then communication between Kim and nurse can be

open to set and achieve desired goals.

“Perceptions form the basis for development of the self” (Alligood &

Tomey, 2006, p.194). Kim is tearful and upset. She states she is scared of

the future, unhappy with her marriage/ living arrangement, and blames

herself for her current diagnosis. Kim is also experiencing pain, nausea, and

inability to void. She is experiencing psychological and physical stressors at

the same time. The nurse would communicate and work with Kim to explore

perceptions and decrease stressors.

Other interpersonal systems in occurring in Kim’s life is with her

husband. Her husband is emotionally distant and sometimes both

emotionally and physically abusive. He is unemployed and their living

arrangements are currently undesirable. It is obvious to see that this

situation adds stress to Kim’s life and may interfere with her health after

discharge from the hospital. “ Coping with personal and interpersonal

stressors is likely to influence both health and illness outcomes” (Alligood &

Tomey, 2006, p.194). The nurse and Kim must communicate and work

together to find solutions to Kim’s personal and interpersonal stressors. Kim

may need outside support from friends or family, or a possible social

services consult.

King defined communication as “the interchange of thoughts and

opinions individuals” (Khowaja, 2006). Communication is key to establish

trust between the patient and the multidisciplinary health care team. "The

nurse has a responsibility to communicate and interact with the patients to

ensure that their thinking is transparent to one another" (Alligood & Tomey,

2006, p.191).King emphasized that the nurse must use critical thinking,

observation and collection in order to make decisions that will benefit the

needs of the patient. " King's theory provides direction for nursing practice

by emphasizing the process of multidisciplinary collaboration,

communication, interaction, transaction and use of critical thinking"

(Khowaja, 2006). Kim and the nurse needs to establish mutually agreeable

goals. In Kim’s case it will be important to control pain and nausea. The

nurse will also have to educate Kim in terms of how to self catheterize at

home, and to empty and record JP drainage.. Communication will have to be

open, and Kim/nurse will have to assess goals based upon the situation. The

nurse and Kim must assess her fear/anxiety and understand its relevance in

terms of achieving goals.

In conclusion, if communication is open and transactions are made

between Kim and nurse, then goals should be achieved. If goals are not

achieved then the nurse-patient must re-evaluate the nursing process and

goals. In King’s model, it is important to understand the patient’s

perceptions and how they relate to their medical situation. However, the

nurse must also assess her own perceptions and how they relate to the

patients situation. The nurse must also understand how the patients

perceptions influence their ability to improve their health. It is up to the

nurse to utilize the nursing process, critical thinking, and transactions to

improve patient outcomes. Only in utilizing these tools will Kim’s health

improve and her stressors decline.

 References

Alligood, M.R. and Tomey, A.M. (2006). Nursing Theory Utilization &

Application. St. Louis: Elsevier, Mosby.Khowaja, K. (2006). Utilization of

King's interacting systems framework and theory of goal attainment with

new multidisciplinary model: Clinical pathway. Australian Journal of

Advanced Nursing, 24(2), 44-50. Retrieved from ProQuest database on April

14, 2009.Killeen, M.B., & King, I.M. (2007). Viewpoint: Use of King's

conceptual system, nursing informatics, ans nursing classification systems

for global communication. International Journal of Nursing Terminologies

and Classifications, 18(2), 51-57. Retrieved from ProQuest database on April

14, 2009.King, I.M. (2007). King's conceptual system, theory of goal

attainment, and transaction process in the 21st century. Nursing Science

Quarterly, 20(2), 109-116. Retrieved from ProQuest database on April 14,

2009.