Virgina Handerson Theory 1

Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Florence Nightingale Advance Concept in Nursing I Abdul Hakeem Mrs. Ruth K. Alam

Date:

Virgina Handerson Theory 2 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Florence Nightingale (The Lady of Lamp) Florence Nightingale observed with a little lamp in her hand making her solitary rounds. As her slender form glides through the corridor, every poor fellow’s face softens with gratitude at the sight of her. She had become the heroine. Her name becomes a synonym for gentleness, efficiency and heroism. Although Florence Nightingale cannot be considered as the product of her time, since she was ahead of and beyond it. But the season was ripe for her genius as the founder of modern nursing. Florence Nightingale has great deal for nursing profession. She has emphasize on unique role of nurse and believed that nurses should spend their time caring for patients and not cleaning. Nurses must continue learning throughout their lifetime and not become stagnant that nurses should be intelligent and should use that intelligence to improve condition for the patients and that nursing leaders should have social standing. She had a vision of what nursing could and should be. Major Theme – A major of Florence Nightingale is “Unique Role of the Nurse”. Person Florence Nightingale in context of person stated that “An individual who has the recuperate powers within self to restore own health”. Health is a pattern of energy that is mutually enhances and expresses full life potential. Positive health symbolizes wellness.

Virgina Handerson Theory 3 According to her a person defined as to recover or improve the power for restore the health after desire process through hygienic conditions. Environment According to Florence Nightingale environment involves those external conditions that affect life and the development of the individual, with a focus on ventilation, warmth, odours and light, and diet, such as noisy environment could distress patients sleep which leads to sleeplessness or restlessness causing delay in patient’s recovery. Assessment I collect information and examine the client through two ways. Subjective Data In subjective data the client tells me about his health. He says that “he is not feeling comfortable and weakness occurs since last one month. Objective Data In objective data, I observe and examine the client carefully and consciously. I look the 35 years old patient lying on the bed and looking:         Very irritable. Worried. Anemic. Sleeplessness. Depression/Anxiety. Dry skin due to lack of nutrition. Sunken eyes. Fatigue.

Virgina Handerson Theory 4 His vital signs are:       Blood Pressure Temperature Pulse Respiratory Rate Weight Hb 120/70 mmHg. 99.6°F 92 per min. 22 per min 50 Kg 7.8 gm/dl

The following investigations were performed.     CP. Chest X-ray. Urine D/R Electrolytes.

Acceptable Nursing Diagnosis      Health-seeking behaviors. Ineffective management of therapeutic regimen. Ineffective family management of therapeutic regimen. Altered health maintenance. Risk of infection.

Nursing Diagnosis Health maintenance altered, due to anxiety secondary to disease process. Expected Outcome  The client will relate improvement of health maintenance within 7-10 days.

Virgina Handerson Theory 5 Nursing Interventions and Rationales Interventions    Facilitate the client to take high  protein diet Educate the client to take fiber diet.  Rationales High protein diet is a good source of health maintenance. Fiber diets also improve the health. Fresh juices and plenty of water required for maintenance of health. For healthy living, daily light exercise is essential. This will improve health status. Sharing of feelings among family members brings the client towards life and healthy activities. To improve and maintain client’s health. To maintain health of the client.

Encourage the client to use fresh  juices and drink daily 10-12 glasses of water. Teach the client daily go to walk in  early morning. Allow the family as individual’s and  as a group to share their feelings. Facilitate the client to take one cup of  milk in early morning with one apple. Prescribe the client to use  multivitamins and iron form tablets or capsules as per order of the doctor.

 

Evaluation  The client has verbalized that his weakness had reduced, he gained weight and take more active part in daily life than before.  The client has verbalized that he had planned for a regular exercise program to maintain his health status. I looked the client’s condition and assessed that the client is looking very happy and comfortable and achieve my desired goal within target period.

Virgina Handerson Theory 6 Summary Florence Nightingale major theme is “Unique Role of the Nurse”. She defined person as to recover or improve the power for restore the health after desire process through hygienic conditions. Environment involves those external conditions that affect life and the development of the individual, with a focus on ventilation, warmth, odours and light, and diet, such as noisy environment could distress patients sleep which leads to sleeplessness or restlessness causing delay in patient’s recovery. The nurse uses a caring process to help the individual achieve an optimal degree of inner harmony to promote self-knowledge, selfhealing, and insight into the meaning of life.

Virgina Handerson Theory 7 References  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  www.yahoo.com.florence nightingale.

Virgina Handerson Theory 8

Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Martha E. Rogers Theory Advance Concept in Nursing I Bella Benjamin Mrs. Ruth K. Alam Date:

Virgina Handerson Theory 9 Martha E Rogers’s theory depends on “interaction between person and environment” from the framework view of energy human beings are said to participate with the environment to actualize unique potentials. We do not use or exchange energy we are unceasingly transforming energy with the rest of the universe. Martha E. Rogers also defines:    Health Nursing Goal of Nursing

Health - According to the Martha. E. Rogers it is defined as “Health and illness are seen as cultural values denoting behaviors of high and low value as defined by individuals and cultures.” Health is a rhythmic patterning of energy that is mutually enhancing and expresses full life potential. Health is participation in the life process by choosing and executing behaviors that leads to the optimum fulfillment of a persons potential. Health can be viewed as a process of actualizing potentials for well being by knowing participation in change. Positive health symbolizes wellness. It is a value term defined by the culture or individual. Health and illness are considered “to denote behaviors that are of high value and low value” Nursing - Martha. E. Rogers defined nursing as “A profession with a focus on promotion protection and restoration of health in people.” It can be more described as a humanistic science dedicated to compassionate concern with maintaining and promoting health, preventing illness and caring for and rehabilitating the sick and disabled. Nursing seek to promote sympatric interaction between the environment and the person, to strengthen the coherence and integrity of human beings and to direct and to direct and redirect patterns of interaction between the person and the environment for the realization of maximum health potential.

Virgina Handerson Theory 10 Focus of nursing is unitary human being sis mutual process with their environment and that nursing intervention would be to create ways in which the client might become more aware of his or her field and collaborate with the nurse in proposing and using patterning strategies. Goal of Nursing – According to the Martha E. Rogers, the goal of nursing is “to promote harmonious interaction between the patient and the environment.” The goal of nursing according to Rogers’s science of unitary human beings is to promote human environment filed and the human field is in constant interaction with the environment field. The best and suitable pattern is the health perception and health management pattern because in this theory the person is in constant interaction with the environment. Applicable Nursing Diagnosis           Altered health maintenance. Ineffective management of therapeutic regimen. Total health management deficit. Health management deficit. Health seeking behaviors. High risk for infection. High risk for injury (Trauma). High risk for poisoning. High risk for suffocation. Altered protection.

Assessment The specific data collected about a client’s health needs. I assessed the client and collect data though the following two ways.

Virgina Handerson Theory 11  Subjective Data In subjective data client tells that he is having pain in abdomen due to surgery.  Objective Data In objective data, I observed the client very carefully. The client was 30 years old and conscious and well oriented to time place and person. She is lying on bead and looking irritable, facial expressions show pain, redness and tenderness on surgical site and skin is warm on touching. Her vital signs are:
• • • •

Blood pressure 130/70 mmHg. Temperature 99.4°F. Pulse 90 per min Respiration 22 per min.

Nursing Diagnosis High risk for infection related to site for organism invasion secondary to surgery. Expected Outcome The person will be verbalized risk factors associated with infection and precautions need and report that she is comfortable within 2-3 days. Nursing Interventions and Rationales Interventions

Rationales To build relationship. nurse and patient

Explain the risk factors associated • with the infection and precautions needed. Reduce the entry of organisms into • individuals by using aseptic techniques. Teach individual and family members • signs and symptoms of infection.

To prevent from infection

To give awareness about how to minimize infection.

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Interventions

Rationales

Limit visitors when appropriate.

To prevent infection.

client

from

further

Encourage and maintain caloric and • protein intake in diet. Administer prescribed antimicrobial • therapy within 15 minutes of schedule time. Minimize length of say in hospital.

To improve immunity. To minimize microbial activity.

To minimize the risk of infection.

Evaluation The client verbalized that she has no complain of pain. On observation, client looks relaxed and comfortable and tells that, “She is better than before”. According to Martha E. Rogers’s theory, “science of unitary human beings”, the life process in human beings is homodynamic, involving continuous and creative change. She provides three principles of homodynamics to offer a way of perceiving how unitary human beings develop integrity resonancy and helicy. According to the principle of integrality the human and environmental fields interact mutually and simultaneously. Resonancy means the wave pattern in the fields change continuously and from lower to higher frequency patterns. Helicy probabilistic, and characterized by increasing diversity of field patterns and repeating rhythmicities. Rogers first presented her theory of unitary human beings in 1970. Key concepts Rogers uses to describe the individual and the environment are energy fields, openness pattern and organization, and multidimensionality. Energy fields are dynamic constantly exchanging energy from one to another. The concept the of openness holds that the energy field of human and the environment are open systems that infinite, integral with one another, and in continuous process. Pattern refers to the unique identifying behavior qualities, and characteristics of the energy fields change continuously and innovatively.

Virgina Handerson Theory 13 Summary In her theory, Martha E. Rogers considers the individual as an energy field coexisting within the universe. The individual is in continuous interaction with the environment, and a unified whole, possessing personal integrity and manifesting characteristics that are more than the sum of the parts. Unitary human beings is a four dimensional energy field identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from the knowledge of parts. The four dimensions used in Rogers’s theory – energy fields, openness, pattern and organization and dimensionality are used to derive principles related to human development. Rogers views nursing primarily as a science and is committed to nursing research and theory development. Nursing’s body of scientific knowledge is a new product specific to nursing. Nursing is a humanistic science.

Virgina Handerson Theory 14 References    Crips and Taylor. Fundamentals of Nursing. pp 97-98. Kozier, B., Erb, G., Jean A, Burke K. Fundamentals of Nursing. 6th Edition; pp 37-45. Kozier, B., Erb, G., Blais, K., Wilkinson, J.M., van Leuven K. Fundamentals of Nursing. 5th Edition; p 50.  www.google.com.pk/martha e. rogers theory.

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Sleep and Rest Pattern Advance Concept in Nursing I Bella Benjamin Nazia Javed Sajida Parveen Mrs. Ruth K. Alam Date:

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INDEX TABLE
S# 1. 2. 3. Content Pattern Description Conceptual Information Conceptual Framework   4. Rapid Eye Movement (REM) Non-rapid (NREM) Infant Toddler and Pre-Schooler School Age Child Adolescent Adults Older Adults Eye Movement Page # 01 01 02 03 03 04 05 06 06 07 07 07

Development Consideration      

5. 6. 7. 12.

Factors that effecting on Sleep and Rest Pattern Applicable Nursing Diagnosis Summary References

08 10 13 14

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OBJECTIVES
At the end of this presentation, audience will be able to: 1) Define sleep and rest pattern. 2) Describe the conceptual information. 3) Explain conceptual framework. 4) Discuss development consideration. 5) Enlist factors that effecting on sleep and rest pattern. 6) Identify applicable nursing diagnosis.

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1

SLEEP AND REST PATTERN
Pattern Description
The sleep and rest pattern includes relaxation in addition to sleep and rest. The pattern is based on a 24 hour day and looks specifically at how an individual rates or judges the adequacy of his or her sleep, and relaxation in terms of both quantity and quality. The pattern also looks at the patient’s energy level in relaxation to the amount of sleep, rest and relaxation described by the patient as well as any aids to sleep the patient uses. 1.Does the patient report a problem falling asleep? 2.Does the patient report interrupted sleep?

Conceptual Information
A person at rest feels mentally relaxed, free from anxiety, and physically calm. Rest need not imply inactivity, and inactivity does not necessarily afford rest.  Rest is a reduction in bodily work that results in the persons feeling refreshed, with a sense of readiness to perform activities of daily living.  Sleep is a state of rest that occurs for sustained periods essential repair and recovery of body systems. 2  A person who sleeps has temporarily reduced interaction

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with the environment.  The referred Sleep restores a person’s energy and sense of well being. Recent studies conform that sleep is a cyclic phenomena. most to as common the sleep cycle In is general the the 24-hour, diurnal day – night cycle. This 24-hour cycle is also circadian rhythm. 24-hour circadian rhythm is governed by light and darkness. Additional factors that influence the sleep-wake cycle of the individual are biological, such as hormonal and thermoregulation cycles. The two specialized area of the brain stem that controls the cyclical nature of sleep are the reticular activating system in the brain stem and cerebral cortex. After falling asleep, a person passes through a series of stages that afford rest and recuperation physically, mentally and emotionally.

Conceptual Framework
A day of heavy physical exertion a person is likely to awaking with felling of heavy slept long and soundly.

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3 Stage 4 is only one type of sleep which does not meet all sleep needs by the end of about 90 min total sleep time gradually returns up through the lighter stage of sleep to stage 1 instead of awaking at this time, once enters the stage of REM (rapid eye movement) sleep and there proceeds back through stage 2, 3, 4 again.

Rapid Eye Movement (REM)
In this stage individual dreams. Other characteristics of this stage of sleep are:       Irregular pulse Variable blood pressure Muscular twitching Profound muscular relaxation Increase in gastric secretions Complete relaxation of lower jaw.

Non-Rapid Eye Movement (NREM)
It is slow wave sleep consist of four stages. Stage 1     This is a transition stage 1-7 minutes between wakefulness and sleep The person is relaxed with close eye during this time. Respiration and pulse are irregular. If awakens, the person will be often say that he has not been sleeping.

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4 Stage 2    This is the first true sleep. Unaware of surroundings Little harder to awaken.

Stage 3       This is the period of moderately deep sleep. Person is very relaxed. Body temperature falls Blood pressure decreases. It is difficult to awake the person. This stage occurs 20 min after falling asleep. Stage 4    Deep sleep occurs. The person is very relaxed. Respond slowly if awaken.

Development Consideration
In general, as age increases, the amount of sleep per night decreases. The length of each sleep cycle active (REM) and quiet (NREM) changes with age. For adults there is no particular change in the actual number of hours slept, but there is a change in the amount of deep sleep and light sleep. As age increases, the amount of deep sleep decreases and the amount of light sleep increases.

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5 This helps explain why the older patient wakens more easily, and spends time in sleep throughout the day and night. REM sleep decreases in amount from the time of infancy (50 percent) to late adulthood (15 percent) the changes in sleep pattern with age development are.  INFANT: awakes 7 hours, NREM sleep 8.5 hours REM sleep 8.5 hours.  AGE 1: awakes 13 hours NREM sleep 7 hours, REM sleep 4 hours.  AGE 10: awakes 15 hours, NREM sleep, 6 hours REM sleep 3 hours.  AGE 20: awakes 17 hours, NREM sleep, 5 hours REM sleep 2 hours.  AGE 75: awakes 17 hours, NREM sleep, 6 hours, sleep 1 hour. Infant The development of sleep and wakefulness can be traced to intrauterine life. A gestational age of 36 weeks seems to be a landmark. Term birth leads to a number of profound changes, especially in respiratory regulation. Five distinct sleep activity states for the infant have been noted.

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6 1. 2. 3. 4. 5. Regular sleep Irregular sleep Drowsiness Alter inactivity Awaking and crying The toddler needs approximately 10 to 12 hours of sleep at night with an approximate 2 hours nap in afternoon. The proportion of REM sleep is 25 percent. The preschooler sleeps approximately 10 to 12 hours per day. Dreams and nightmares may occur at this time. Rituals for preparation of sleep are important, with bedtime associated as separation from family and fun, quite time to gradually unwind, favorite object for security are suggested. School Age Child The school age child seems to do well without a nap and requires approximately 10 hours of sleep per day, with REM sleep being approximately 18.5 percent. Individualized rest needs are developed by this age. When the school ager alters the usual routine of sleep and rest, fatigue may be a result.

Toddler and Pre-Schooler

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7 Adolescent The adolescent sleep approximately 8 – 10 hours per day with REM sleep being 20 percent. Irregular sleep pattern seem to be the norm for the adolescent due to high activity levels and usual peer related activities. There may be a tendency to overexertion, which is made more pronounced by numerous physiologic changes that create increased demands on the body. Fatigue may occur during this time. Adult The adult sleeps approximately 8 hours per day with REM sleep being 22 percent. Research has shown that women of all ages have higher rates of sleep disturbance than man. This is due to hormonal changes and postpartum periods. A new baby does not allow for uninterrupted sleep for approximately 4-6 weeks after birth. The major cause of sleep disturbance in menopause is frequent nocturnal hot flashes coupled with early morning awakenings. Older Adult The older adult requires less sleep on the average approximately 5 – 7 hours of sleep per day.

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8 The proportion of REM sleep may vary from 20 - 25 percent. Older adults report problems in falling asleep and increased periods of waking the night. The etiology is unknown, safety needs during sleep and rest periods should be kept in mind.

Factors that Effecting on Sleep and Rest Pattern
Factors effecting on individual life can contribute to sleep pattern disturbance.        Physiological factor Psychological factor Environment factor Life-style factor Diet Habit and personality Drugs 1. Physiological Factor       Respiratory disease Impaired bowel and bladder elimination. Pain Pregnancy Immobility (e.g., traction) Hormonal changes

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9 2. Psychological Factor      Stress Anxiety Fear Depression Psychotic disorder 3. Environmental Factor       Hospitalization Unfamiliar or uncomfortable sleep environment Noise and lighting Day time long sleep During traveling Polluted environment 4. Lifestyle Factor     Change in working shift Change in sleep routine Change in activity pattern Overload of work 5. Diet  Food consumed impact on the quality and quantity of sleep   Coffee, cola and chocolate Heavy and spicy food

Virgina Handerson Theory 27

Hungry when going to bed 10

6. Habit and Personality     Habitual of medication Fatty people sleep long time Child always want to sleep with mother Some people can’t sleep alone. 7. Drugs Alcohol and nicotine - many medications, both prescription and over the counter, list fatigue, sleepliness, restlessness, agitation or insomnia as side effect, all of which will have an impact on the quality and quantity of rest and sleep.

Applicable Nursing Diagnosis Disturbed Sleep Pattern
Definition The state in which an individual experiences or is at risk of experiencing a change in the quantity or quality of his or her rest pattern that causes discomfort or interferes with desired life style. Defining Characteristics Adults  Major (must be present) a) Difficulty falling or remaining asleep.

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11  Minor (may be present) a) b) c) Children Sleep disturbance in children are frequently related to fear, enuresis, or inconsistence responses of parents to the child's requests for changes in sleep rules, such as requests to stay up late.   Frequent awakening during the night Desire to sleep with parents Many factors in life can contribute to disturbed sleep pattern. Some common factors are:       Related to excessive daytime sleeping Related to inadequate daytime activities Related to pain Related to anxiety response Related to discomforts secondary to pregnancy Related to lifestyle disruptions (e.g., occupational, emotional, social, sexual, financial)  Related to environmental changes (e.g., noise, fear, hospitalization, disturbing roommate or travel).  Related to fear Fatigue on awakening or during the day mood alterations Agitation Dozing during the day

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12 Related Clinical Concerns Sleep will be altered due to        Colic Hyperthyroidism Anxiety Depression Chronic obstructive pulmonary disease Any post operative state Pregnancy, post partum

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13

Summary
The nurse who understands the need for rest and sleep as a basic human need and is knowledgeable about individual sleep needs and factors that influence sleep will be able to provide for rest and promote sleep for the patient. Knowing what foods promote sleep, the importance of taking a nursing history for sleep, the ability to observe a sleeping patient and identify abnormal behavior during sleep, the importance of establishing routine or practicing good sleep hygiene all will give the nurse a basis for teaching the patient.

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14

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References

Tong B.C. and Phipps W.J. (1985). Medical Surgical Nursing: A Nursing Process Approach. 3rd Edition. Mosby Boston.

Cox H.C., Hinz M.D. and Lubno M.A. (1989). Clinical Applications of Nursing Diagnosis, Williams and Wilkins London; pp 339-397.

Carpenito

L.J.

(1989).

Nursing

Diagnosis:

Application to Clinical Practice. 3rd Edition. J.B. Lippincott Company New York.  Smith S. and Dvell D. (1982). Nursing Skills and Evaluation: A Nursing Process Approach. Nursing Review, California, USA.

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Self Assessment
The nurse not only proves for the patient’s rest and sleep, but takes responsibility for personal rest and sleep needs as well by practicing proper sleep hygiene and knowing individual sleep needs. The student is especially vulnerable to unmet sleep needs. Late night studying, cramming for finals and increases stress (I wonder if I flunked my chemistry test?) are a few examples of behavior that interferes with rest and sleep. The student who skips meals and exists on coffee or cola drinks is subjected to fragmented sleep at night, irritability, and gastrointestinal symptoms during the day. Practicing proper sleep hygiene is the most effective aid to a good night’s sleep. Ask yourself if you practice the components of sleep hygiene that are designed to maximize your ability to sleep. S. # 1. 2. 3. Do you? Go to bed and get up at the same time everyday? Have a comfortable mattress, large enough for turning and stretching? Fall asleep with the television or radio on? (Light and sound may help some people to fall asleep, but can be a detriment to others). Keep your bedroom temperature comfortable? Yes No

4.

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S. # 5.

Do you? Use your bedroom as a place for other activities (studying, craftwork, ironing clothes)? Except for sexual activity, the bedroom is a place for sleeping. Consume large amounts of coffee, cola, or alcohol during the day? (More than two cups of coffee can alter sleep). Nap during the day? Smoke cigarettes? Nicotine is a stimulant. Do you wake up at night to have a cigarette? Study just before bedtime? Use the hour before bedtime to relax. Take a warm bath, listen to music, minimize anxiety. Take drugs to keep you awake or consume more than an ounce of alcohol in the evening?

Yes

No

6.

7. 8.

9.

10.

A “Yes” answer to questions 3, 5, 6, 7, 8, 9 and 10 may indicate a violation of one or more components of sleep hygiene. If you feel tired and poorly rested or do have trouble falling asleep, consider altering your behavior so you can answer “yes” to questions 1, 2, 4 and “No” to the rest.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Madeleine Leininger Theory Advance Concept in Nursing I Bushra Sultana Mrs. Ruth K. Alam

Date:

Virgina Handerson Theory 36 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Madeleine Leininger Theory is a development and current status of transcultural nursing. In 1970, she observed that one of authropology’s most important contributions to nursing is, “the realization that health and illness status are strongly influenced and often primarily determined by the cultural background of an individual”. Madeleine described the major theme, the person and the environment. Major Theme – A major aim of transcultural nursing is to understand and assist diverse cultural groups and members of such groups with their nursing and health care needs. A through assessment of the cultured aspects of a client’s lifestyle, health beliefs and health practices will enhance the nurse’s decision making and judgment when providing care. Nursing interventions that are culturally relevant and sensitive to the needs of the client decrease the possibility of stress or conflict arising from cultural misunderstandings. Person – Often problems occur when persons from two cultural backgrounds with conflicting values meet unless at least one person is willing and able to recognize and adapt to the values of the other. One method for reducing potential misunderstandings is to sensitize nurses to their own cultural biases and behaviors as well as to those of their clients. Both the process of sensitization and the result more sensitive and effective nursing care, are the concerns of transcultural nursing. Environment – A conceptual framework in the environment of transculture clarifies what is important to the development of theory in transcultural nursing. As the model shows

Virgina Handerson Theory 37 all four concepts must be interrelated to produce transcultural nursing knowledge because the focus in transcultural nursing is on the cultural dimension of care, each concept is approached from his perspective. When nurses understand the four central concepts involved, which are environment, health, people and nursing, they can provide effective transcultural nursing care to clients. Transcultural nursing care also be provided to childbearing women and her family, children and adolescents and middle age adults. Model for Components in Transcultural Nursing Environmental/Culture Physical Social Symbolic
People Cultural variations Biological variations Health/illness behaviors

Theory TRANSCULTURAL NURSING Education Practice Health Major belief paradigms Art and practices of healing Health care system Research Nursing The professional nurse Nurse-client interactions (cultural encounters) Nursing care concepts Nursing care practices Nurse/provider culture

According to this theory, Madeleine focused on the value and belief of the client and I assess the client according to value and belief pattern. Assessment I collect information and examine the client about value and belief related the transculture. I assess the client through two ways.

Virgina Handerson Theory 38 Subjective Data In subjective data the client tells me about his culture. He tells me his values and beliefs are very strong about his culture. Objective Data In objective data, I observe and examine the client carefully and consciously. I look the 30 years old patient lying on the bed and looking:      Lethargic. Express anger towards God. Verbalizes inner concern about beliefs. Separation from religious or cultural ties. Challenged beliefs and values system. For example, due to moral or ethical implications of therapy due to intense suffering. Nursing Diagnosis Spiritual distress (distress of the human spirit). Expected Outcome Because of the largely subconscious nature of spiritual beliefs and values, it is recommended that the target data be at least 5 days from the data of diagnosis. Interventions Rationales

Assist patient to identify and define his Clarifies values and beliefs and helps or her values, particularly in relation to patient understand the impact of values health and illness, through the use of and beliefs on health and illness. value clarification, rank-ordering exercises, and completion of health values scales. Demonstrate respect for and acceptance of the patient’s value and spiritual system by not judging, moralizing, arguing, or advising changes in values or religious practices. Spiritual values and beliefs are highly personal. A nurse’s attitude can positively or negatively influence the therapeutic relationship.

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Interventions

Rationales

Adapt nursing therapeutics as necessary Maintains and respects patient’s to incorporate values and religious preferences during hospitalization. beliefs, e.g., diet, administration of blood or blood products, or rituals. Schedule appropriate rituals as necessary, Provides comfort for patient. e.g., baptism, confession, or communion. Arrange visits from needed support Promotes comfort and reduces anxiety. persons, e.g., pastor, rabbi, priest, or prayer group, as needed Provide privacy for religious practices Allows for expression of religious and rituals as necessary. practices. Encourage family to bring significant Promotes comfort. symbols to patient. Plan to spend at least 15 min twice a day Promotes mutual sharing and builds a at (times) with patient to allow trusting relationship. verbalization, questioning, counseling, and support on a one-to-one basis. Assist patient to develop problem-solving Involves patient in self-management behavior through practice of problem- activities. Increases motivation. solving techniques at least twice daily at (times) during hospitalization. Evaluation The client verbalize that he feels more comfortable spiritually. According to Madeleine Leininger theory, transcultural nursing is a humanistic and scientific area of formal study and practice in nursing which is focused upon differences and similarities among cultures with respect to human care, health and illness based upon the people’s cultural values, beliefs, and practices and to use this knowledge to provide cultural specific nursing care to people. Nurses, who have more direct interactions with clients than any other health team member, should be especially aware of the cultural aspects of nursing care. Application of transcultural nursing principles can lead to more effective and sensitive encounters between clients and nurses.

Virgina Handerson Theory 40 Summary It is concluded that concept of transculture facilitate nursing care that is culturally relevant and help nurses work more effectively with clients from different cultures. Nurses, who have more direct interactions with clients than any other health team member, should be especially aware of the cultural aspects of nursing care. A major aim of transcultural nursing is to understand and assist diverse cultural groups and members of such groups with their nursing and health care needs. The development of the theory of transcultural nursing can be traced to the work of early leaders in the field, who were interested in applying concepts, primarily from anthropology, to nursing care. Several themes emerge from this definition. First, cultures can be compared and contrasted with respect to health beliefs, health behaviors, and nursing care measures. Second, the goal of such study is to identify, test, refine, and apply such knowledge to the provision of culturally relevant care. Third, the outcome of such study is a body of knowledge useful to the practicing nurse. Fourth is the idea that this body of knowledge defines transcultural nursing.

Virgina Handerson Theory 41 References

Cox, H.C. et al. Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition.

www.cultrediversity.org/basic.htm. The Basic Concepts of Transcultural Nursing.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Betty Neuman Theory Advance Concept in Nursing I Daisy Nasreen Mrs. Ruth K. Alam

Date:

Virgina Handerson Theory 43

Betty Neuman
RN, BSN, MS, PhD, PLC, FAAN

Virgina Handerson Theory 44 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Betty Neuman Theory’s major theme is “System Models”. Her system models are comprehensive guides for nursing practice, research, education, and administration that are, open to creative implementation and have the relationship of variables in nursing cared and role definitions at various levels of nursing practices. The multidimensionality and wholistic systemic perspective of Neuman systems model is increasingly demonstrating its relevance and reliability in a wide variety of clinical and education settings throughout the world. In her system models, she described various aspects of system models, but I emphasize on the following:  Health – Health or wellness is equated with system stability. Wellness is the condition in which all parts and subparts of an individual are in harmony with the whole system. Wholeness is based on interrelationships of variables that determine the resistance of an individual to any stressor. Illness indicates lack of harmony among the parts and subparts of the system of the individual. Health is viewed as a point along a continuum from wellness to illness; health is dynamic (i.e., constantly subject to change). Optimal wellness or stability indicates that all a person’s needs are being met. A reduced state of wellness is the result of unmet systemic needs. The individual is in a dynamic state of wellness-illness in varying degrees at any given time.

Virgina Handerson Theory 45 Neuman’s Client System Basic structure Basic factors common to all organisms, i.e., • Normal temperature range • Genetic structure • Response pattern • Organ strength or weakness • Ego structure • Knowns or commonalities

Basic structure energy resources

Note: Physiologic, psychologic, sociologic, developmental and spiritual variables occur and are considered simultaneously in each client concentric circle.

Virgina Handerson Theory 46  Definition of Nursing – A unique profession focusing on the total person (patient system) and his or her, or group, reactions to stress and on factors influencing reconstitution. Neuman sees nursing as a unique profession, which is concerned with all of the variables, which influence the response a person night have to a stressor. The person is seen as a whole, and it is the task of nursing to address to whole person.  Goal of Nursing – To promote system stability. The Neuman systems model is used at all levels of nursing education from diploma through doctorate. The model is used in many clinical areas in institutions and community nursing practice at national and international sites. Additionally, the model is used in physical therapy programs and in nurse anesthesia. Assessment     Does the client verbalize inability to cope? Does the client demonstrate inability to problem solve? Does the client deny problems or weaknesses in spite of evidence to contrary? Did the client delay seeking health care assistance to the detriment of his or her health?       Does the client verbalize non-acceptance of health status changes? Is the client’s primary caregiver denying the severity of the client’s problem? Does the client demonstrate indications of neglect? Does the family indicate physical and emotional support for client? Does the family or primary caregiver indicate interest in a support group? Is there evidence of positive communication and community participation in planning for predicted community stressors?  Is the evidence of community conflict and deficits in community participation?

Virgina Handerson Theory 47 I collect information and examine the client about the stress coping pattern and collect data in two ways.  Subjective Data In subjective data the client tells me about his stress.  Objective Data In objective data, I observe and examine the client carefully and consciously. I look the client lying on the bed and looking:      Stress Uncomfortable Irritable. Sleepless with sunken eyes. Anxiety

Applicable Nursing Diagnosis  Adjustment, Impaired.
• • • • •

Ineffective individual coping. Powerlessness. Sensory-Perceptual alteration. Altered thought process. Dysfunctional grieving.

  

Community coping ineffective and potential for enhanced. Family coping ineffective compromised and disabling. Individual coping ineffective. Adjustment, Impaired (the state in which the individual is unable to modify his or her

lifestyle or behavior in a manner consistent with a change in health status).

Virgina Handerson Theory 48 Planning Adjustment to a change in health status will require time; therefore, an acceptable initial target date would be no sooner than 7 to 10 days following the date of diagnosis. Expected Outcome   Client will verbalize increase adaptation to change in health status. Client will return-demonstrate measures necessary to increase independence.

Nursing Interventions and Rationales Interventions Rationales

Establish a therapeutic relationship with A therapeutic relationship promotes client and significant others by showing cooperation in the plan of care and gives empathy and concern for client, calling client to talk with. client by name, answering questions honestly, involving client in decision making. Explain the disease prognosis of patient. process and Knowledge of disease process and limitations are necessary for adjustment. to

Encourage client to ask questions about Verbalization of feelings leads health status by allowing opportunity and understanding and adjustment. by asking client to share his or her understanding of the situation.

Identify previous coping mechanisms, Determines what coping strategies have and assist client to find new ones. been successful and provides an opportunity to try new strategies. Help client find alternatives or Helps client continue to have satisfaction modification in previous lifestyle in activities and provides a sense of behavior by using assistive devices, control in lifestyle. changing level of participation in activities, learning new behaviors, etc. Encourage independence in self-care Provides a sense of control and increase activities by focusing on client’s self-esteem and adjustment. strengths, rewarding small successes, etc. Refer client practitioner. to psychiatric nurse Collaboration promotes holistic approach to care, and problems may need intervention by specialist.

Virgina Handerson Theory 49 Evaluation   The client has verbalized increase adaptation to change in health status. The client has returned-demonstrated measures necessary to increase independence.

Summary According to Betty Neuman Theory, a system models person environment an interacting open system that is dynamic and composed of five interacting variables physiological, psychological, sociocultural development and spiritual has both external and internal components, the external includes normal lines of defense coping patterns lifestyle, family flies. Economic status and educational level the internal includes the lives of resistance defending basic structure. Health or wellness is equated with systems stability. A unique profession focusing on the total systems, and his or her group reactions to stress and on factors influencing reconstitution and to promote system stability. The Betty Neuman Theory (Client Model) is used in many clinical areas in institutions and community nursing practice at national and international sites. Additionally, the model is used in physical therapy programs and in nurse anesthesia.

Virgina Handerson Theory 50 References

Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.

Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.

http//www.neuman system models.com.

Virgina Handerson Theory 51

Virgina Handerson

Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Virgina Handerson Theory Advance Concept in Nursing I Farzana Gulzar Mrs. Ruth K. Alam

Date:

Virgina Handerson Theory 52 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Virgina Handerson Theory’s major theme is “Basic Needs”, in which she described:  Person – a unique individual in whom mind and body are inspirable, who has 14 fundamental needs.  Environment not defined specifically.

Basic Needs  Physiological
• • • • • • •

Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable posture. Sleep and rest. Select suitable clothes – dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying the environment.

• • • •

Keep the body clean and well groomed and protect the integument. Avoid dangers in the environment and avoiding injuring others. Communicate with others in expressing emotions, needs, fears or opinions. Learn, discover or satisfy the curiosity that leads to normal development and health and use the available health facilities.

Virgina Handerson Theory 53  Spiritual

Worship according to one’s faith.

Sociological
• •

Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation.

Psychological

Environment Individuals in relation to families   Support task of private and public agencies. Society expects nurses to act for individuals who are unable to function independently.  Basic nursing care involves providing conditions under which the patient can perform the fourteen activities unaided.  Analysis Philosophical Claims - The philosophy reflected in Handerson’s theory is an integrated approach to scientific study that would capitalize on nursing’s richness and complexity and not to separate art from science the “doing” of nursing from the “knowing” the psychological from the physical and the theory from clinical care. Values and Beliefs - Based on what we’ve found. Handerson believed nursing as primarily complementing the client by supply what he needs in knowledge, will or strength to perform his daily activities and to carry out the treatment prescribed for him by the physician. She strongly believed in “getting inside the skin” of her client in order to know, “what he or she need?” The nurse should be the substitute for the client, helper to the client and partner with the client.

Virgina Handerson Theory 54 Assessment  Does the client express anger toward a Supreme Being regarding his or her current condition?    Does the client verbalize conflict about personal spiritual beliefs? Does the client indicate positive thoughts about spirituality? Does the patient indicate comfort with self?

Subjective Data In subjective data the client tells me about his values and beliefs. He tells me his values and beliefs are very strong about his culture. Objective Data In objective data, I observe and examine the client carefully and consciously. I look the client lying on the bed and looking:      Lethargic. Express anger towards God. Verbalizes inner concern about beliefs. Separation from religious or cultural ties. Challenged beliefs and values system.

Nursing Diagnosis  Spiritual well-being (is the process of an individual developing or unfolding of mystery through harmonious interconnectedness that spring from inner strengths.  Spiritual distress (disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s biologic and psychosocial nature). Planning

Virgina Handerson Theory 55 Short-term - Client will verbalize sense of spiritual peace at least one week from the date of diagnosis because of the largely subconscious nature of spiritual beliefs and values.

Virgina Handerson Theory 56 Expected Outcome   Client will verbalize sense of spiritual peace. Client will describe at least support systems to use when spiritual conflict arises. Nursing Interventions and Rationales Interventions Assist patient to identify and define his or her values, particularly in relation to health and illness, through the use of value clarification, rankordering exercises, and completion of health values scales. Demonstrate respect for and acceptance of the patient’s value and spiritual system by not judging, moralizing, arguing, or advising changes in values or religious practices. Rationales Clarifies values and beliefs and helps patient understand the impact of values and beliefs on health and illness.

Spiritual values and beliefs are highly personal. A nurse’s attitude can positively or negatively influence the therapeutic relationship.

Adapt nursing therapeutics as Maintains and respects patient’s necessary to incorporate values and preferences during hospitalization. religious beliefs, e.g., diet, administration of blood or blood products, or rituals. Schedule appropriate rituals as Provides comfort for patient. necessary, e.g., baptism, confession, or communion. Arrange visits from needed support Promotes persons, e.g., pastor, rabbi, priest, or anxiety. prayer group, as needed comfort and reduces

Provide privacy for religious Allows for expression of religious practices and rituals as necessary. practices. Encourage family to bring significant Promotes comfort. symbols to patient. Plan to spend at least 15 min twice a Promotes mutual sharing and builds a day at (times) with patient to allow trusting relationship. verbalization, questioning, counseling, and support on a one-to-

Virgina Handerson Theory 57 one basis. Assist patient to develop problem- Involves patient in self-management solving behavior through practice of activities. Increases motivation. problem-solving techniques at least twice daily at (times) during hospitalization.

Virgina Handerson Theory 58 Evaluation During an interview, client indicates through verbalization that he feels more comfortable spiritually. Summary Virgina Handerson presents her theory on fourteen basic needs of the human needs and absence of these needs cause disease. Their presence cure illness, their absence need fulfillment and their fulfillment restore health.

Virgina Handerson Theory 59 References

Cox, H.C. et al. Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition.


http//www.anglefire.com/ut/virginiahanderson/concepts.html. www.unc.edu/~ehallora/handerson.htm.

Virgina Handerson Theory 60

Role and Relationship Pattern Advance Concept in Nursing I Hidayatullah Sharifa Bibi Shagufta Rani Mrs. Ruth K. Alam Date:

Virgina Handerson Theory 61

INDEX TABLE
S# 1. 2. Content Pattern Description Definitions   3. Role Relationship Achieved role Ascribed role Page # 01 01 01 01 02 02 02 02 04 05 05 06 family 09 09 11 11 12 13

Types of Role  

4. 5. 6. 7. 8. 9. 10. 11. 12 13. 14.

Terms Why is needed to discuss role relations pattern? Definition of family Types of family Development consideration Manifestation functions of altered

Primary role relationship in family Which types of questions we can ask? Applicable nursing diagnosis Summary References

Virgina Handerson Theory 62

OBJECTIVES
At the end of this presentation the learner will be able to: 1. 2. 3. 4. 5. 6. 7. 8. 9. Define role and relationship. Enlist types of role. Explain terms related to role and relationship. Discuss why it is needed to discuss role relations pattern. Define family. Identify types of family. Describe development consideration and manifestation of altered family functions. Enumerate which types of questions we can ask. Summarize applicable nursing diagnosis.

Virgina Handerson Theory 63

1

Pattern Description
Role relationship pattern is concerned with how a person he or she is performing the expected behavior delineated himself and others. Each of us has several roles some related responsibilities included in our role are family, work and social relationship. Disruption in these roles relationship can lead patient to seek assistance from the health care system like wise satisfaction with the roles relationship and responsibilities is patient strength that can be used in planning care for other health problem areas.

Definitions 1. Role
 Role may be define is a pattern of behavior’s structure around specific rights and duties, that is associated with particular status.  A standardized behavior associated with the status of an individual.  A role is a set experience about how the person occupying one’s position behaves towards a person occupying another position.

2. Relationship

Virgina Handerson Theory 64

The connection of an individual to another by blood or otherwise. 2

Types of Role 1. Achieved Role
It is the one and individual chooses or earns through his own efforts and actions, such is the role of a nurse.

2. Ascribed Role
It is acquired by an individual at birth or on the attainment of a certain age: infant, mother, father and gender etc.

Terms 1. Role Performance
Relates what a person does in a particular role to the behaviors expected of the role.

2. Role Mastery
Mean that the person’s behavior meets social expectation. Expectation or standards of behavior of a role are set by the smatter group to which a person belongs. Each person has several roles, such is husband, parent, brother, son, employee, friend, nursing association member. Some roles are assumed for only limited periods such as client, student, and ill person.

3. Role Development

Virgina Handerson Theory 65

Involved socialization into a particular role for example nursing students are socialized into instructions, clinical

Virgina Handerson Theory 66

3 experience classes, laboratory simulations, and seminars to act appropriately people need to know who they are in relation to others and what society expect for the position they hold.

4. Role Ambiguity
Occurs when expectations are unclear, and people do not know what to do or how to do it and are unable to predict the reactions of others to this behavior. This creates confusion and stress to relate or interact appropriately with others; people also need to know the role positions that other occupy. Failures to master a role create frustration and feeling of inadequate often with consequent lowered self esteem.

5. Multi Roles
Refer to the occupancy of individual for example a nurse a wife a mother, a member of concealing etc.

6. Role Conflict
It is a condition when two or more roles happened to be played in a certain social situation and the individual has to perform one role and reject the other. Role conflict could be the result of education, industry and urban life. It keeps on increasing as the number of roles increase. In rural area of Pakistan people face a little but of role conflict due to simple culture and simple social life pattern.

Virgina Handerson Theory 67

4

7. Effect of Role Conflict
   The decision power becomes weak. Peculiar thinking habit develops which result in staying up late in night or sleeplessness. The individual becomes short-tempered and a marked change is seen in his behavior, he become angry or happy without any reason.  The individual may develop different medical problems. a) b) c) d) e) Generalized weakness. Indigestion Hyper tension Asthma Neurosis

8. Role Strain
Role strain occurs when the performance expected in respect to given role is too much demanding for an individual this stain may be due to one of the following reasons.  The individual is acting in too many roles. Feeling of individual, adult performing expected behavior  Role  Alteration in role relationship  Nurses’ role

Why is needed to Discuss Role Relations Pattern?

Virgina Handerson Theory 68

5

Family Definition
 This is a structured system of relationship in which individual are bond to one another by complex, interlocking relationship, such type of relationship is also known as kinship system.  A group of people living together, they are emotionally involved and related either by blood or adaptation.

Types of Family
1. Nuclear Family  Husband + wife + unmarried children. Husband + wife. One head household (mother or father). Either by chance or choice, divorce or death of spouse. Three or more generation living in a single house. Nuclear household or unmarried members living in close geographical proximity. 2. Nuclear Dyad  3. Single Parent Family  4. Single Adult Alone  5. Three Generation Family  6. Kin Networking

Virgina Handerson Theory 69

6 7. Institutional Family   Children in orphanage or residential school hostel. Homosexual couple with or without children.

Developmental Considerations 1. Neonate and Infant
Attachment behavior
Crying

Cuddling

Attachment behavior

Smiling

Following

Clinging

       

Depend on parents for basic needs Reciprocal interaction b/w infant and parents Feelings fear in of loneliness Behavior in despair specific consideration Fulfilling of basic needs Assess infant emotionally especially when he? she is alone, or in despair Understand crying process Understand and respond symbolic interaction 7

Virgina Handerson Theory 70

2. Toddler and Preschooler
Increased sense of indent a) Toddler              Sense of right/wrong Confirmation of social demands Depend on mother (parents) Starting of school interactions Make friends of same sex Capable of internalizing the social norms Tolerate belief separation of their parents Learn social roles as male, female Enjoy school + peer interaction Make friends of same sex Capability of expressing feelings Acknowledge limitations Get allowance for increasing interest out side from the home

b) Pre-schooler

3. School Age Children

4. Adolescent
    Dependence and interdependence Intensive relationship with opposites sex Spend more time alone Peer and social interaction according to family needs

Virgina Handerson Theory 71

8

5. Young Adult
      Peak level of biophysical and cognitive skill Meaningful intimate relationship Primary focus on establishment of family Marriage and parenting Thinking involves reasoning Consider past experience, education and possible out comes of a situation  Learn how to deal with personal and desired needs of others

6. Middle Age Adult
      Productive years for an individual Parenting role Mostly secure in a profession/ career Initiation of biophysical, physical changes Accept the changes of age Prone to chronic disease/ illnesses

7. Older Adult
  Volunteer role (choice, demand) Elder role modeling

Depending upon others

Virgina Handerson Theory 72

9

Manifestation of Altered Family Functions
      Stress Life is disturb Impaired concentration Performance is affected even at job Decreased thinking capability Affected decision makings process

Primary Role Relationship in Family 1. Husband and Wife
  Economic specialization cooperation, sexual cohabitation Joint responsibility for support, care and upbringing of children.

2. Father and Son
Economic cooperation in masculine activities under leadership of father, obligation of maternal support vested. In father during childhood of son and in son during old age of father responsibilities for instruction and discipline of duty of obedience and respect on part of son

3. Mother and Daughter
Relationship similar to that between father and son, but with more emphasis on child care and economic cooperation, and less on authority material support.

Virgina Handerson Theory 73

10

4. Father and Daughter
Responsibility of father material support and daughter economic co-operation and obligation.

5. Mother and Son
Relationship similar to daughter and mother but with more emphasis on financial and emotional support in later life of mother.

6. Elder and Younger Brother
Relationship of elder and younger brother as define. Economic co-operation under leadership of elder, moderate responsibility of elder for instruction and discipline of younger.

7. Elder and Young Sister
Relationship between alder and younger brother but with more emphasis on physical care of younger sister.

8. Brother and Sister
Early relationship of playmates different with relative age, gradual development of an incest Taboo, commonly coupled with some measure of reassure, moderate, economic co-operation, and partial assumption parental role especially by the elder sibling.

Virgina Handerson Theory 74

11

Which Types of Question We can Ask?
Q1) Tell me about your family? Q2) What are your relationship like with your other relatives? Q3 Q Q5 Q6 Q7 Q8 Q9 What are your responsibilities in the family? Are you proud of your family members? How do you spend your free time? Are you involved in any community group? Are you most comfortable alone with one person or in a group? Who is most important to you? What goals in life are important to you?

Q10 Are you satisfied with your life? Q11 What are your personal strengths, talents and abilities?

Applicable Nursing Diagnosis
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Altered family process. Ineffective family coping. Spiritual distress. Impaired verbal communication. Social Isolation. Altered parenting. Impaired social interaction. Ineffective individual coping. Anxiety or fear. Sensory perceptual alteration.

Virgina Handerson Theory 75

12

Summary
We have learned about the definition of role and relationship that is the standardized behavior associated with the status of an individual and relationship is the connection of an individual to others. Types of role that is achieved and ascribed roles along with role performance, role mastery role development, role ambiguity, multi role, role conflict, effect of role conflict and role strain were also discussed. We learn about family that is group of people living together which is emotionally involved and related either by blood or adaptation. Types of family e.g. nuclear family nuclear dyad, single parent family, single adult alone, Three generation family, institutional family, homosexual family. Development consideration of relationship and primary relationship in the family including husband and wife, father and son, mother and daughter, father and daughter, mother and son, elder and younger brother, sister and sister, brother and sister. We learn also about types of asking questions and applicable diagnosis.

Virgina Handerson Theory 76

13

References

Tong B.C. and Phipps W.J. (1985). Medical Surgical Nursing: A Nursing Process Approach. 3rd Edition. Mosby Boston.

Cox H.C., Hinz M.D. and Lubno M.A. (1989). Clinical Applications of Nursing Diagnosis. Williams and Wilkins London; pp 339-397.

Carpenito L.J. (1989). Nursing Diagnosis: Application to Clinical Practice. 3rd Edition. J.B. Lippincott Company New York.

Virgina Handerson Theory 77

Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Rosemarie Parse Theory Advance Concept in Nursing I Inayatullah Mrs. Ruth K. Alam Date:

Virgina Handerson Theory 78 Theory - is the group of concept that forms a pattern of reality. A theory is a statement that explains or characterized a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory - differentiates nursing from other disciplines and activities in that it serves the purpose describing, explaining, predicting and controlling desired outcomes of nursing care practice. Rosemarie Parse Theory - The human becoming theory of nursing presents an alternative in both the conventional biomedical approach and the biopsychosocial spiritual (but still normative) approach of most other theories of nursing. Person - The human becoming theory posits quality of life from each person’s own perspective as the goal of nursing practice. Rosemarie Rizzo Parse first published the theory in 1981 as the Man-living-health theory. The name was officially changed to the human becoming theory in 1992 to remove the term Man after the change in the dictionary definition of the word from its former meaning of human kind. The human becoming theory was developed as a human science nursing theory in the tradition of Dilthey, Heidegger, Sartre, Merleau-Ponty and Granddame. The assumptions underpinning the theory were synthesized from works by the European philosophers Heidegger, Sartre and Merleau Ponty along with works by the pioneer American Nurse Theorist, Martha Rogers. The theory is structured around three abiding themes meaning rhythmicity and transcendence. Person may be an individual or family. The person as a unitary indivisible human being in constant interchange with the environment who is free to make decisions and choices about health behaviors based on parts or present experience. Environment - The first theme “meaning” is expressed in the first principle of the theory which states that structuring meaning multidimensionally is cocreating

Virgina Handerson Theory 79 reality through the language of valuing and imaging. This principle means that people coparticipate in creating what is real for them through self expression in living their values in a chosen way. The second theme ‘Rhythmicity’ is expressed in the second principle of the theory which state cocreating rhythmical pattern of relating is living the paradoxical unity of revealing concealing and enabling limiting while connecting separating. This principle means that the unity of life encompasses opportunities and limitations emerge in moving with and apart from others. The third theme, “Transcendence” is expressed in the third principle of the theory, which states that “cotranscending with the possible is powering unique ways of originating in the process of transforming.’ This principle means that moving beyond the “now” moment is forging a unique personal path for onself in the midst of ambiguity and continuous change. Nurses who practice guided by the human becoming theory live the processes of the Parse’s practice methodology illuminating meaning synchronizing rhythms and mobilizing transcendence. Research guided by the human becoming theory sheds lights on the meaning of universal humanly lived experiences such as hope taking life day by day grieving suffering and time passing. For references on any of these topics the practice method the research method or specific studies. Rosemarie exists on a constantly changing energy field that surrounds the person and is an integral part of the state of being. According to this theory Rosemarie focused on the health perception and health managing of the client. I assess the client according to health perception and health management pattern. Assessment

Virgina Handerson Theory 80 I collect information and examine the client about health perception and health management. I collect data in two ways during assessment.

Virgina Handerson Theory 81  Subjective Data In subjective data the client tells me about his health perception and management of his health in daily life.  Objective Data In objective data, I observe and examine the client carefully and consciously. I saw a 35 years old client lying on the bed and looking here and there.  Major defining characteristics:         Temperature change (warmth, coolness). Visual changes (image, color) Disruption of the field (vacant, hold, spike) Movement (wave, spike, tingling, dense). Sounds (tone, words).

Insomnia Chronic fatigue syndrome Pain

Nursing Diagnosis         Energy field disturbance. Health maintenance Altered. Health seeking behavior. Infection risk for. Injury risk for. Management of therapeutic regimen. Preoperative positioning injury risk for. Protection altered.

Virgina Handerson Theory 82 Expected Outcome Client will verbalize a perception of consistent energy level one week after the date of initial diagnosis (locating the reason(s) for Energy Field Disturbance may require several days or even weeks). Nursing Interventions and Rationales Interventions    Establish trusting relationship  with client. Allow client to talk about  condition. Assess energy field  Rationales Promotes accurate assessment. Promotes nurse-client relationship. Alterations, variations and/or asymmetry in the energy field is detected through assessment.

Center self – imaging self as open system with energy flow content in, through, and out of the system. Assess for heat or tingling over specific body areas – Glide hands, palm down, and slowly move over body, head to toe, 2-4 in above body. Be sensitive to any images  that come to mind: words, symbols, pictures, colors, sound, mood, emotion, etc. Attempt to get a sense of the dynamics of the energy field. Synthesize assessment data into an understandable format Redirect areas of  accumulated energy, reestablish the energy flow and direct energy to depleted areas. Repattern or rebalance client’s energy field. Energy transfer or transformation can occur without direct physical contact between two systems. Hands are focal points for the direction and modulation of There may be a loss of energy, disruption or blockage in the flow of energy, or an accumulation of energy in a part of the body.

Virgina Handerson Theory 83

Interventions   Do therapeutic touch for no  longer than 10 min. Assess client’s subjective  reaction to therapeutic touch. Client should feel more relaxed, less anxious, and less pain. Teach client relaxation  exercises using some of the same techniques as therapeutic touch: Assist client to center self. Teach client to imagine a peaceful place. Help client to verbalize place through all the senses and to allow the energy of the imagined place to bring about a state of calmness. Teach patient to scan his or her body to self-assess areas of body or muscle tension. Assist client to consciously relax that tense area of the body. Evaluation

Rationales Could disrupt the energy field of the therapist. Nurse acts as a conduit through which the environmental or universal energy passes to the client.

Relaxation requires the client to stop trying and to step outside of self and adopt a nontrying attitude. This allows the person to release and use the inherent energy of self.

Rebalances energy flow through the body.

Client states that he has established energy level and resolved the problem and met to expected out come. Summary The human becoming theory of nursing presents an alternative in both the conventional biomedical approach and the biopsychosocial spiritual (but still normative) approach. The human becoming theory posits quality of life from each person’s own perspective as the goal of nursing practice. The person as a unitary indivisible human being in constant interchange with the environment who is free to

Virgina Handerson Theory 84 make decisions and choices about health behaviors based on parts or present experience. Rosemarie Prase theory is structured around three abiding themes; meaning, rhythmicity and transcendence. The first theme “Meaning” is expressed in the first principle of the theory which states that structuring meaning multidimensionally is cocreating reality through the language of valuing and imaging. This principle means that people coparticipate in creating what is real for them through self expression in living their values in a chosen way. The second theme ‘Rhythmicity’ is expressed in the second principle of the theory which state cocreating rhythmical pattern of relating is living the paradoxical unity of revealing concealing and enabling limiting while connecting separating. This principle means that the unity of life encompasses opportunities and limitations emerge in moving with and apart from others. The third theme, “Transcendence” is expressed in the third principle of the theory, which states that “cotranscending with the possible is powering unique ways of originating in the process of transforming.’ This principle means that moving beyond the “now” moment is forging a unique personal path for onself in the midst of ambiguity and continuous change. Rosemarie exists on a constantly changing energy field that surrounds the person and is an integral part of the state of being. According to this theory Rosemarie focused on the health perception and health managing of the client.

Virgina Handerson Theory 85 References

Cody, W.K. Parse’s Theory of Human Becoming: A Brief Introduction. www.discoveryinternationalonline.com.

Cox, H.C. et al. Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition.

Cognitive Perceptual Pattern Advance Concept in Nursing I

Inayatullah Kharunnisa

Virgina Handerson Theory 86

Musarrat Begum Mrs. Ruth K. Alam Date:

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INDEX TABLE
S# 1. 2. 3. 4. 5. 6. Introduction Definition Aging Changes Pattern Assessment Conceptual Information Developmental Consideration       7. 8. 9. 10. 11. 12. Infant Toddler Pre-School School Age Children Adolescent Adult and Older Adult Content Page # 01 01 01 02 03 06 06 07 07 07 08 08 10 12 13 14 15 16

Alteration in Cognitive Perception Sensory Perceptual Alteration Thought Process Uni-lateral Neglect Summary References

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OBJECTIVES
At the end of this presentation, audience will be able to: 7) Define cognitive perceptual pattern. 8) Enlist the aging changes. 9) Explain the pattern assessment. 10) Describe the conceptual information. 11) Discuss development consideration according to age. 12) Identify the alterations in cognitive perception.

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COGNITIVE PERCEPTUAL PATTERN
Introduction
The cognitive perceptual pattern deals with thought, through processes and knowledge as well as the way the patient acquires and applies knowledge. A major component of the process is perceiving. Perceiving incorporates the interpretation of sensory stimuli.

Definition
According to Erickson (1923), “Ability to think is known as cognitive perception.” Elderly differ from the younger in serial aspects of cognitive and parietal function. The most dramatic changes occur in central nervous system (Peripheral motor nervous system, autonomic nervous system).

Aging Changes
       Aging changes include: Decreased brain weight. Diminished enzyme activity. Solved reflexes. Decreased sensory receptors for temperature. Weakness of interneuron connections. Increased response time. Chronic hypoxia.

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These changes affect complex processes such as learning, laughing, memory, language and mutation.

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Pattern Assessment
1. It includes patient’s description of adequacy of special senses. Vision: Glasses? Content lenses? Regular check ups, results of test with Snellen chart. Hearing: Any changes in hearing, difficulty, hearing aid? Result of testing? Taste: Any changes? Any persistent taste sensation results of testing? Touch: Any decreased or increased tingling sensations? Results of testing? Smell: Any changes? Any persistent odor? Result of testing. 2. 3. 4. 5. 6. 7. Patient’s description of pain, pain acuity, what has been used to relieve pain, adequacy of this measure. Any problem with decision making, learning and memory. Patient’s feelings about uncertainty of choices. Delayed decision making. Verbal questioning or actual discussion of specific values being questioned. Physical manifestations of resultant tension due to inability to make a decision, such as increased heart rate, restlessness, tension, failure to relax and carryout usual role.

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8. 9.

Inability to feel at ease regarding the threat of the need to make a decision to resolve a conflict. Inability to feel at ease regarding the threat of the need to make a decision to resolve a conflict.

Conceptual Information
A person who has a normal perceptual pattern experiences conscious thought, is oriented to reality, solves problems, is able to perceive through sensory input and responds. All of these functions depend on a healthy nervous system containing receptors to detect input, a brain which can transport decoded information, transmitters which can interpret the information, and transmitters which can transport decoded information. Bodily response is also a basic requisite to respond to the sensory and perceptual demands of the individual. Cognition is the process obtaining and using knowledge about one’s word with the use of perceptual abilities symbols and reasoning with human sensory capabilities, the process leads to perception which is extracting information in such a way an individual transforms sensory input into meaning. In the other sense thinking activities may be considered as internally adaptive response to intrinsic and extrinsic stimuli. The thought process serves to express inner impulses and appropriate goal seeking behavior by the individual.

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The senses which serve as the origin of perceptual stimuli are: 1. Extractors (distance sensors) a) b) 2. a) b) c) 3. a) b) Visual Auditory Coetaneous (sense via skin e.g. pain, tamp) Chemical sense of taste. Chemical sense of smell. Kinesthetic sense (which transducers position, motion of muscles, tendons and joints) Static or vestibular sense (changes related to marinating position in space and regulation of organic functions such as metabolism, fluid balance and sensual stimulation. Conceptual information is also the process of obtaining and using knowledge about one’s world through the use of perceptual abilities, symbols and reasoning. For this reason it includes the use of human sensory capabilities to receive input about the environment. There are two general approaches to contemporary cognitive theory.

Proprioceptors (near sensors)

Interceptors (deep senses)

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1(a). Information Processing Approach – it attempts to understand human thought. 1(b). Reasoning Process – it is comparing the mind to a sophisticated computer system. 2. According to Swiss Psychologist, Jean Piaget, the second approach is based on work. He considered cognitive adaptation in terms of two basic processes. a) Assimilation – is the process by which the person integrates new perceptual data or stimulus events into existing schemata or existing patterns of behavior. b) Accommodation – is the process of changing that model the individual has of the world by developing in mechanisms to adjust to reality. The American Psychologist, Jerome Bruner broadened Piget’s conception by suggesting that the cognitive process is affected by three modes. i) ii) iii) The Enactive Modes – involves representation through action. The Iconic Mode – uses visual and mental images. The Symbolic Mode – uses language.

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Developmental Consideration 1. Infant
The neonate born with the ability to use the senses generally papillary reflexes in response to light. The sensory hyalinization is best developed at the birth for hearing, taste and smell. Vision - in structure of eye macula is not completely differentiated. The newborn has ability to see an object held within 8 inches in mid line of the visual field. Binocular flexation and convergence to near object is possible by 4 month of age. Hearing - the neonate is capable of detecting a loud sound of 90 decibels and reacts. Ear structure is fully developed at birth. However, the lack of cortical integration and normal pathway prevents special response to sound. The two month infant turns the side where as sound comes. Smell - seems to be a factor in breast- fed infants response to mother’s engorgement and leaking. Newborn will turn away face from strong odors e.g. alcohol. Taste - newborns respond to various solutions with following gastofacial reflexes.  A tasteless solution elicits no expression.  A sweet solution elicits an eager suck and look of satisfaction.  Bitter liquid produces an angry, upset expression  At one year infant appreciate taste flavors

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Touch - at birth newborn capable for perception of touch with mouth, hands and soles of feet. Propriception - the infant at birth is limited in perceiving itself in space. There is momentary head control, exacting neurological reflexes provide in depth supplementary data. He prevents from falling himself at the age of 7 months. The infant offers localized reaction in response to pain at 6-9 month of age.

2.

Toddler
Vision - binocular is well established. He can differentiate in

different colours. Hearing, smell and touch are developed as the toddler see on object, handle it and enjoy with it He can prevent himself from dangerous objects. Toddlers demonstrate tolerance for painful procedures by understanding.

3.

Pre-School
Pre-School has capacity for magical thinking and enjoys role-

play of parent of same-sex. He enjoys in learning colours and using words in sentences. 4. School Age Child He develops significant ability to perform logical operations. He can fellow simple rules and has concept of death. He begins to interpret the experience of pain source of pain complications and attempts to establish a trusting relationship to best manage the pain.

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5.

Adolescent
Vision acuity of 20/20 is reached by now. Squinting should be

investigated. In hearing further investigations should be done who speak loudly and fail to respond loud noises. Touch - under reaction to painful stimuli is cause for further investigations. Taste may prefer food fads for length of time. He complains of foods not tasty as they used to be. Smell - he can distinguish a full range of odor. Proprioception - he is capable of formal operational thought and abstract ideas. There is an interest in values. The adolescent attempts to deal with pain as adults. Sexuality factor responds.

6.

Adult and Older Adult
Vision - the adult is capable of 20/20 vision but gradual decline

in acuity oater 40 years. There is tendency towards far sightedness. Colour discrimination decrease in later age. Degenerative process such as macula degeneration light sensitivity, cataract formation associated with diabetes. Hearing - the adult has a sensitivity to accurately differentiate 1600 different frequencies. There should be equal sensation of sound for right and left ear. With the passage of time acuity of hearing affected.

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Smell - at age of 60 there may be deterioration of sensitivity for smell .There may be attired gastrointestinal enzyme production which interfere the perception of smell. Touch - the adult is able to discriminate on a wide range of tactile stimuli e.g., pressure, temperature, pain with aging changes such as decrease in subcutaneous fat, loss of skin turgor and decease in conduction of impulses. Propriocetion - the adult is well co- ordinate and has a keen sense of his/her body in space. There are multiple protective mechanisms which maintain balance. The tolerance and thresh hold one has for pain is well-established. In later age, a gradual decline in problem solving capacity which may be aggravated by illness. Focus should be on factors such as chronic illness, financial deficits and realization of age integrity, vascular changes and degeneration of brain and CNS disorders impaired thought process by later age.

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Alteration in Cognitive Perception 1. Comfort, Altered Pain
A state in which an individual experiences and reports presence of severe discomfort or an un-comfortable sensation. Characteristics (Nanda, 1987) Major defining characteristics are: 1. 2. Subjective: Objective: a) Guarding behavior, protective. b) Self focusing. c) Narrowed d) Distraction focus (time perception; withdraw from social contact, impaired thought. behaves (moaning, crying, restlessness, seeking out other people. e) Facial mark of pain. f) Alteration in muscle tone. g) Autonomic response. Related Factors - Pain Injuring agents (biological, chemical, psychological) Decisional Conflict The state of uncertainty about choice among competing actions involving risk, loss or challenge to personal life values. This is communication of pain description.

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Characteristics (Nanda, 1988) Major characteristics are:               Verbalize un-certainty about choices Verbalization of undesired consequences. Vacillation between alternative choices. Delayed decision making. Minor characteristics are: Verbalized feeling of distress. Self focusing. Physical signs of distress or tension. Questioning personal values and beliefs. Un-clear personal values or beliefs. Perceived threat to value system. Lack of experience with decision making. Lack of relevant information. Support system deficit. Multiple sources of information. The situation in which individual experiences a lack of information or has difficulty in applying information thus increases the risk of actual compromise in health care.

Related Factors

Knowledge Deficit

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Characteristics (Nanda, 1983)           Verbalization of the problem. Inaccurate follow through of instruction. Inaccurate performance of test. In-appropriate behavior. Lack of exposure. Lack of recall. Information minister petition. Cognitive limitation. Lack of interest in learning. Un-familiarity with information resources A state in which an individual experiences a change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated disoriented or impaired response to such stimuli. Characteristics (Nanda, 1987) Major characteristics include:      Disoriented in time, place and person. Altered abstraction. Altered conceptualization. Change problem solving abilities. Change in sensory acuity.

Related Factors

Sensory Perceptual Alteration

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        1. 2. 3. 4.

Change in behavior pattern. Anxiety, Apathy Change in visual response to stimuli. Altered communication pattern. Minor characteristics are: Complaints of fatigue. Alteration in posture. Inappropriate responses. Hallucinations. Altered environmental stimuli, excessive or insufficient. Altered sensory reception, transmission, integration. Chemical alteration, endogenous (electrolytes), exogenous (drugs) Psychological stress. A state in which an individual experiences a disruption in

Related Factors

Thought Process
cognitive operations and activities Characteristics (Nanda, 1987) Major characteristics include     Inaccurate interpretation of environment. Memory deficits. Egocentricity. Minor characteristics are Inappropriate non-reality based thinking.

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Uni-lateral Neglect
The state in which an individual is perceptually unaware of and inattentive to one side of the body. Characteristics (Nanda, 1987) Major characteristics are consistent in attention to stimuli on an affected side. Minor characteristics are:     Inadequate self care. Positioning precautions in regard to the affected side. Do not look toward the affected side. Leaves food on plate on the affected side. Related Factors Effects of disturbed perceptual abilities e.g., one side blindness, neurologic illness or trauma.

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Summary
In this presentation we discussed about cognitive perceptual pattern’s definition, description, aging changes, normal pattern assessment, conceptual information, developmental consideration according to age and alteration in cognitive perception. If we understand all these topics, we will be able to make nursing care plan in nursing practice. Similarly, if we know the normal assessment pattern of cognitive perception, we will be able to judge the altered cognitive perception.

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References

Tong B.C. and Phipps W.J. (1985). Medical Surgical Nursing: A Nursing Process Approach. 3rd Edition. Mosby Boston.

Cox H.C., Hinz M.D. and Lubno M.A. (1989). Clinical Applications of Nursing Diagnosis, Williams and Wilkins London; pp 339-397.

Carpenito L.J. (1989). Nursing Diagnosis: Application to Clinical Practice. 3rd Edition. J.B. Lippincott Company New York.

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CONCEPTUAL INFORMATION

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ALTERATION IN COGNITIVE PERCEPTION

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Dorothy Orem Theory Advance Concept in Nursing I Karim Bux Mrs. Ruth K. Alam

Date:

Florence Nightingale109 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Dorothy Orem Major Theme The major theme of Dorothy Orem is “Self Care Needs”. Dorothy Orem Theory Dorothy Orem presented “Self Care Model” in 1980. This model has goal of consistency for the person and speaks to the concept of self care is the person own action that has pattern and sequence and when effectively informed contribute to the way he or she developed and function. Self Care Model According to Dorothy Orem self care model defined as “the individual needs for self care action, which is practice of the activities that individual initiates and perform of own behalf in maintaining life, health and well-being.” Person According to Dorothy a person is defined as “unity functioning biologically, symbolically, and socially”. Three categories of self care needs are:    Universal. Developmental. Caused by the health deviations.

Florence Nightingale 110 It proposed about the human becoming on main three assumptions.  Human becoming is freely choosing personal meaning in situations in the intersubjective process o relating value properties.  Human becoming is co-creating rhythmic patterns or relating in mutual process with the universe.  Human becoming is contranscending multidimensionally with the emerging possibilities. These three assumptions focus on meaning, rhythmicity, and contranscendence.  Meaning arises from a person’s interrelationship with the world and refers to happenings to which the person attaches varying degrees of significance.   Environment Dorothy Orem said that environment elements are seen as external to person and compose of both physical and psychosocial component. Physical components are included as nutrition, drug and alcohol, sleep, rest, relaxation and exercise body mechanism, posture grooming are those physical components are important to achieve the physical wellness of the person. Psychosocial components included as anxiety, emotion, attitude, behavior, customs, value and belief, family and society these influences on an individual self care. Self Perception and Concept Pattern  Body Image – the picture that each of us creates concerning our physical self is called body image.  Self Ideal – it is the ideas about who actually makeup the self care up or perceived self whereas ideas about who I should be form my ideal self e.g., “Me that I would like to be”. Rhythmicity is the movement toward greater diversity. Contranscendence is the process of reaching out to bond the self.

Florence Nightingale 111  Self Concept – the complete being of an individual comprising both physical and psychological characteristics and including both conscious and unconscious components (Miller and Keane, 1992). According to Arnold and Boggs (1995), self concept is the term given to the part of self that lies within conscious awareness. It encompasses all that a person perceived, knows values, feels and holds to be true about his/her identity. It is made up of the conscious components only. There are four dimensions of self concept.
• • • •

Physical dimension. Social dimension. Psychological dimension. Spiritual dimension.

Self Esteem – is defined as the individual’s personal judgments of his/her own worth. It is the key of behavior influences thinking process, emotional desires and values and goals.

Assessment I collect information and examine the client through two ways. Subjective Data In subjective data the client tells me about his health. He says that “he is not feeling comfortable due to the repeated admission for Diabetic mellitus. Objective Data In objective data, I observe and examine the client carefully and consciously. I look the 50 years old client lying on the bed and looking:    Lethargic. Sunken eyes. Irritable in condition.

Florence Nightingale 112         Worried. Restlessness. General weakness. Sleeplessness. Depression/Anxiety. Pus discharge from the wound having foul spell from septic wound. Swelling on wound area. Fatigue

His vital signs are:       Blood Pressure Temperature Pulse Respiratory Rate Weight Hb 150/95 mmHg. 99.6°F 92 per min. 22 per min 60 Kg 8.8 gm/dl

The following investigations were performed.      CP. RBS Foot X-ray. Urine for ketone. Electrolytes.

Acceptable Nursing Diagnosis   Health-seeking behaviors. Ineffective management of therapeutic regimen.

Florence Nightingale 113     Ineffective family management of therapeutic regimen. Altered health maintenance. Risk of infection. Anxiety related to repeated hospitalization.

Nursing Diagnosis Anxiety related to repeated hospitalization due to secondary disease process. Expected Outcome  The client will cope up with anxiety within 4-5 days.

Nursing Interventions and Rationales Interventions       Reassure the client To encourage for the hygienic care. Change wound dressing daily.    Rationales To build up the trust and confidence. To improve the client’s health status. To prevent the secondary infection. To maintain the requirement of the body. nutritional

To encourage the high protein diet,  and high caloric low fat diet. To give the diversion therapy 

For mentally satisfaction of the client. Because due to sharing of feelings the client has be maintained a good health. For mentally relaxation. To maintain health and prevent infection.

Allow the family as individual and as  group to show their feelings. To provide safe environment. 

 

To educate client about the self  hygienic care.

Evaluation   The client has verbalized that, I feel comfortable and relax. The client has verbalized that he had planned for a regular exercise program to maintain his health status.

Florence Nightingale 114 I looked the client’s condition and assessed that the client is looking very happy and comfortable and achieve my desired goal within target period. Summary The Dorothy Orem theory offers way of conceptualizing a disciple in clear exploit terms that can be communicated to others because opinions about the nature an structure of nursing vary, this theory continue to be developed. Her theory consists of four major concepts vary in accordance with personal philosophy. Scientific orientation, experience in affected the nursing profession and how the nurses developed and enhance their profession. Her model of self care has goal of consistency for the person and speaks to the concept of self care is the person own action that has pattern and sequence and when effectively informed contribute to the way he or she developed and function. In terms of environment, she emphasize on self care need consisting of physical and psychosocial components, which influence on an individual self care.

Florence Nightingale 115 References  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  www.yahoo.com.dorothy orem theory.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Jean Watson Theory Advance Concept in Nursing I Khar-un-nisa Mrs. Ruth K. Alam Date:

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Jean Watson
PhD, RN, AHN-BC, FAAN

Florence Nightingale 118 Theory is a group of concept that forms a patter of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Jean Watson’s Caring Theory is a human to human process of caring. The Theory of Human Caring was developed between 1975-1979, while engaged in teaching at the University of Colorado; it emerged from my own views of nursing, combined and informed by my doctoral studies in educational-clinical and social psychology. It was my initial attempt to bring meaning and focus to nursing as an emerging discipline and distinct health profession with its own unique values, knowledge and practices, with its own ethic and mission to society. The work also was influenced by my involvement with an integrated academic nursing curriculum and efforts to find common meaning and order to nursing that transcended settings, populations, specialty, subspecialty areas, and so forth. From emerging perspective, Jean Watson tried to make explicit nursing's values, knowledge, and practices of human caring that are geared toward subjective inner healing processes and the life world of the experiencing person, requiring unique caring-healing arts and a framework called "curative factors," which complemented conventional medicine, but stood in stark contrast to "curative factors." At the same time, this emerging philosophy and theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and its public. Jean Watson’s caring model or theory can also be considered a philosophical and moral/ethical four for professional nursing and part of the central focus for nursing at the disciplinary level, model or caring includes a call for both art and science.

Florence Nightingale 119 Curative factors include the following original work:         Formation of a Humanistic-altruistic system of values. Instillation of faith-hope. Cultivation of sensitivity to one's self and to others. Development of a helping-trusting, human caring relationship. Promotion and acceptance of the expression of positive and negative feelings. Systematic use of a creative problem-solving caring process. Promotion of transpersonal teaching-learning. Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment.   Assistance with gratification of human needs; Allowance for existential-phenomenological-spiritual forces. Major theme of Jean Watson’s Theory is “The Human to Human Process of Caring”. Person She defined person as, “A living constantly growing totality comprising mind, body, emotion and soul.” She viewed person/client as greater than and different from the sum of the parts and to be valued, cared for, respected, nurtured, understood, and assisted. The individuality of each person is important. According to Watson’s assumptions of caring:  Human caring in nursing is not just an emotion, concern, attitude, or benevolent desire. Caring connotes a personal response.    Caring is an intersubjective human process and is the moral ideal of nursing. Caring can be effectively demonstrated only interpersonally. Effective caring promotes health and individual or family growth.

Florence Nightingale120   Caring promotes health more than does curing. Caring responses accept a person not only as they are now, but also for what the person may become.  Caring occasions involve action and choice by nurse and client. If the caring occasion is transpersonal, the limits of openness expand, as do human capacities.  The most abstract characteristic of a caring person is that the person is somehow responsive to another person as a unique individual, perceives the other’s feelings, and sets one person apart from another.  Human caring involves values, a will and a commitment to care, knowledge, caring actions, and consequences.  The ideal and value of caring is a starting point, a stance, and an attitude that has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete acts. Environment According to Jean Watson, it is “the external reality of the person. Environment encompasses social, cultural, and spiritual aspects and all the influences of society, which provides value to determine how a person should behave and the goals to strive toward.” A caring environment offers the development of potential while allowing the person to choose the best action for the self at a given point in time. According to Watson’s caring theory, I assess the client according to health perception and health management. Pattern Description Nurses assist individuals, families, and communities who have limited knowledge or understanding of:  Their current health status.

Florence Nightingale121   How to achieve a good health status. How to maintain a good health status. This lack of perception (awareness) leads to problems for the individual or family in the management (control) of their health status. The nursing diagnoses in this pattern result from this lack of perception and management. Pattern Assessment   Review the client’s vital signs. Is the temperature within normal limits? Review the results of the complete blood cell count (CBC). Are the cell counts within normal limits?     Review sensory status. Is the client’s sensory-status within normal limits? Was client and family satisfied with the usual health status? Did the client, family, or community describe the usual health status as good? Had the client, family, or community sought any health care assistance in the past year?      Did the client, or family follow the routine the prescribed? Did the client or family have any accidents or injuries in the past year? Is there a disruption of the flow of energy surrounding the person? Was the client, family, or community able to meet therapeutic needs of all members? Is the client scheduled for surgery, or has he or she recently undergone surgery?

Assessment I collect information and examine the client about the health perception and health management and therefore I collect data in the following two ways.  Subjective Data

Florence Nightingale122 In subjective data the client tells me about his health perception and health management.

Florence Nightingale123  Objective Data In objective data, I observed and examine the client very carefully and consciously. I saw a 46 years old client lying on bed and looking here and there.
• • • • • • •

Very irritable. Looks very anemic. Sleeplessness. Very weak. Depression/Anxiety. Dry skin due to malnutrition. Uncomfortable.

Vital signs:
• • • •

Temperature Pulse Respiration Blood Pressure

99.6°F. 100 per min 22 per min 122/72 mmHg.

Investigations:
• •

Hb Weight

8.8 g/dl 49 Kg

Applicable Nursing Diagnosis  Energy Field Disturbance (A disruption of the flow of energy surrounding a person’s being which results in a disharmony of the body, mind and spirit).  Health Maintenance, Altered (Inability to identify, manage, and/or seek out help to maintain health).

Florence Nightingale124  Health Seeking Behaviors (A state in which an individual in stable health is actively seeking ways to alter personal health habits and/or the environment in order to move toward a higher level of health.  Infection, Risk for (The state in which an individual is at increased risk for being invaded by pathogenic organisms).  Injury, Risk for (A state in which the individual is at risk for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources).  Management of Therapeutic Regiment (Individual), Effective (A pattern of regulating and integrating into daily living a program for treatment of illness and its sequelae that is satisfactory for meeting specific health goals).  Management of Therapeutic Regimen (Individuals, Families, Communities, Ineffective).  Perioperative Positioning Injury, Risk for (A state in which the client is at risk for injury as a result of the environmental conditions found in the perioperative setting).  Protection, Altered (The state in which an individual experiences a decrease in the ability to guard the self from internal or external threats such as illness or injury). Nursing Diagnosis  Health maintenance altered.

Related Clinical Concern      Spiritual distress. Ineffective coping. Altered family process. Activity intolerance or self-care deficit. Powerlessness

Florence Nightingale125   Knowledge deficit. Impaired home maintenance management.

Expected Outcome  The client will describe at least (number) contributing factors that lead to health maintenance alteration and at least one measure to alter each factor by (date).  The client will design a positive health maintenance plan by (date).

Nursing Interventions and Rationales Interventions

Rationales Healthy living habits reduce risk. Assistance is often required to develop long-term change. Identification of the factors significant to the client will provide the foundation for teaching positive health maintenance. Increase client’s sense of control and keeps the idea of multiple changes from being overwhelming.

Assist client to identify factors • contributing to health maintenance alteration through one-to-one interviewing and value clarification strategies.

Develop with the client a list of • assets and deficits as he or she perceives them. From this list, assist the patient in deciding what lifestyle adjustments will be necessary. Identify, with patient, possible • solutions, modifications, etc., to cope with each adjustment. Develop a plan with the client, which • shows both short-term and long-term goals. For each goal specify the time the goal is to be reached. Have client identify at least two • support persons. Arrange for these persons to come to the unit and participate in designing the health maintenance plan.

The more the client is involved with decisions, the higher the probability that the client will incorporate the changes. Avoids overwhelming the client by indicating that not all goals have to be accomplished at the same time. Provides additional support patient in maintaining plan. for

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Interventions

Rationales People most often approach change with more of the same solution. If an individual does not think that the strategy will have to be implemented, he or she will be more inclined to develop creative strategies for change. Placing items in priority according to client’s motivation increases probability of success.

Assist client and significant others to • develop a list of potential strategies that would assist in the development of the lifestyle changes necessary for health maintenance. After the list is developed, review each item with the client, combining and eliminating strategies when appropriate. Develop with the client a list of • benefits and disadvantages of behavior changes. Discuss each item with the client as to the strength of motivation that each item has. Develop a behavior change contract • with the client, allowing the client to identify appropriate rewards and consequences. Remember to establish modest goals and short-term rewards. Note reward schedule here. Teach client appropriate information • to improve health maintenance such as hygiene, diet, medication administration, relaxation techniques, and coping strategies. Review activities of daily living with • client and support person. Incorporate these activities into the design for a health maintenance plan. Assist client and support person to • design a monthly calendar that reflects the daily activities needed to succeed in health maintenance. Have client and support person • return-demonstrate health maintenance procedures at least once a day for at least 3 days before discharge. Times and types of skills should be noted here.

Positive reinforcement enhances selfesteem and supports continuation of desired behaviors. This also promotes client control which in turn increases motivation to implement the plan. Provides the client with the basic knowledge needed to enact the needed changes.

Incorporation of usual personalizes the plan

activities

Provides a visual reminder.

Permits practice in a nonthreatening environment where immediate feedback can be given.

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Interventions

Rationales Provides an opportunity to evaluate and to give the client positive feedback and support for achievements.

Set a time to reassess with the patient • and support person progress toward the established goals. This should be on a frequent schedule initially and can then gradually decrease as the client demonstrates mastery. Note evaluation times here. Communicate the established plan to • the collaborative members of the health care team. Refer client to appropriate • community health agencies for follow-up care. Be sure referral is made at least 3-5 days before discharge.

Provides continuity and consistency in care. Ensures the services can complete their assessment and initiate operations before the client is discharged from the hospital. Use of the network of existing community services provides for effective utilization of resources. Facilitates client’s keeping of appointments and reinforces importance of health maintenance.

Schedule appropriate follow-up • appointments for client before discharge. Notify transportation service and support persons of these appointments. Write appointment on brightly colored card for attention. Include date, time, appropriate name, address, telephone number and name and telephone number of person who will provide transportation.

Evaluation  The client has described at least (number) contributing factors that lead to health maintenance alteration and at least one measure to alter each factor by (date).  The client has designed a positive health maintenance plan by (date).

Florence Nightingale128 Summary According to Jean Watson theory is the theory of the human to human process of caring, which rely on unity and harmony within mind, body and soul of the person and the external reality of the person. Health encompasses a high level of overall physical, mental, and social functioning and nursing combine the research process with the problem-solving approach and is concerned with promoting and restoring health, preventing illness and caring for the sick. Watson’s theory of human caring has received worldwide recognition and is a major force in redefining nursing as a caring-health health model. Therefore according to Watson’s theory, nurses should assist individuals, families, and communities who have limited knowledge or understanding of their current health status, how to achieve a good health status and how to maintain a good health status. The nurse uses a caring process to help the individual achieve an optimal degree of inner harmony to promote self-knowledge, selfhealing, and insight into the meaning of life.

Florence Nightingale129 References  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  Jean Watson and the Theory of Human Caring.1.htm (2006). Watson’s Caring Theory: Theory Evolution.  Jean Watson and the Theory of Human Caring.2.htm (2006). Watson’s Caring Theory: Transpersonal Caring and the Caring Moment Defined.  Jean Watson and the Theory of Human Caring. (2006). Watson’s Caring Theory: implications of Caring Theory.

Florence Nightingale130 Introduction I am studying in Advance Concepts of Nursing, which is related to nursing care concepts make theories and are used in patient’s care. Theories provide a framework which is criteria for sen method for nursing care. My theorist name is “Betty Neuman”. Her major theme is “Provide holistic are and develop health model system.” Betty Neuman was born on a farm in Lowell, Ohio in 1924. Her first nursing education was completed in Peoples Hospital (now named as General Hospital), School of Nursing in Akron, Ohio in 1947. She completed her BS Nursing in 1957 and then MS in Mental Health, Public Health Consultation from UCLA in 1966 and finally PhD in clinical psychology. She began developing health model while a lecture in community health nursing in the University of California. Major Theme of her model is “provide holistic care and develop health model system.” Health is equated with optional stability that is the best possible wellness stale, at any given time. There are ten basic assumptions underlying Neuman’s Conceptual Framework.  Though each individual client or group as a client system is unique, each system is a composite of common known factors or innate characteristics within a normal, given range of response contained within a basic structure.  The particular interrelationships of client variable physiological, psychological, sociocultural-developmental and spiritual at any point in time can affect the degree to which a client is protected by the flexible time of defense against possible reaction to a single stressor or a combination of stressors.  Each individual client/client system, over time, has evolved a normal range of response to the environment that is referred to as a normal line of defense, or usual wellness/stability state.

Florence Nightingale131  When the cushioning accordion like effect of the flexible line of defense is no longer capable of protecting the client system against an environment stressor, the stressor breaks through the normal line of defense.  The client, whether in state of wellness or illness is a dynamic composite of the interrelationships of variables physiological, psychological, sociocultural,

developmental and spiritual wellness is on a continuum of available energy to support the system in its optimal state.  Implicit within each client system is a state of internal resistance factors known as lines of resistance, which function to stabilize and return the client to the usual wellness state (normal line of defense) or possibly to a higher level of stability following an environmental stressor reaction.  Primary prevention relates to general knowledge that is applied in client assessment and intervention in identification and reduction or mitigation of risk factors associated with environmental stressor to prevent possible reaction.  Secondary prevention relates to symptomalogy following a reaction to stressors, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.  Tertiary prevention relates to the adjustive processes taking place as reconstitution begins and maintenance factors move the client back in a circular manner toward primary prevention.  The client is in dynamic constant energy of change with the environment. Betty Neuman began developing her health system model while a lecture in community health nursing at the University of California. Her framework is basically a system model with the major components of stressors, reaction to stressors, and the person. It is also dynamic and can be altered rapidly over a short period of time. Its effectiveness can be

Florence Nightingale132 reduced by such changes as loss of sleep, malnutrition, or any alteration in activities of daily living. The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient Problem’s in Nursing Research”. It was refined and subsequently published in the first edition of conceptual models for nursing practice 1974, and in the second edition in 1980. Health – the assumption of this model can lead one to see wellness as a dynamic composite of physical, psychological, sociocultural developmental and spiritual balance that is, flexible yet retains an unbroken ability to resist disequilibrium. Goal of Nursing – the primary goal of nursing is the retention and attainment of client system stability. The assessment or intervention instrument various aspects of Neuman’s model but is flexible enough to allow for inclusion of any additional data deemed necessary. Factors influencing in use of the instrument would be the client, client situation. In Neuman’s work the in men is accompanied by an explanatory section that includes specific role charts to categorize data, and plan for interventions at all levels. The nurse helps the client through primary,

secondary, and tertiary prevention modes to adjust to environment stressors and maintain client system stability. In later writings, she stated that health is equated with optimal system stability, that is the best possible wellness state. Conclusion Conceptual models are imperative to the development of nursing as a profession. Neuman’s total person approach to health care is one such model. In essence, she presents an approach to viewing the person’s perception of the stressors affecting the part of the whole individuals in constant interaction with the environment. In as much as the model emphasizes to total person it transcends the nursing model to become a health care model, applicable to all health care disciplines. Even though the model is interdisciplinary, it certainly has universal applicability to nursing. One of its greatest strengths is the clear direction it gives for interventions through primary, secondary and tertiary prevention. Nursing theory, nursing

Florence Nightingale133 research and nursing practice, the applicability of the model to all health disciplines could foster a common perspective and thereby fail to point over the distinctive contribution of nursing or any other health disciplines to health care.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Moyra Allen Theory Advance Concept in Nursing I Musarrat Begum Mrs. Ruth K. Alam Date:

Florence Nightingale135 Theory is a group of concept that forms a patter of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Moyra Allen Theory The theory of Moyra Allen is depend on the nature of healthy living, a continuum process of aging, dealing actively with life situations, losing some functional ability cognitive interpersonal physiological, withdrawing from life dying, the family or other social group in which learning is initiated natured and directed, the social context in which learning take place, this may be at home, the workplace, community group, a hospital or a clinic. Major Theme “The nature of healthy living”. According to Moyra Allen, dealing actively with life situation, losing some functional ability cognitive interpersonal physiological withdrawing from life dying. Person According to Moyra Allen theory, the family or other social group in which learning is initiated natured and directed throughout life individuals develop notions of their personal freedom and independence in activities of living. In old age, persons continue to maintain these notions while coping with the phases of the aging process. Elderly persons who become ill are placed in a position of dependency and their reaction to this state varies in view of their past experience and stage of aging. Thus a person still dealing actively with life may exhibit a high degree of dependency is so doing; while another person may demonstrate much autonomy of self in approaching death. In other words, aging is reflected in the varying

Florence Nightingale136 stages of disengagement of the individual from life, and to some extent, independently of this disengagement, individuals perceive their ability to control what happens to them, the decisions they make and the choices or alternatives that are available to them. Environment According to Moyra Allen theory, the social context in which learning take place, this may be at home, the workplace, community group, a hospital or a clinic. In addition to the perception and status of the individual person, the nurse has a method for making decision about a person’s need, areas of autonomy the types and number of choices, etc. Her approach to this problem may be established a prior for the varying phases of aging and disengagement or, on the other hand, she may respond to the individual and assist him to make his perceptions and ideas of living operative for him within the hospital or other community setting. Thus we have differential responses of nursing to aging persons and to their lifestyle. According to this theory, she focused on the cognitive perception of the client. I, therefore also assess the client according to cognitive perception. Pattern Description Rationality, the ability to think, has often been described as the defining attribute of human beings. Thus, the cognitive-perceptual pattern becomes the essential premise for all other patterns used in the practice of nursing. The cognitive-perceptual pattern deals with thought, thought processes and knowledge as well as the way the client acquires and applied knowledge. A major component of the process is “Perceiving”. Perceiving incorporates the interpretation of sensory stimuli. Understanding, how a client thinks, perceives, and incorporates these processes to best adapt and function is paramount in assisting the patient to return to or maintain the best health state possible. Alterations in the process of cognition and perception are an initial step in any assessment.

Florence Nightingale137 Pattern Assessment                 Does ICP fluctuate following a single activity? Does the client have a problem with appropriate response to stimuli? Does the client have a problem with fluctuating levels of consciousness? Does the client indicate difficulty in making choices between options for care? Is the client delaying decision making regarding care options? Has the client been disoriented to person, place, and time for over three months? Can the client respond to simple directions or instructions? Does the client indicate lack of information regarding his or her problem? Can the client restate regimen he or she needs to follow for improved health? Review the mental status examination. Is the client fully alert? Does the client or his or her family indicate that the client has any memory problems? Review sensory examination. Does the client display any sensory problems? Does the client use both sides of body? Does the client verbalize that he or she is experiencing pain? Has the pain been experienced for more than six months? Does the client display any distraction behavior?

Assessment I collect information and examine the client about cognitive perception and collect data in the following two ways.  Subjective Data In subjective data the client tells me about his cognitive perception.  Objective Data

Florence Nightingale138 In objective data, I observed and examine the client very carefully and consciously. I saw a 40 years old client lying on bed and looking here and there. Major Defining Characteristics       Distraction behaves (moaning, crying, restlessness, seeking out other people). Physical significant (signs of distress or tension). Behavior (inappropriate behavior). Orientation (with time, place and person). Memory (memory deficits). Consistent in attention to stimulation.

Applicable Nursing Diagnosis           Adaptive capacity, decreased intercranial. Confusion, acute and chronic. Decisional conflict. Environmental interpretation syndrome, impaired. Knowledge deficit. Memory, impaired. Pain. Sensory-Perceptual alteration. Thought process, altered. Unilateral neglect.

Nursing Diagnosis  Chronic pain Related clinical concerns:

Any surgical diagnosis.

Florence Nightingale139
• • • • •

Any condition labeled chronic, for example rheumatoid arthritis. Any traumatic injury. Any infection. Anxiety or stress Fatigue.

Expected Outcome    The client will verbalize a decrease in pain within 1-2 days. The client will practice selected noninvasive pain relief measures. The client will verbalize an increase in psychological and physiological comfort level and demonstrate ability to cope with anxiety as evidenced by normal vital sign and a verbalize reduction in pain intensity within one week. Nursing Interventions and Rationales Interventions
• • •

Rationales Promotes accurate assessment. Promotes nurse-client relationship. Determines a baseline for further assessment. Acknowledging client’s pain decreases anxiety by communicating acceptance and validating his or her perceptions. Reduces skeletal muscle tension and anxiety, which potentates the perception of pain. Make the client and his family aware of the availability of treatment options. Lack of knowledge and fear may

Establish trusting relationship with • client. Allow the client to talk about • condition. Assess client’s level of pain • determining the intensity at its beast and worst. Listen to client while he or she • discusses the pain, acknowledge the presence of pain. Teach relaxation techniques such as • deep breathing, progressive muscle relaxation, and imagery. Teach client and his family about • treatment approaches (biofeedback, hypnosis, massage therapy, physical therapy, acupuncture and exercise). Teach client about the use of •

Florence Nightingale140 medication for pain relief. Provide accurate information to reduce fear of addiction.

prohibit the client from taken analgesic medications as prescribed. Fatigue increases the perception of pain.

Encourage the client to rest at • intervals during the day.

Evaluation  After practicing relaxation techniques, the client rates his pain as a 2 to 3 on the pain intensity scale.  The client has demonstrated the use of deep breathing and progressive muscles relaxation. Summary The Moyra Allen theory is a social process, a way of living rather than a state of being, and similar in meaning to health behavior. It is something that can be measured and can be modified. A professional response to the person’s nature search for health living and assist people to enhance their problem solving skills in dealing with health matters. Pain may be define as an unpleasant sensory and emotional experience associated with acute or potential tissue damage and whenever, the client says, it is existing, whenever the client says it does. Invasive techniques are interventions used when the noninvasive and pharmacological measures do not provide adequate relief, methods include nerve block, neurosurgery, radiation therapy and acupuncture. According to Moyra Allen aging is reflected in the varying stage of disengagement of the individual from life and to some extent independently of this disengagement individuals perceive their ability to control what happens to them, the decisions they make, and the choices or alternatives that are available to them.

Florence Nightingale141 References  Article published in Nursing Papers (1972). 4(2):23, 33. (National Health Grant Project No. 604-7-667).  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  White, L. (2001). Foundations of Nursing: Caring for the Whole Person. Demar USA.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Jean Watson Theory Advance Concept in Nursing I Nazia Javed Mrs. Ruth K. Alam

Date:

Florence Nightingale143 Theory is a group of concepts that form a pattern of reality. It is a statement that explains or characterizes a process, an occurrence or an event and is based on observed fact but lacks absolute or direct proof. Theory is defined as:   A set of proper argued ideas intended to explain facts or event. It is a statement that purports to account for or characterizes some phenomena. Nursing Theory is any description or explanation the phenomena about nursing and patient care. It is also the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care and practices. The theory of the Jean Watson depends on man living health. Human beings are inseparable interchanging energy unfolding together for greater complexity and diversity and influencing one another’s rhythmic patterns of relating. The Jean Watson Theory is about human caring and also described health, nursing about health and goal of nursing. Health – According to Jean Watson health is “unity and harmony within mind, body and soul of the person encompasses a high level of overall physical, mental and social functioning.” It is a subjective state, one which each person defines. Nursing About Health – According to Jean Watson, the definition of nursing about health is “a human art and science directed towards the protection, enhancement and prevention of human dignity.” Jean Watson also described nursing as:  Human caring in nursing is not just an emotion, concern, attitude, or benevolent desire caring cannot a personal response.    Caring is an intersubject human process and is the moral ideal of nursing. Caring can be effectively demonstrated only interpersonally. Effective caring promotes health and individual or family growth.

Florence Nightingale144   Caring promotes health more than does caring. Caring responses accept a person not only as they are now, but also for what the person may become.  A caring environment offers the development of potential while allowing the person to choose the best action for the self at a given point in time.  Caring, occasions involve action and choice by nurse and client. If the caring occasion is transpersonal, the limit of openness expands, as do human capacities.  The most abstract characteristics of a caring is that the person is somehow responsive to another person as a unique individual, perceives the other’s feelings and sets one person apart from another.  Human caring involves values, a will and a commitment to care, knowledge caring action and consequences.  The ideal and value of caring is a starting point, a stance, and an attitude that has to become a will, an intention, a commitment and a conscious judgment that manifests itself in concrete acts. According to the theory of Jean Watson, the goal of nursing, are to help people, gain more self knowledge, self control and readiness for self healing regardless of the external health condition. Nursing intervention related to human care referred to as “curative factor” a guide Watson refers to as the “core of nursing”. Watson outlined the following ten factors.      Forming a humanistic altruistic system of values. Instilling faith and hope. Cultivating sensitivity to one’s self and others. Developing a helping trust (human care) relationship. Promoting and accepting the expression of positive and negative feeling.

Florence Nightingale145    Systematically using the scientific problem-solving method for decision making. Promoting interpersonal teaching – learning. Providing a supportive, protective or corrective mental, physical, sociocultural, and spiritual environment.   Assisting with the gratification of human needs. Allowing for existential – phenomenologic forces. Watson's theory of human caring has received worldwide recognition and is a major force in redefining nursing as a caring-healing health model. Functional Health Pattern – the nursing care plan that is very much interrelated to this theory. The best and suitable pattern is the health perception/health management, because in this theory life and if he/she knows about health perception/health management, I think he/she maintains the good health. Good health is a part of our life and it our health is not good or healthy, we cannot do anything. So according to this theory health perception and health management of the patient/client is very important and I assess the client. Nursing Care Plan According to this pattern: Assessment - I collect information and examine the patient about health status and also assess the client thought two ways: subjective data and objective data. Subjective Data In subjective data the client tells me about his health. He tells me, he is not feeling comfortable and having weekness since last one month. Objective Data In objective data I observe and examine the client very carefully and consciously. I look the 30 years old male patient lying on bed and looking:

Florence Nightingale146         Worried Non cooperative Disturb nutrition pattern Nausea and vomiting Lack of self-confidence Irritability Angry out bursts Crying

Vital Sign     Temperature: Blood Pressure: Pulse rate: Respiration rate: 98 °F 110/70 mmHg 98 per min 22 per min

Investigations   Haemoglobin: Weight: 7.8 g/dl 50kg

Nursing Diagnosis Health maintenance altered due to anxiety secondary to disease process. Expected Outcome The client will relate improvement of health maintenance within 7-10 days.   Decrease level of anxiety within 7 days. The person will be increase psychological and physiologic comfort.

Florence Nightingale147

Interventions

Rationales

Assess the client to identity the level of These actions help the client. anxiety. Help the client to coping pattern and their Identify usual coping mechanism. effectiveness. Provide reassurance and comfort. Try to Decrease the sense of aloneness. stay with the client Decrease sensory stimulation. Excessive stimulation may increase the client anxiety.

Provide privacy and assist the client to Client will feel more easier to express express feelings. in supportive environment. Support the client to expressing feeling of Provide accurate grief or anger, reduce to change body reduce anxiety. image. Convey a understanding. sense of information and

empathic Touch and allow crying decrease the sense of aloneness. Gain confidence.

Establish the trusting relationship.

Allow the family as individual’s and as a Due to sharing of feelings, the client group to share their feelings. can maintain good health. Evaluation The patient verbalized that I am relax and reduce anxiety. I look the patient condition and arsers that I achieve my goal and patient is comfortable better then before. Patient anxiety has relieve and facial expression showed taking food and asleep very comfortable .He is very relaxed and free from anxiety Applicable Nursing Diagnosis  Energy filled disturbance. A disruption, the flow energy surrounding a person, which results in disharmony of the body, mind and spirit.

Florence Nightingale148  Health maintenance altered Inabilities to identify manage and seek out help to maintain health.  Health seeking behavior A state in which individual in stable health is actively seeking way to alter personal health habits in order to move toward a higher of health.  Infection risk for The state in which an individual is at increased risk for being invaded by pathoyenic organisms.  Injury risk for A state in which the individual is at risk for injury as a result of environment condition.  Management of therapeutic regimen A pattern of regulating and integrating into daily living a program for treatment of illness.  Preoperative positioning injury risk for A state in which the client is at risk for injury, as a result of the environmental condition found in the preoperative setting.  Protection altered The state in which an individual experience a decrease in the ability to guard the self from internal or external threats.

Florence Nightingale149 References  Barbara, Kozier Glenora Erb Audrey, Jean and Karen Burke. Fundamental of Nursing 6th Edition. Pp. 39 to 44.  Lynda Suall Carpenito- Moyet. Nursing diagnosis. 10th edition.

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Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-I, Session 2006-2008 Madeleine Leininger Theory Advance Concept of Nursing Naheed Jamal Mrs. Ruth K. Alam Dated: _____________

Florence Nightingale151 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Madeleine Leininger Theory is a development and current status of transcultural nursing. In 1970, she observed that one of authropology’s most important contributions to nursing is, “the realization that health and illness status are strongly influenced and often primarily determined by the cultural background of an individual”. Madeleine described the major theme, the person and the environment. Major Theme – A major aim of transcultural nursing is to understand and assist diverse cultural groups and members of such groups with their nursing and health care needs. A through assessment of the cultured aspects of a client’s lifestyle, health beliefs and health practices will enhance the nurse’s decision making and judgment when providing care. Nursing interventions that are culturally relevant and sensitive to the needs of the client decrease the possibility of stress or conflict arising from cultural misunderstandings. Person – Often problems occur when persons from two cultural backgrounds with conflicting values meet unless at least one person is willing and able to recognize and adapt to the values of the other. One method for reducing potential misunderstandings is to sensitize nurses to their own cultural biases and behaviors as well as to those of their clients. Both the process of sensitization and the result more sensitive and effective nursing care, are the concerns of transcultural nursing. Environment – A conceptual framework in the environment of transculture clarifies what is important to the development of theory in transcultural nursing. As the model shows

Florence Nightingale152 all four concepts must be interrelated to produce transcultural nursing knowledge because the focus in transcultural nursing is on the cultural dimension of care, each concept is approached from his perspective. When nurses understand the four central concepts involved, which are environment, health, people and nursing, they can provide effective transcultural nursing care to clients. Transcultural nursing care also be provided to childbearing women and her family, children and adolescents and middle age adults. Model for Components in Transcultural Nursing Environmental/Culture Physical Social Symbolic
People Cultural variations Biological variations Health/illness behaviors

Theory TRANSCULTURAL NURSING Education Practice Health Major belief paradigms Art and practices of healing Health care system Research Nursing The professional nurse Nurse-client interactions (cultural encounters) Nursing care concepts Nursing care practices Nurse/provider culture

According to this theory, Madeleine focused on the value and belief of the client and I assess the client according to value and belief pattern. Assessment I collect information and examine the client about value and belief related the transculture. I assess the client through two ways.

Florence Nightingale153 Subjective Data In subjective data the client tells me about his culture. He tells me his values and beliefs are very strong about his culture. Objective Data In objective data, I observe and examine the client carefully and consciously. I look the 30 years old patient lying on the bed and looking:      Lethargic. Express anger towards God. Verbalizes inner concern about beliefs. Separation from religious or cultural ties. Challenged beliefs and values system. For example, due to moral or ethical implications of therapy due to intense suffering. Nursing Diagnosis Spiritual distress (distress of the human spirit). Expected Outcome Because of the largely subconscious nature of spiritual beliefs and values, it is recommended that the target data be at least 5 days from the data of diagnosis. Interventions Rationales

Assist patient to identify and define his Clarifies values and beliefs and helps or her values, particularly in relation to patient understand the impact of values health and illness, through the use of and beliefs on health and illness. value clarification, rank-ordering exercises, and completion of health values scales. Demonstrate respect for and acceptance of the patient’s value and spiritual system by not judging, moralizing, arguing, or advising changes in values or religious practices. Spiritual values and beliefs are highly personal. A nurse’s attitude can positively or negatively influence the therapeutic relationship.

Florence Nightingale154

Interventions

Rationales

Adapt nursing therapeutics as necessary Maintains and respects patient’s to incorporate values and religious preferences during hospitalization. beliefs, e.g., diet, administration of blood or blood products, or rituals. Schedule appropriate rituals as necessary, Provides comfort for patient. e.g., baptism, confession, or communion. Arrange visits from needed support Promotes comfort and reduces anxiety. persons, e.g., pastor, rabbi, priest, or prayer group, as needed Provide privacy for religious practices Allows for expression of religious and rituals as necessary. practices. Encourage family to bring significant Promotes comfort. symbols to patient. Plan to spend at least 15 min twice a day Promotes mutual sharing and builds a at (times) with patient to allow trusting relationship. verbalization, questioning, counseling, and support on a one-to-one basis. Assist patient to develop problem-solving Involves patient in self-management behavior through practice of problem- activities. Increases motivation. solving techniques at least twice daily at (times) during hospitalization. Evaluation The client verbalize that he feels more comfortable spiritually. According to Madeleine Leininger theory, transcultural nursing is a humanistic and scientific area of formal study and practice in nursing which is focused upon differences and similarities among cultures with respect to human care, health and illness based upon the people’s cultural values, beliefs, and practices and to use this knowledge to provide cultural specific nursing care to people. Nurses, who have more direct interactions with clients than any other health team member, should be especially aware of the cultural aspects of nursing care. Application of transcultural nursing principles can lead to more effective and sensitive encounters between clients and nurses.

Florence Nightingale155 Conclusion It is concluded that concept of transculture facilitate nursing care that is culturally relevant and help nurses work more effectively with clients from different cultures. Nurses, who have more direct interactions with clients than any other health team member, should be especially aware of the cultural aspects of nursing care. A major aim of transcultural nursing is to understand and assist diverse cultural groups and members of such groups with their nursing and health care needs. The development of the theory of transcultural nursing can be traced to the work of early leaders in the field, who were interested in applying concepts, primarily from anthropology, to nursing care. Several themes emerge from this definition. First, cultures can be compared and contrasted with respect to health beliefs, health behaviors, and nursing care measures. Second, the goal of such study is to identify, test, refine, and apply such knowledge to the provision of culturally relevant care. Third, the outcome of such study is a body of knowledge useful to the practicing nurse. Fourth is the idea that this body of knowledge defines transcultural nursing.

Florence Nightingale156 References

Cox, H.C. et al. Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition.

www.cultrediversity.org/basic.htm. The Basic Concepts of Transcultural Nursing. Retrieved on November 18, 2007.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Margrate Campbell Theory Advance Concept in Nursing I Romana Javed Mrs. Ruth K. Alam Date:

Florence Nightingale158 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Margrate Campbell Theory The UBC model for nursing was developed in 1972, which takes the position that individual behavior is motivated by basic that universal human needs, even though we may have dramatically diverse individualized goals that we aim for within these needs. Major Theme Margrate Campbell’s theory major theme is “The person as a behavioral system with interacting and interdependent subsystem each is representing a basic human need.” Margarate Campbell’s U.B.C. Model of Nursing The U.B.C Model of Nursing conceives of individual systems composed of nine subsystems or, one together represents the whole. The main prime systems theory that are, critical for our purpose while all of the parts interact to make a whole understand parts “as if” they were separate in step in learning how to understand whole system their complexity. The model tells us that there is no “random” behavior in the behavior of people can be understood, when people act in a manner that seems counter productive, they are doing so for the purpose of attempting to meet one or more of their needs. In the UBC model, the system is made up of subsystems, each of which represents one of need. The names assigned to reflect the need they represent and are:

Florence Nightingale159 Need and Goal of Nine Subsystems Subsystem Achieving Affective Ego-Valuative Excretory Ingestive Protective Reparative Respiratory Satiative Need (Universal) Mastery Goal (Individualized) Feelings of accomplishment; satisfaction with accomplishments

Love, belongingness and Feelings of love, belongingness dependence and dependence Self respect Self esteem

Collection and removal of Absence of accumulated wastes accumulated wastes Intake of food and fluid; Nourishment; satisfaction nourishment hunger and thirst. Safety and security Integrity of the system. of

Balance between production Capacity for activity. and utilization of energy Intake of oxygen Stimulation of the system’s Oxygenation; easy respirations. Sensory satisfaction senses.

The subsystems of U.B.C. Model of Nursing also coincide with the Maslow’s Hierarchy of needs model, which is as under:

Self-actualization Esteem Love Maslow’s Sex Food Air Safety Activity Self-esteem Belonging Security Exploration Closeness Protection Manipulation Rest Novelty Pain avoidance

Temperature

Elimination

Hierarchy of Needs Model

Florence Nightingale160 Health According to Margrate Campbell, “Optimal health is the highest level of behavioral system stability perceived by an individual as achievable at any given time”. The behaviors or the range of the behaviors that an access to in order to meet a particular need in the subsystem structure. The philosophy of basic human needs tells us that the need produce and continual striving towards meeting them. In general people repertoire of coping behaviors from which in order to maintain meeting their need such breathing to meet the basic needs for oxygen make predictable adaptations to meet need changing circumstances. The questions of when nurses should or should not involve themselves with an individual as client have become increasingly more complex with time. Decades ago, sick people needed nurses, well people did not. More recently nursing considered its mandate as clients who were hospitalized. Definition of Nursing According to Margrate Campbell, “The nurturing of individuals experiencing critical periods in the life cycle, so that they may develop and use a range of coping behaviors that prevent them to satisfy their basic human needs, to achieve stability and to reach optimal health”. Margrate Campbell’s subsystem structure includes the inner need, abilities and coping behaviors, as well as psychological environment, with the individualized goals and forces some understanding of all important for the nurse to understand client as a behavioral system. Goal of Nursing In the context, Margrate Campbell stated that, “To nurture the behavioral system that is the person.” As the Margrate Campbell’s theory focused on the basic needs of human i.e., nutrition, I therefore, decided to study a case having nutritional imbalance less than body requirement.

Florence Nightingale161 Applicable Nursing Diagnosis       Adjustment impaired. Coping ineffective individual. Altered nutrition (less than body requirements) Fluid volume deficit. Impaired skin integrity. Post trauma syndrome.

Assessment I assess the client carefully and collect information. I examine the client though the following two ways.  Subjective Data The client tells about her nutritional status. She is eating less with less intake of water, resulting loss of weight from the last six months.  Objective Data A 50 years old woman lying on bed in restless condition with:
• • • • •

Lethargic. Fatigue. Pale. Sleeplessness. Sunken eyes. Her vital signs are:

• • •

Blood Pressure Temperature Pulse

100/80 mmHg 98°F 90 per min.

Florence Nightingale162

Respiratory rate

20 per min.

Investigation performed includes:
• •

CBC LFT’s

Nursing Diagnosis Nutrition imbalance, less than body requirement related to decrease desire of eat. Expected Outcome The client will be take daily requirement of diet and also increase desire of eat within 2-3 days. Nursing Interventions and Rationales Interventions
• • •

Rationales
• •

Reassure the client Determine daily calorie requirement.

To build trust and confidence. To improve health status. To give knowledge about nutrition. To increase interest in eating food. To give psychological support. To increase desire of eating. To give nourishment. To change taste. To provide energy.

Explain the importance of adequate • nutrition. Make diet menu and ask about • favorite dishes of client. Provide pleasant atmosphere and relaxed •

• •

Teach good oral hygiene

Offered frequent small feeding (six • per day plus snacks) Teach the client to use spices to help • improve the taste and aroma of food. Give medicine to improve desire of • eat as prescribed.

Evaluation  The client has expressed desired of eat food.

Florence Nightingale163  The client has gained weight and made plan to use balance diet.

Summary The philosophy of basic human needs tells us that the need produce and continual striving towards meeting them. In general people repertoire of coping behaviors from which in order to maintain meeting their need such breathing to meet the basic needs for oxygen make predictable adaptations to meet need changing circumstances. Margrate Campbell’s subsystem structure includes the inner need, abilities and coping behaviors, as well as psychological environment, with the individualized goals and forces some understanding of all important for the nurse to understand client as a behavioral system. Her model “The UBC Model for Nursing” is a mechanism for the development and refinement of systematic thinking in nursing at the same time as it orients the nurse towards some rather than complex and abstract values about clients and nursing. It creates a means by which holistic interpretation can be developed, individual meaning understood, and context specific plans created by encouraging a systematic, holistic clinical reasoning process. It aims to provide the beginning nurse with coherent intellectual directions and the more experienced nurse with a strong logical structure on which to defend and articulate skilled nursing judgments.

Florence Nightingale164 References  Bigge, M.L. (1971). What is Field Psychology in Learning Theories for Teachers. 2nd Edition. Harpes and Row New York.   Campbell, M.A. (1987). The UBC Model for Nursing Direction for Practice . Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  http://216.109.125.130/search/cache.p=margaret Campbell UBC model of nursing. Need and Goal of Nine Subsystems.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Hildegarde Peplau Theory Advance Concept in Nursing I Sharifa Bibi Mrs. Ruth K. Alam Date:

Florence Nightingale166 Theory is a group of concept that forms a patter of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Hildegarde Peplau Theory Hildegarde Peplau (1952), widely regarded as a pioneer among contemporary nursing theorists and herself a psychiatric nurse, defined nursing in interpersonal terms: “Nursing is a significant, therapeutic, interpersonal process, Nursing is an educative instrument that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal and community living”. She reinforced the idea of the client as an active collaborator in his own care. Major Theme Hildegrade Pepalu major theme is "Psychodynamic Nursing - Interpersonal process within the Nurse-Patient Relationship”. Peplau's training in mental health evident in her work. Her theory is not useful if patient unable to interact. Focuses only on individuals; not communities or groups Person A self-system of biochemical, physical, and psychological characteristics and needs (with emphasis on the psychological). It is defined as an individual organism who lives in an unstable equilibrium. Peplau's model describes the individual as a system comprising the components of the physiological, psychological and social spheres. The model views the individual as being an unstable system where equilibrium is a desirable state, but occurs only through death. This is supported by Peplau's statement that "man is an organism that lives in

Florence Nightingale167 an unstable equilibrium (i.e., physiological, psychological, and social fluidity) and life is the process of striving in the direction of stable equilibrium, i.e., a fixed pattern that is never reached except in death". Environment Within the concept of the environment, Peplau's Interpersonal Relations Model sharply differs from other models pertaining to nursing. The model views the environment as being and occurring in the context of the nurse client relationship. The interpersonal focus of the model on this relationship is unique as it examines not only the client, but also the selfreflection of the nurse in the context of the ongoing relationship between the nurse and the client. This interpersonal relationship between the nurse and the client as described by Peplau has four clearly discernible phases. These phases are orientation, identification, exploitation and resolution. Each of these phases are seen as being interlocking and requiring overlapping roles and functions as the nurse and the client learn to work together to resolve difficulties in relation to health problems. During the orientation phase of the relationship, the client and nurse come together as strangers meeting for the first time. During this phase, the development of trust and empowerment of the client are primary considerations. An essential component during orientation as described by Peplau is "The patient needs to recognize and understand his difficulty and the extent of need for help". This is best achieved by encouraging the client to participate in identifying the problem and allowing the client to be an active participant in what is of concern to them. Peplau stated that "such orientation is essential to full participation and to full integration of the illness event into the stream of life experiences of the patient". The client, by asking for and receiving help, will feel more at ease expressing their needs knowing that the nurse will take care of those needs. Once orientation has been accomplished, the relationship is ready to enter the next phase.

Florence Nightingale168 During the identification phase of the relationship, the client in partnership with the nurse, identify problems that require working on within the relationship. At this stage, the client will selectively respond to a nurse that seems to offer the kind of help needed by the client. Once the client has identified the nurse as a person willing and able to provide the necessary help, the main problem and other related sub-problems can then be worked on, in the context of the nurse client relationship. Throughout the identification phase, both the nurse and the client must clarify each other's perceptions and expectations. The perceptions and expectations of the nurse and the client will affect the ability of both to identify problems and the necessary solutions. When clarity of perceptions and expectations is achieved, the client will learn how to make use of the nurse client relationship. In turn, the nurse, will make full use of their professional education to assist the client in achieving full use of the relationship. Once identification has occurred, the relationship enters the next phase. During the phase of exploitation, the client takes full advantage of all available services. The degree to which these services are used is based upon the needs and the interest of the client. During this time, the client begins to feel like an integral part of the helping environment and starts to take control of the situation by using the help available from the services offered. Within this phase, clients begin to develop responsibility and become more independent. From this sense of self-determination, clients develop an inner strength that allows them to face new challenges. This is best described by Peplau who stated that "Exploiting what a situation offers gives rise to new differentiation's of the problem and to the development and improvement of skill in interpersonal relations". It's important to note that although the nurse client relationship may predominately be more in one phase, all phases can be seen in every interaction between the nurse and the client. As the relationship passes through all of the aforementioned phases and the needs of the client have been met, the relationship passes to closure or the phase of resolution.

Florence Nightingale169 Resolution occurs when all of the needs of the client are met. Peplau states "the stage of resolution implies the gradual freeing from identification with helping persons and the generation and strengthening of ability to stand more or less alone". Applicable Nursing Diagnosis           Caregiver role strain. Role performance, ineffective. Family coping, readiness for enhanced Disabled family coping. Decisional conflict. Anxiety Family process interrupted. Coping, ineffective community. Coping, ineffective individual. Parenting, impaired.

Assessment I assess the client according to the role relationship pattern. I collect information and examine the client though the following two ways.  Subjective Data According to the client, he was alright before fracture of femur. He developed fever and hospitalized for last three months. Being head of the family, he is having tension/stress of his family responsibilities for daily living and who is taking care of them. Therefore, presently, he is total unaware about what is his role in his family being a father.  Objective Data

Florence Nightingale170 A 40 years old man lying on bed in restless condition, with:
• • • •

Weakness. Fatigue. Anxiety. Pale skin. His vital signs are:

• • •

Temperature Pulse Blood Pressure

98.4°F. 100 per minute. 120/80 mmHg.

Nursing Diagnosis Parental role conflict related to illness (Fracture femur). Expected Outcome The client will:
• •

Verbalize the role of being parent in the family at end of my shift. Develop broad minded sense for his parental role in his family.

Nursing Interventions and Rationales Interventions
• •

Rationales
• •

Reassure the client. Relaxing to helping the client.

To relieve anxiety of the client. To reduce anxiety. client’s tension and

Encourage the client to take caregiver • role by active listening and reflection Discuss the expectations and the role • conflict. Encourage the client to think deeply • usually in silence in order to relax.

To give moral and psychological support to the client. To clear the role ambiguity and understanding of role. To provide relaxation to the client so that he or she can think about actual problem with less tension and anxiety.

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Facilitate the client for charm and • quite. Encourage positively. the client to think •

To relieve fatigue and feel fresh. To reduce ambiguity and tension. Family can provide mental and psychological support.

Develop the faith over good and • improve mutual understanding with family.

Evaluation   The client has verbalized the role of being parent in the family. The client has developed broad minded sense for his parental role in his family after discharge. Summary According to Hildegarde Peplau Theory, defined nursing in interpersonal terms: “Nursing is a significant, therapeutic, interpersonal process, Nursing is an educative instrument that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal and community living”. Peplau's training in mental health evident in her work. Her theory is not useful if patient unable to interact. Peplau's model describes the individual as a system comprising the components of the physiological, psychological and social spheres. The model views the individual as being an unstable system where equilibrium is a desirable state, but occurs only through death. Peplau's Interpersonal Relations Model views the environment as being and occurring in the context of the nurse client relationship. The interpersonal focus of the model on this relationship is unique as it examines not only the client, but also the self-reflection of the nurse in the context of the ongoing relationship between the nurse and the client. This interpersonal relationship between the nurse and the client as described by Peplau has four clearly discernible phases. These phases are orientation, identification, exploitation and

Florence Nightingale172 resolution. Each of these phases are seen as being interlocking and requiring overlapping roles and functions as the nurse and the client learn to work together to resolve difficulties in relation to health problems.

Florence Nightingale173 References  Chitty, K.K. (1993). Professional Nursing: Concepts and Challenges. W.B. Saunders Co. Philadelphia.  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  wps.prenhall.com/…/0,11275,2665105-2665118,00.html. Interpersonal Relations in Nursing.  http://www.hsc.dlsu.edu.ph/cnm/lectures/nsg%20theories .doc Peplau, H.E. (1992).

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Sister Callista Roy Theory Advance Concept in Nursing I Shamim Lawrence Mrs. Ruth K. Alam Date:

Florence Nightingale175 Theory is a group of concept that forms a patter of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Sister Callista Roy Sister Callista Roy is a highly respected nurse theorist, writer, lecturer, researcher and teacher who currently hold a position of Professor and Nurse Theorist at the Boston College School of Nursing in Chestnut Hill, MA. She teaches courses on epistemology of nursing and strategies for creating knowledge at the master's and doctoral levels, as well as directing doctoral dissertation research. Her current scholarly interests include research involving families in the cognitive recovery of patients with mild head injury and nurse coaching as an intervention for patients after ambulatory surgery. In addition, she is also interested in conceptualizing and measuring coping, developing the philosophical basis of adaptation nursing including the distinction between veritivity and relativity, and in group projects on emerging nursing knowledge and practice outcomes. Sister Callista Roy Theory The major concepts of Sister Callista Roy’s theory are the person or group as an adaptive system; the environment as internal and external stimuli; health as being and becoming whole and integrated; and nursing as the art and science of promoting adaptation. The philosophic and scientific assumptions are basic underlying concepts. The model aims to direct nursing practice, research and education. The widespread us of the model in each of these areas is well documented, for example, in all areas of practice, all levels of education, and in quantitative and qualitative research. According to Sr. Callista Roy, "The model

Florence Nightingale176 provides a way of thinking about people and their environment that is useful in any setting. It helps one prioritize care and challenges the nurse to move the patient from survival to transformation." Major Theme The major theme of Dr. Roy’s theory is “Adaptation”. Adaptive Modes of Sister Callista Roy

Florence Nightingale177 Adaptive Modes Individual Group

Five needs-oxygenation, nutrition, elimination, activity and rest, Operating resources: participrotection. Four complex processesPhysiologic-physical pants, capacities, physical senses; fluid, electrolyte, and acid-base facilities, and fiscal resources balance; neurologic function; endocrine function Need is group identity integrity through shared relations, goals, Need is psychic and spiritual integrity values, and coresponsibility for Self-concept-group so that one can be or exist with a sense goal achievement; implies identity of unity, meaning, and purposefulness honest, soundness, and in the universe completeness of identifications with the group Need is role clarity, Need is social integrity; knowing who understanding and committing one is in relation to others so one can to fulfill expected tasks so acct; role set is the complex of group can achieve common Role function positions individual holds; involves goals; process of integrating role development, instrumental and roles in managing different roles expressive behaviors, and role taking and their expectations; process complementary roles are regulated Need is to achieve relational integrity using processes of Need is to achieve relational integrity developmental and resource using process of affectional adequacy, adequacy, i.e., learning and Interdependence i.e., the giving and receiving of love, maturing in relationships and respect, and value through effective achieving needs for food, relations and communication shelter, health, and security through independence with others As the discipline of nursing grew in articulating its scientific and philosophical assumptions, Dr. Roy also articulated her assumptions. Early descriptions included systems theory and adaptation-level theory, as well as humanist values. Later Dr. Roy developed the philosophical assumption of veritivity as a way of addressing the limitations she saw in the relativistic philosophical basis of other conceptual approaches to nursing and a limited view of secular humanism. Health Health: a state and process of being and becoming integrated and whole that reflects person and environmental mutuality. It has a number of meanings depending on the purpose,

Florence Nightingale178 time or circumstances governing its use. Dr. Roy defined health as “Health is a function of the degree of change and the state of the person experiencing the change”. It is an ideal state or exuberant well-being, ability to fulfill social roles or to contain or limit symptoms and a strong sense of coherence. There are no universal norms of health perceptions vary across individuals and cultures. Health is viewed as a formal wholeness or completeness which continually changes. Definition of Nursing According to Dr. Roy, “Nursing is the science and practice of promoting adaptation in individuals, or groups in order to help them achieve health”. Thus nursing is the science and practice that expands adaptive abilities and enhances person and environment transformation. Goal of Nursing According to Dr. Roy, goal of nursing is “to assist the patient to achieve a higher level of wellness”. 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. 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 person’s adaptive behaviors. Stimuli are classified as: 1) Focal- those most immediately

Florence Nightingale179 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. Assessment I collect information about health perception and health management and therefore collect data in the following two ways.

Florence Nightingale180 Subjective data In subjective data the client tells me about her health perception and management of her health in daily life. Objective data In objective data, I observe and examine the client carefully and consciously. I saw a 40 years client lying on the bed. She is looking:     Very irritable. Anemic. Sleeplessness. Weak.

Acceptable Nursing Diagnosis             Temperature change (warmth, coolness) Visual change (image and color) Health Maintenance, Altered (Inability to identify or manage) Distribution of the field (vacant, hold, spike) Movement (wave, spike, tingling, dense) Sound (Tone, words) Insomnia Chronic fatigue syndrome Pain Sensory-Perceptual alteration. Thought process, altered. Unilateral neglect.

Nursing Diagnosis

Florence Nightingale181  Health maintenance altered.

Florence Nightingale182 Nursing interventions and rationales Interventions   Establish trusting a relationship  with client. Allow client condition. to talk about  Rationales Promotes accurate assessment. Promote nurse and client relation Ship.

Assess energy field

Alterations, variations or symmetry in the energy field is deducted through assessment Increase client’s sense of control and keeps the idea of multiple changes from being overwhelming.

Develop with the client a list of • assets and deficits as he or she perceives them. From this list, assist the patient in deciding what lifestyle adjustments will be necessary. Teach client appropriate • information to improve health maintenance such as hygiene, diet, medication administration, relaxation techniques, and coping strategies. Be sensitive to any image that  come to mind words, symbols, pictures colors, sounds, mood emotions etc. Allow the family as individual’s  and as a group to share their feelings. Redirect area of accumulated  energy, Reestablish the energy flow and direct Energy to depleted area. Repattern or Rebalance clients energy field Do therapeutic touch for no longer  than 10 minutes.

Provides the client with the basic knowledge needed to enact the needed changes.

There may be a loss of energy, disruption or blockage in the flow of energy in a part of body. Due to sharing of feelings, the client can maintain good health. Energy transfer or transmission can occur with out direct physical contact between two systems. Hands or focal Points for direction and modulation. Could disrupt the energy field of Therapist.

Florence Nightingale183

Interventions  Teach client relaxation exercise  using Assess client’s subjective reaction to therapeutic touch. Client should feel more relaxed, less anxious and less pain. Some of the same techniques as  therapeutic touch Assist client to centre self. Teach client to imaging a peaceful place. Help client to Verbalize place through all the senses and To Allow the energy of the imagined place to bring about a state of calmness. Teach patient to scan his or her body to Self assesses area of body or muscle tension. Assist client to consciously relax that tense area of the body Assist patient to develop problem-  solving behavior through practice of problem-solving techniques at least twice daily at (times) during hospitalization.

Rationales Relaxation requires the client to nurse acts as a conduit through which the environmental or universal stopping and step outside of self and energy passes to the client. Adopt a non-trying attitude. This allows the person to release and use the inherent energy of self. Rebalance energy flow through the body.

Involves patient in self-management activities. Increases motivation.

Expected Outcome  Client has verbalized various factors that lead to health maintenance alteration and at least one measure to alter each factor.  Client has designed a positive health maintenance plan within one week.

Summary The Adaptation Model introduced by Sister Callista Roy for nursing has been widely accepted by the Nursing Community, Nationally, and Internationally. She also describes an Adaptive system with copying processes described as a whole comprised of part and includes people as individuals are in groups (families, organizations, communities, nations and society as a whole). Also describe the process and out come where by thing feeling persons as individuals and in groups use conscious awareness and choice to create human and

Florence Nightingale184 environmental integration. This also responses that promotes integrity in terms of the goals of the human system, that is, survival, growth, reproduction mastery and personal and environmental transformation. Sister Callista Roy explains the process of being and becoming and whole that reflexes person and environment. She also explain process and outer come there thing and feeling person, as individual and in groups, conscious and awareness and choice to recreate human and environmental integration. She drew upon expanded insights in relating spirituality and science to present a new definition of adaptation and related scientific and philosophical assumptions. 1) expanding the adaptive modes to include relational persons as well as individual persons and 2) describing adaptation on three levels of integrated life processes, compensatory processes, and compromised processes. Dr. Roy has also outlined a structure for nursing knowledge development based on the Roy Adaptation Model and provided examples of research within this structure. Dr. Roy remains committed to developing knowledge for nursing practice and continually updating the Roy Model as a basis for this knowledge development.

Florence Nightingale185 References  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  www.yahoo.com.sister callista roy theory.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Margrate Campbell Theory Advance Concept in Nursing I Shagufta Majeed Mrs. Ruth K. Alam Date:

Florence Nightingale187 Margrate Campbell theory The UBC model for nursing was developed in 1972, which takes the position that individual behavior is motivated by basic that universal human needs, even though we may have dramatically diverse individualized goals that we aim for within these needs. Major Theme The person as a behavioral system with interacting and interdependent subsystem each is representing a basic human needs. The model conceives of individual systems composed of nine subsystems or, one together represents the whole. The main prime systems theory that are, critical for our purpose while all of the parts interact to make a whole understand parts “as if” they were separate in step in learning how to understand whole system their complexity. The model tells us that there is no “random” behavior in the behavior of people can be understood, when people act in a manner that seems counter productive, they are doing so for the purpose of attempting to meet one or more of their needs. In the UBC model, the system is made up of subsystems, each of which represents one of need. The names assigned to reflect the need they represent and are: Need And Goal of Nine Subsystems Subsystem Achieving Affective Ego-Valuative Excretory Ingestive Need (Universal) Mastery Goal (Individualized) Feelings of accomplishment; satisfaction with accomplishments

Love, belongingness and Feelings of love, belongingness dependence and dependence Self respect Self esteem

Collection and removal of Absence of accumulated wastes accumulated wastes Intake of food and fluid; Nourishment; satisfaction nourishment hunger and thirst. of

Florence Nightingale188

Subsystem Protective Reparative Respiratory Satiative Person

Need (Universal) Safety and security

Goal (Individualized) Integrity of the system.

Balance between production Capacity for activity. and utilization of energy Intake of oxygen Stimulation of the system’s Oxygenation; easy respirations. Sensory satisfaction senses.

An individual with nine basic human needs constantly striving to satisfy these needs by using a range of coping behaviors, both innate and acquired. The behaviors or the range of the behaviors that an access to in order to meet a particular need in the subsystem structure. The philosophy of basic human needs tells us that the need produce and continual striving towards meeting them. In general people repertoire of coping behaviors from which in order to maintain meeting their need such breathing to meet the basic needs for oxygen make predictable adaptations to meet need changing circumstances. The abilities and the coping behaviors are a “core” of subsystem, important parts, the goals each person has it to illustrate the way in which our understanding of a person ought to include not only the concrete from we see before us but also all of the objects and events that have some meaning in that person’s life. Environment The questions of when nurses should or should not involve themselves with an individual as client have become increasingly more complex with time. Decades ago, sick people needed nurses, well people did not. More recently nursing considered its mandate as clients who were hospitalized. Now we recognized that some well people need nurses to stay well. Some ill people are fine on their own, and being in hospital may signal the need for nursing care but it is not a very reliable signal. The nurses recognition the individual is in a

Florence Nightingale189 need and the forces that influence how the need conceptualizing these as part of the “psyche environment” or that theoretical area of mind perceptions and aspirations, that extend beyond function of the substance. The idea of psyche environment is to guide us to get know our as we can in order to be as accurate as possible matters to them and what factors are influence obviously. An unconscious client provides a challenge than does an insightful and verbal adult. The subsystem structure includes the inner need, abilities and coping behaviors, as well as psychological environment, with the individualized goals and forces some understanding of all important for the nurse to understand client as a behavioral system. According to this theory, Margrate Campbell focused on the stress coping behavior and tolerance of the client. Applicable Nursing Diagnosis              Adjustment impaired. Coping ineffective individual. Caregiver role strain. Defensive coping. Infective denial. Coping disabled family. Compromised family coping. Coping ineffective community. Post trauma response. Post trauma syndrome. Relocation stress syndrome. Self harm, risk for. Self abuse.

Florence Nightingale190   Suicide, risk for. Violence, risk for.

Assessment I assess the client according to the coping stress tolerance pattern. I collect information and examine the client though the following two ways.  Subjective Data A 50 years old woman admitted in Psychiatric unit. Her sister states that she was alright 15 days back, when she loss her son in an accident. After that she is not interested in taking food, isolated, hostile, insomnia. In subjective data client tells that he is having pain in abdomen due to surgery.  Objective Data A 50 years old woman lying on bed in restless condition with:
• • • • •

Self destructive behavior. Dysfunctional grieving. Express anger towards her environment. Lethargic. Pale skin.

Nursing Diagnosis Ineffective coping. Expected Outcome The client will:

Express feelings in a non-self-destructive manager within 2-3 days and verbalize plans for using alternative ways of dealing with stress and emotional problems when they occur after discharge.

Florence Nightingale191 Nursing Interventions and Rationales Interventions

Rationales Ventilating feelings can help the client to identify, accept, and work through feelings, even if these are painful or otherwise uncomfortable. Participating in his or her plan of care can help increase the client’s sense of responsibility and control. Your presence demonstrates interest and caring. The client may be testing your interest or pushing you away to isolate him-/her-self. Telling the client you will return conveys your continued caring. Ventilating feelings can help the client identify and work through those feelings, even if they are painful or otherwise uncomfortable. Role playing allows the client to try out new behaviors in a supportive environment. The client needs to develop skills with which to replace self-destructive behavior.

Encourage the client to ventilate his • or her feelings; convey your acceptance of the client’s feelings. Involve the client as much as possible • in planning his or her own treatment. Convey your interest in the client and • approach him or her for interaction at least once per shift.

Encourage the client to express fears • and emotions. Help the client identify situations in which he or she would feel more comfortable expressing feelings; use role-playing to practice expressing emotions. Provide opportunities for the client to • express emotions and release tension in non-self-destructive ways such as discussion, activities, and physical exercise. Teach the client about depression, • self-destructive behavior, or other psychiatric problems. Discuss the future with the client; • hypothetical situations, emotional concerns, significant relationships, and future plans. Teach the client about the problem- • solving process: identify a problem, identify and evaluate alternative solutions, choose and implement a solution, and evaluate its success.

The client may have very little knowledge of or insight into his or her behavior and emotions. Anticipatory guidance can help the client prepare for future stress, crises, and so forth. Remember: although the client may not be suicidal, he or she may not yet be ready for discharge. The client may never have learned a logical, step-by-step approach to problem resolution.

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Interventions

Rationales The client may lack skills and confidence in social interactions; this may contribute to the client’s anxiety, depression, or social isolation. Recreational activities can help increase the client’s social interaction and provide enjoyment.

Teach the client social skills, and • encourage him or her to practice with staff members and other clients. Give the client feedback regarding social interactions. Encourage the client to pursue • personal interests, hobbies, and recreational activities. Consultation with a recreational therapist may be indicated. Administer prescribed antimicrobial • therapy within 15 minutes of schedule time. Minimize length of say in hospital.

To minimize microbial activity.

To minimize the risk of infection.

Evaluation   The client has expressed feelings in non-self-destructive managers. The client has verbalized plans for using alternative ways of dealing with stress and emotional problems. Summary The UBC model for nursing represents a mechanism for the development and refinement of systematic thinking in nursing at the same time as it orients the nurse towards some rather than complex and abstract values about clients and nursing. It creates a means by which holistic interpretation can be developed, individual meaning understood, and context specific plans created by encouraging a systematic, holistic clinical reasoning process. It aims to provide the beginning nurse with coherent intellectual directions and the more experienced nurse with a strong logical structure on which to defend and articulate skilled nursing judgments.

Florence Nightingale193 References  Bigge, M.L. (1971). What is Field Psychology in Learning Theories for Teachers. 2nd Edition. Harpes and Row New York.   Campbell, M.A. (1987). The UBC Model for Nursing Direction for Practice . Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  http://216.109.125.130/search/cache.p=margaret Campbell UBC model of nursing. Need and Goal of Nine Subsystems.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Florence Nightingale Advance Concept in Nursing I Sofia Noreen Javed Mrs. Ruth K. Alam

Date:

Florence Nightingale195 Theory is a group of concepts that form a pattern of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Florence Nightingale (The Lady of Lamp) Florence Nightingale observed with a little lamp in her hand making her solitary rounds. As her slender form glides through the corridor, every poor fellow’s face softens with gratitude at the sight of her. She had become the heroine. Her name becomes a synonym for gentleness, efficiency and heroism. Although Florence Nightingale cannot be considered as the product of her time, since she was ahead of and beyond it. But the season was ripe for her genius as the founder of modern nursing. Major Theme – A major of Florence Nightingale is “Unique Role of the Nurse”. Health Health is an ideal state or exuberant well-being, ability to fulfill social roles or to contain or limit symptoms and a strong sense of coherence. Health is viewed as a formal wholeness or completeness which continually changes. In context of health, Florence Nightingale stated that “Absence of disease and the ability to use one’s own abilities to the highest potential, with emphasis on the reparative process of getting well”. Therefore, health is a pattern of energy that is mutually enhances and expresses full life potential. Positive health symbolizes wellness. Definition of Nursing Florence Nightingale stated that it is “A profession for women, separate and distinct from medicine, using nature’s laws of health in the service of humanity.”

Florence Nightingale196 Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill and caring in improving the health status of the public and ensuring safe, effective, quality care. It mirrors the diversion of population, and serves and provides leadership to create positive changes in health policy and delivery systems. Goal of Nursing According to Florence Nightingale goal of nursing is “to place the patient in the best condition for nature to act by providing an environment conductive to healthy living and a nourishing diet.” As she focused on healthy living and nourishing diet, I therefore assess the client according to altered nutrition – risk for more than body requirements or risk for obesity. Assessment I collect information and examine the client through two ways. Subjective Data In subjective data the client verbalizes about his increased eating habits resulting increase in body weight since last two months. His working capacity is reduced and he feels fatigue. Objective Data In objective data, I observe and examine the client carefully and consciously. I look the 50 years old patient lying on the bed and looking:      Lethargic. Weakness. Fatigue. Altered nutrition more than body requirements Sleeplessness.

Florence Nightingale197 His vital signs are:      Blood Pressure Temperature Pulse Respiratory Rate Weight 130/80 mmHg. 98°F 82 per min. 24 per min 102 Kg

The following investigations were performed.     CP. FBS Lipid Profile ECG

Nursing Diagnosis Altered nutrition (more than body requirements or obesity). Expected Outcome  Client will have good knowledge of importance of balance nutrition diet within 2-3 days.  Client will verbalize daily intake nutritional diet to control weight/obesity and exercise pattern. Nursing Interventions and Rationales Interventions    Reassure the client  Rationales To build trust and confidence. To give the knowledge importance of nutrition. about

Increase individual awareness of  amount and type of food consumed Teach the client to keep a diet diary  for one week

Helps to decrease the dietary intake.

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Review high and low calories food.

To decrease body weight.

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Interventions  Plan daily walking program and  gradually increase rate and length of walk. Establish a regular exercise daily. Teach behavior technique. 

Rationales To maintain physical health.

   

To maintain body weight. To restrict diet. For good absorption and elimination. For good absorption of food and elimination.

modification 

Educate client to eat slowly and chew  thoroughly. Encourage client to give maximum  time between two meals.

Evaluation  The client has verbalized that he had reduced weight and take more active part in daily life than before.  The client has verbalized that he had planned for a regular exercise program to reduce weight. Summary Health is an ideal state or exuberant well-being, ability to fulfill social roles or to contain or limit symptoms and a strong sense of coherence. Health is viewed as a formal wholeness or completeness which continually changes. Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill and caring in improving the health status of the public and ensuring safe, effective, quality care. It mirrors the diversion of population, and serves and provides leadership to create positive changes in health policy and delivery systems. The nurse uses a caring process to help the individual achieve an optimal degree of inner harmony to promote self-knowledge, self-healing, and insight into the meaning of life.

Florence Nightingale200 References  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  www.yahoo.com.florence nightingale.

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Liaquat University of Medical & Health Sciences Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2006-2008 Moyra Allen Theory Advance Concept in Nursing I Sajida Parveen Mrs. Ruth K. Alam Date:

Florence Nightingale202 Theory is a group of concept that forms a patter of reality. A theory is a statement that explains or characterizes a process, an occurrence or an event and is based on observed facts but lacks absolute or direct proof. Nursing Theory differentiates nursing from other disciplines and activities in that it serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practice. Moyra Allen Moyra Allen was born in 1921. She obtained her initial nursing education at the Montreal General Hospital School of Nursing and went on to obtain a Bachelor of Nursing from McGill University and a Master degree at Chicago University in 1954. She joined the McGill University’s School of Nursing as Assistant Professor in 1958 and became Associate Professor. She obtained her PhD in education from Stanford University in 1967 and then return to McGill to devote her career to nursing research and education. In 1983, she was appointed as a Acting Director of the School of Nursing and was retired in 1984. She passed away peacefully in Ottawa on May 2, 1996. Moyra Allen Theory The theory of Moyra Allen is depend on the nature of healthy living, a continuum process of aging, dealing actively with life situations, losing some functional ability cognitive interpersonal physiological, withdrawing from life dying, the family or other social group in which learning is initiated natured and directed, the social context in which learning take place, this may be at home, the workplace, community group, a hospital or a clinic. Major Theme “The nature of healthy living”. According to Moyra Allen, dealing actively with life situation, losing some functional ability cognitive interpersonal physiological withdrawing from life dying.

Florence Nightingale203 Health Health has a number of meanings depending on the purpose, time or circumstances governing its use. It is an ideal state or exuberant well-being, ability to fulfill social roles or to contain or limit symptoms and a strong sense of coherence. There are no universal norms of health perceptions vary across individuals and cultures. Health is viewed as a formal wholeness or completeness which continually changes. According to Moyra Allen, health is a social process, a way of living rather than a state of being. Similar in meaning to health behavior, it is something that can be measured and can be modified. Definition of Nursing According to Moyra Allen theory, the definition of nursing is taking a unique, active and complementary role in providing health care. Nurses engage the person/family to actively participate in learning about health. Over the years, the nursing has been developed, refined, tested and implemented in various practice settings and has gained widespread acceptance and a useful framework for nursing practice. This health reform created an increased demand for health care services by the public. Many viewed the reform as an opportunity to expand nursing roles and services. Moyra Allen developed and established the complementary role of the nurse in the 1970s. This innovative role recognized the unique contribution nurses bring to the person and its family. Through a series of field experiments entitled the workshop – A health resource – L’ atelier a votre Sante, the model was developed. Nurses provides a vehicle for holistic nursing care identifying unmeet needs as they become health care needs and considering all dimensions. Nursing seeks to promote symphonic interaction between the environment and man, to strengthen the coherence and integrity of the human beings, and to direct and redirect

Florence Nightingale204 patterns of interaction between man and his environment for realization of maximum health potential. Focus of nursing is unitary human beings in mutual process with their environment and that nursing intervention would be to create ways in which the client might become more aware of his or her field and collaborate with the nurse in proposing and using patterning strategies. Moyra Allen sought to transform the nature and the image of the profession. The nurses role within the health care system as complementary to rather than replacement of other professionals. Goal of Nursing According to Moyra Allen, the main goal of nursing is to form a partnership with the person/family to foster health. From that conviction, Moyra Allen along with contributors from the school of nursing developed a model best known today as the “McGill Model of Nursing.” Moyra Allen model of human becoming emphasizes how individuals choose and bear responsibility for patterns of personal health. The goal of nursing is directed at understanding the interrelationship of health, illness and human behavior. This model is designed around the caring process, assisting clients to attain or maintain health or to die peacefully. This caring process requires that the nurse be knowledgeable about human behavior and human responses to actual or potential health problems and individual needs. The nurse assists the client in interacting with the environment and re-establishing health. The nurse assists the client in this growth by sustaining a safe and protective environment. Applicable Nursing Diagnosis   Comfort altered pain. Knowledge deficit.

Florence Nightingale205     Impaired thought process. Decisional conflict. Unilateral neglect. Sensory – Perceptual alteration.

Assessment I collect information and examine the client about health status. I assess the client through two ways.  Subjective Data In subjective data the client tells me about his cognitive perception.  Objective Data In objective data, I observed and examine the client carefully and consciously. I saw a 30 years old client lying on bed.       Looking very irritable. Restlessness. Weak and pale. Look lethargic. Facial expressions show severe pain. Increase pulse rate.

Vital Signs     Blood Pressure Pulse Temperature Respiratory Rate 130/90 mmHg. 110 per min. 99°F. 22 per min.

Nursing Diagnosis

Florence Nightingale206  Pain related to tissue trauma and reflex muscle spasms secondary to surgery.

Expected Outcome  The client will verbalize reduction of pain within 1-2 hours.

Nursing Interventions and Rationales Interventions
• • • • • • • • •

Rationales Promotes accurate assessment. To develop the trust of the patient. To assess the level of pain. To maintain baseline data. To promote relaxation. To divert mind from pain. This will reduce the intensity of the pain. To reduce pain. To assess effectiveness of medication.

Establish trusting relationship with • client. Explain causes of pain to the patient.

Assess pain by using Colderra very • one hour. Check vital sign two hourly. Encourage technique use of

relaxation •

Provide diversional activities, e.g., • books, watch TV, play games, etc. Instruct on techniques to reduce • skeletal muscle tension. Provide optimal pain relief with • prescribed analgesic. After administering a pain relief • medication, return in 30 minutes.

Evaluation   The client verbalized that pain has reduced from 7/10 to 2/10 on the pain scale 0-10. Facial expressions show relaxed. I look the client’s condition and assess that, I achieved my desired goal and the client is looking better than before.

Florence Nightingale207 Summary The Moyra Allen theory is a social process, a way of living rather than a state of being, and similar in meaning to health behavior. It is something that can be measured and can be modified. A professional response to the person’s nature search for health living and assist people to enhance their problem solving skills in dealing with health matters. Each nursing theory bears the wave up the person or group who developed it and reflects the beliefs of developed. According to Moyra Allen aging is reflected in the varying stage of disengagement of the individual from life and to some extent independently of this disengagement individuals perceive their ability to control what happens to them, the decisions they make, and the choices or alternatives that are available to them. The Moyra Allen theory describes the nature of living health.

Florence Nightingale208 References  Cox, H.C., Hinz, M.D., Lubno M.A., Newfield, S.A., Ridenour, N.C., Slater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. New York.  Kozier, B., Erb, G., Berman, A.J., Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  www.yahoo.com.moyra allen theory.

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Value and Belief Pattern Advance Concept in Nursing I Sofia N. Javed Roman Javed Mrs. Ruth K. Alam Date:

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INDEX TABLE
S# 1. Definitions:  Value  Belief Pattern description Pattern assessment Conceptual information Developmental consideration  Infant  Toddler and Pre-Schooler  School Age Child  Adolescent  Adult  Older adult Factors effecting on value and belief  Situational or Environmental factor  Treatment or Clinical factor Possible Nursing Diagnosis  Spiritual distress  Spiritual well being, potential for enhances Summary References Content Page # 01 01 01 02 02 03 03 03 03 04 04 04 04 04 04 05 05 05 06 07

2. 3. 4. 5.

6.

7.

8. 9.

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OBJECTIVES
At the end of this presentation, audience will be able to: 13) Define value and belief. 14) Describe the pattern. 15) Explain pattern assessment. 16) Discuss conceptual information. 17) Classify developmental consideration. 18) Enlist factors effecting on value and belief. 19) Identify possible nursing diagnosis.

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1

VALUES AND BELIEF PATTERN
Definition 1. Value
Value is a standard idea or things, which are given importance by the people living in society. The people like them want them to be implemented.

2. Belief
 It is a state or habit of mind in which trust, or confidence in some unknown person or thing without any previous experience.  It is mental acceptance of something offered to society as truth. Most of religious activities are based on belief e.g., “God is one”.

Pattern Description
1. 2. 3. 4. A person value and belief system is interconnected with his/her spiritual site and environment. Value and belief gives meaning of life. It enables us to exit during in between time, damage or in face of death. Value and belief can be in many things a superior being environment, self, family and community.

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2

Pattern Assessment
1. 2. 3. 4. 5. 6. 7. Does the patient express anger towards Supreme Being regarding his/her current condition? Does the patient verbalize conflict about spiritual distress? Does the patient indicate positive thought about spirituality? Does the patient indicate comfort with self? Collect subjective and objective data. Question about his/her faith (belief). Provide privacy encourage patient to express his/her reason for living or meaning of life?

Conceptual Information
1. The value and belief system of person can be described as 2. 3. the predomination force (spirituality). The predomination force can be faith in Supreme Being of god. It is conceptual that each person must find his/her place in world nature and relationship with other being. The value and belief system is show by individual; informed of organized religion, attitude action and related to individual senses of what is right cultural belief and internal motivation.

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3 4. 5. The spirituality is what gives like meaning and allow person to function in a more total manner. Value/belief effect on behavior to attitude what is right/wrong and with life style.

Developmental Consideration
The geographical, social, political and home environment, which one lives has a major effect on how a person develop, how he or she will view health, and how spirituality, values and beliefs are formulated.

1. Infant
The infants are totally dependent on the parents of those about him or her and is busy building trust or mistrust. Unable at this stage to form values or distinguish spirituality.

2. Toddler and Pre-Schooler
The toddler imitates those about him or her parents, siblings and other adults. The toddler develops by mimicking observed behavior and receiving either positive or negative reinforcement. Values begin to form as the toddler starts to become aware of others and to interact with those around him or her.

3. School Age Child
begins to be influenced by peers outside the family structure are begin question and make choice and want be implemented. 4

4. Adolescent

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The adolescent searches for his or her own identity and begins to practice values that are separate and yet congruent with his or her family units. The adolescent is still struggling with his or her own independence and formulating his or her own values beliefs.

5. Adult
Usually strengthen the values and beliefs. They have formed according to their life experiences. The adult is continually exploring and trying to see if his or her value system fits within his/her lifestyle.

6. Older Adult
Older adult find great solace in their spirituality and the values and beliefs they have formed through a lifetime.

Factors Effecting on Value and Belief
The main two factors effecting value and belief are:

1.
   

Situational or Environmental Factor
Death or illness. Intensive care restriction. Lack of privacy. Related to divorce/separation from loved one.

2.
     

Treatment or Clinical Factor
Abortion Amputation Dietary restriction. Isolation. Cancer. Mental retardation

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5

Possible Nursing Diagnosis
1. Spiritual distress (distress of human spirit) is defined as, “Disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s biologic and psychosocial nature.” 2. Spiritual well being, potential for enhances is defined as, “Spiritual well being is the process of an individual’s developing or unfolding of mystery through harmonious interconnectedness that springs from inner strengths.

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6

Summary
In this presentation, we discussed various aspects of value and belief pattern. Value is a standard idea or things, which are given importance by the people living in society. Belief is a state or habit of mind in which trust, or confidence in some unknown person or thing without any previous experience. The value and belief system is show by individual; informed of organized religion, attitude action and related to individual senses of what is right cultural belief and internal motivation. If we understand all aspects of value and belief, we will be able to make nursing care plan in nursing practice up to the standard.

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7

References

Tong B.C. and Phipps W.J. (1985). Medical Surgical Nursing: A Nursing Process Approach. 3rd Edition. Mosby Boston. Cox H.C., Hinz M.D. and Lubno M.A. (1989). Clinical Applications of Nursing Diagnosis. Williams and Wilkins London. Carpenito L.J. (1989). Nursing Diagnosis: Application to Clinical Practice. 3rd Edition. J.B. Lippincott Company New York. Smith S. and Dvell D. (1982). Nursing Skills and Evaluation: A Nursing Process Approach. Nursing Review, California, USA.

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Irshad Akhter Advance Concept of Nursing Theoretical Framework Mrs. Ruth K. Alam December , 2007

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Irshad Akhter Advance Concept of Nursing Theoretical Framework Mrs. Ruth K. Alam December , 2007

Florence Nightingale221 Topic: Theorist: Introduction My subject is “Advance Concept of Nursing.” The term theory and conceptual framework are often used interchangeably in nursing literature. Strictly speaking, they differ in their levels of abstraction. My theorist is “Florence Nightingale.” Florence Nightingale born on May 12, 1820, in Florence Italy. She belonged to a renowned British Family. She was the second daughter of William Edward Nightingale and France Smith. Florence was educated more than an average English girl. Her father taught her Greek, Latin, French, German, Italian, History, Philosophy and Mathematic. She was also interested in Political Science and Languages. Throughout her life, she read widely in many languages. Social life meant differently to her not the pomp and show of formalities. Florence showed interest in nursing from her childhood. She visited the sick of her neighborhood and helps them. Florence who knew the humanitarian aspect of service in nursing spent a number of years studying the hospitals in England, Scotland, Ireland, France and Belgium before she went for training to the institute for Dacconnesses at Kaiser Worth in Germany. With reference to the value of professional train she wrote “I should like to advise all young ladies to feel the call to came to the definite profession train yourselves for it in the way man train for his work. Do not believe that you can to understand it in any other way”. Crimean war broke out in 1854. At that time England had only untrained men to look after soldiers. She offered her services to the Minister of War Sir Sidney Herbert. With his help she collected 38 nurses from different Orders and went to help at Scutari. She worked in the Barracks Hospital. The hospital was dirty, crowded and poorly ventilated. There was no clothing or other hospital equipment. The quality of food was poor, 42% of parents used to die due to infection and poor sanitary conditions. Theoretical Framework Florence Nightingale

Florence Nightingale222 As an excellent commander, Florence Nightingale accepted the responsibility of nursing the soldiers. For emergencies she used her own money. Her nurses worked under strict discipline with doctors and improved the hygienic and dietary conditions of the soldiers. She employed soldier’s wives to help the nurses. She visited the soldiers with a lighted lamp during shifts so she was known as the lady with the lamp. In 1855 she contacted Crimean fever. After her recovery in 1856 peace was declared and hospitals at Scutari were closed. She returned to England. Born with a silver spoon in her mouth, Florence Nightingale was known to the wounded soldiers as the “Lady with the Lamp” all over the world. Her life was meant to alleviate pain and give relief to the suffering humanity when other young women of her age were absorbed in the gaiety of social life. She undertook the task of nursing and developed it. Nurses all over the world rightly conermmerate her birthday as “International Nurses Day”. The work of Florence Nightingale during the Crimean war was admirable. She reformed the army medical service. Her dedicated work in the profession brought about a revolution in the whole nursing system. She attracted the most intelligent and scrupulous women to join the profession. Florence Nightingale died on August 13, 1910. Her life is a guiding beacon to all the nurses. Let us have her everlasting spirit and selfless dedication in our nursing profession. She improved the health facilities of the soldiers with the help of Sir Sydney Herbert in England. In 1859, she wrote note on nursing. The Nightingale school at the St. Thomas Hospital, England, was started in June 1860. Nursing become a career for women. The nursing graduated from the Nightingale school went all over the world and started nursing school graduates of this school became the early pioneers in nursing education. Florence major theme is “unique role of the nurse”. Her framework for Health stated that “health is a state or exuberant well being ability to fulfill social roles or to contain or

Florence Nightingale223 limit symptoms and a strong sense of coherence. Health is viewed as a formal wholeness or completeness with continually changes. In context of health, Florence stated that being well and using one’s powers to the fullest extent. Health is maintained through prevention of disease via environment health factors. Disease is a reparative process nature institutes because of some want of attention. While defining ‘Nursing’, Florence Nightingale stated that “provision of optimal conditions to enhance the person’s reparative processes and prevent the reparative processes from being interrupted.” Nursing is the pivotal health care profession, highly values for its specialized knowledge, skill and caring in improving the health status of the public and ensuring safe and effective quality care. Goal of Nursing – Florence Nightingale goal of nursing is to place the patient in the best condition for nature to act by providing an environment continuative to health and nourishing diet. Analysis Florence Nightingale believed that she was called by God to help others and to improve the well being of mankind. According to Gordon’s functional health patterns values and beliefs, she was always deeply strong religious. Nightingale’s main focus is on the environment. She defines that concept in the context of her time only. Florence Nightingale’s contributions are numerous and far-reaching recognizing that: nutrition is an important part of nursing, institutions occupational and recreational therapy for sick people, identifying personal needs of the client and the role of the nursing in meeting those needs, establishing standards for hospital management, establishing a respected occupation for women, establishing nursing education, recognizing the two components of nursing health and illness, believing that nursing is separate and distinct from medicine. Stressing the need for continuing education for nurses, Florence Nightingale elevated the status of nursing to a

Florence Nightingale224 respected occupation, improved the quality of nursing care and founded modern nursing education. Nightingale’s theory is noted in her writing notes on nursing, demonstrates her major areas of environmental control: ventilation, warmth, effluvia, noise, and light. Ventilation especially with increase fresh air provided without drafts is of a primary importance. Light refers to sunlight for the most part and is secondary. Warmth, noise and effluvia (smell) are seen as areas in which attention must be given to provide a positive environment. She did recognize that a negative environment could cause physical stress. Her basic environmental concept, interrelated with nursing process can give us specific directions. The environment of the patient was quite encompassing. She did not specifically distinguish among the physical, social or psychological environments as such she speaks of all three in the practice of nursing. The cleanliness of the physical environment has a direct bearing on the prevention of disease and mortality rates within the social environment of the community. Also all patients’ psychological environments are strongly affected by physical surroundings. The effect of the mind on the body could cause physical stress. Nightingale’s theory related with Human or Individual has vital reparative powers to deal with disease. Nursing – the goal is to place the individual in the best condition for nature to act by basically affecting the environment. Health Disease – the focus is on the reparative process of getting well. Society Environment – involves those external conditions that affect life and the development of the individual. The focus is on ventilation, warmth, odors, noises, and light. Nightingale’s theory of nursing is closely related to scientific theories frequently used in nursing practice today. Most significant are the theories of adaptation, need and stress. The Major components of Nightingale’s theory is, the greater the degree of poor air, poor water, poor light, and other negative environmental factors and the longer the duration, the lesser the potential for the patient to cope with his or her illness. As a matter of fact given

Florence Nightingale225 a health individual within a poor environment with multiple stressors of long duration illness would soon occur. Florence Nightingale theories especially all Gordon Function Health Patterns that effect human life. Conclusion Nightingale’s major focus was on the environment of the patient. Nursing goals focused on providing an environment that allowed nature to act on behalf of patient. Environmental factors involved clean air and water, control of noise, proper drainage, reduction of chills and a variety of activities. Nightingale emphasized fresh air as primary and good lightening as secondary to the effective care of the patient and utilizing her theory today as a theoretical base for practice as it was during her time.

Florence Nightingale226 References  Jacob, A. (1997). Fundamentals of Nursing, (Vol. 1). India: Vikas Publishing House Pvt Ltd.  George, J.B. (1990). Nursing Theories: the base for professional nursing practice, (3rd ed.). USA.  Taylor, C. (1993). Fundaments of Nursing, (2nd ed.). Lippincott.

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Mussarat Parveen Advance Concept of Nursing Theoretical Framework Mrs. Ruth K. Alam December , 2007

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Sister Callista Roy (RN, PhD)

Florence Nightingale229 Topic: Theorist: Introduction In subject “Advanced Concepts of Nursing” we learned about concepts of different theorists, which they applied in the process of nursing. I will introduce my theorist “Sister Callista Roy”. Sister Callista Roy born in 1939 is a RN and PhD, is a nurse theorist, Boston College, Massachusetts. Previous to this appointment, Roy was a Post-Doctoral Fellow and Robert Wood Johnson Clinical Nurse Scholar at the University of California, San Francisco. Roy has served in many positions including Chair of the Department of Nursing, Mount Saint Mary’s College, Los Angeles; Adjunct Professor, Graduate Program, School of Nursing, University of Portland; and Acting Director and Nurse Consultant, Saint Mary’s Hospital, Tucson, Arizona. Roy earned her BS in nursing in 1963 from Mount Saint Mary’s College, Los Angeles; her MS in nursing in 1966 and doctorate in sociology in 1977 from the University of California, Los Angeles. She is a Fell of the American Academy of Nursing and active in many nursing organizations including Sigma Theta Tau and the North American Nurses Diagnosis Association. She is the author or co-author of a number of works including introduction to nursing: An adaptation model, essentials of the Roy Adaptation Model, and Theory Construction in Nursing: An Adaptation Model. The Major Theme of Sister Callista Roy Theory is “Roy Adaptation Model”. The adaptive system has input coming from the external environment as well as input coming internally from the person. Roy identifies inputs as stimuli. A stimulus is a unit of information, matter, or energy from the environment or from within the person that elicits a response. Along with stimuli, the adaptation level of the person acts as input to that person as an adaptive system. The adaptation level is the range of stimuli to which the person can adaptively respond with ordinary effort. This range of response is unique to the individual. Theoretical Framework Sister Callista Roy

Florence Nightingale230 Each person’s adaptation level is constantly changing aspect which is influenced by the coping mechanisms of that person. Outputs of the person as a system are the behaviors of the person. Output behaviors can be both external and internal. Thus, these behaviors may be observed, measured, or subjectively reported. Output behaviors become feedback to the system. Roy has categorized outputs of the system as either adaptive responses or ineffective responses. Adaptive responses are those that promote the integrity of the person. The person’s integrity or wholeness is behaviorally demonstrated when the person is able to meet the goals in terms of survival, growth, reproduction, and mastery. Ineffective responses do not support these goals. Sister Callista Roy has used the term coping mechanisms to describe the control processes of the person as an adaptive system. Some coping mechanisms are inherited or genetic, such as the white blood cell defense system against bacteria seeking to invade the body. Other mechanisms are learned, such as the use of antiseptics to cleanse a wound. Roy presents a unique nursing science concept of control mechanisms. She has also outlined a structure for nursing knowledge development based on the Roy Adaptation Model and provided examples of research within this structure. She remains committed to developing knowledge for nursing practice and continually updating the Roy Model as a basis for this knowledge development. The Roy model defined Health as a continuum from death to high-level wellness. This is no longer used in the present model. Instead, Roy presently defines health as “a state and process of being and becoming integrated and whole person.” The integrity of the person is expressed as the ability to meet the goals of survival, growth, reproduction, and mastery. The nurse using Roy’s model uses the concept of health as the goal point for the person’s behavior. When a disproportionate amount of the person’s energy is used in coping, less energy is available to meet the goals of survival, growth, reproduction, and mastery. Nursing

Florence Nightingale231 aims to promote the health of the person by promoting adaptive responses. Energy freed from ineffective behavior becomes available for promotion of health. Nursing is the science and practice that expands adaptive abilities and enhances person and environment transformation. Nursing’s aim of promoting adaptation is contributory to the health of the person and to the unity and solidarity of the person within himself or herself and in relation to others. 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. Conclusion The Roy model consists of the five elements of person, goals of nursing, nursing activities, health and environment. Persons are views living adaptive systems whose behaviors may be classified as adaptive senses or ineffective responses. These behaviors are derived from the cognator mechanisms. These mechanisms work within the adaptive modes of physiological function, self concept, role function, interdependence. The goal of nursing is to promote adaptive response relation to the four adaptive modes, using information about the person adaptation level, and focal, contextual, and residual stimuli. Nursing activities involve the manipulation of these stimuli to promote adaptive responses. Health is a process of becoming integrated and able to meet goals of survival, growth, reproduction, and mastery. The environment consists of the person’s internal and external stimuli. These elements are in a nursing process that consists of first and second levels assessments, diagnosis, goal setting, intervention, and evaluation. First level assessment, or behavioral assessment, deals with the four adaptive modes, whereas second level assessment focuses on the three areas of stimuli. Diagnosis consists of stating the problem. Goals are set in relation to the problem and are written in behavioral terms. Interventions are planned to

Florence Nightingale232 manipulate the stimuli, and evaluation compares the person’s output behaviors with the desired behaviors established in the goals. References  Erb, K., & Wilkinson, B. (1998). Fundamentals of Nursing: Concepts, Process and Practice, (5th ed.). New Jersey: Prentice Hall Health.  George, J.B. (1990). Nursing Theories: the base for professional nursing practice, (3rd ed.). USA.  www.google.com.pk.sister callista roy. Retrieved on December 18, 2007.

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Nargis Bashir Advance Concept of Nursing Theoretical Framework Mrs. Ruth K. Alam December , 2007

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Betty Neuman
RN, BSN, MS, PhD, PLC, FAAN

Florence Nightingale235 Topic: Theorist: Introduction I am studying in Advance Concepts of Nursing, which is related to nursing care concepts make theories and are used in patient’s care. Theories provide a framework which is criteria to see method for nursing care. My theorist name is “Betty Neuman”. Her major theme is “Provide holistic are and develop health model system.” Betty Neuman was born on a farm in Lowell, Ohio in 1924. Her first nursing education was completed in Peoples Hospital (now named as General Hospital), School of Nursing in Akron, Ohio in 1947. She completed her BS Nursing in 1957 and then MS in Mental Health, Public Health Consultation from UCLA in 1966 and finally PhD in Clinical Psychology. Her teaching experience includes mental health, consultation and organization, leadership and counseling. She was a pioneer in the community mental health movement in the late 1960s. During her UCLA work in organization and planning with the community mental health movement, she developed her nursing model of the “whole person approach” based on a systems adaptation framework. Her theoretical approach to nursing is exemplified in a holistic approach to her own life. She has a great zest for life and a keen sense of using time creatively and usefully. She began developing health model while a lecture in community health nursing in the University of California. Major Theme of her model is “provide holistic care and develop health model system.” Health is equated with optional stability that is the best possible wellness stale, at any given time. Betty Neuman began developing her health system model while a lecture in community health nursing at the University of California. Her framework is basically a system model with the major components of stressors, reaction to stressors, and the person. It is also dynamic and can be altered rapidly over a short period of time. Its effectiveness can be reduced by such changes as loss of sleep, malnutrition, or any alteration in activities of daily Theoretical Framework Betty Neuman

Florence Nightingale236 living. The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient Problem’s in Nursing Research”. It was refined and subsequently published in the first edition of conceptual models for nursing practice 1974, and in the second edition in 1980. Health – the assumption of this model can lead one to see wellness as a dynamic composite of physical, psychological, sociocultural developmental and spiritual balance that is, flexible yet retains an unbroken ability to resist disequilibrium. She further stated that, wellness is the condition in which all parts and subparts of an individual are in harmony with the whole system. Wholeness is based on interrelationships of variables that determine the resistance of an individual to any stressor. Illness indicates lack of harmony among the parts and subparts of the system of the individual. Health is viewed as a point along a continuum from wellness s to illness; health is dynamic (i.e., constantly subject to change). The person retains varying degrees of balance and harmony between internal and external environment. The factors effecting on the health are physiological factor, physiosocial factor, activity and exercise, and nutrition, as communication with other people and adjustment to other. Health is also affected by socioculture to know about other cultures and spiritual believes about health and how they perceive it, perceiving of coping stress and how person cope the stress. Goal of Nursing – the primary goal of nursing is the retention and attainment of client system stability. The assessment or intervention instrument various aspects of Neuman’s model but is flexible enough to allow for inclusion of any additional data deemed necessary. Factors influencing in use of the instrument would be the client, client situation. In Neuman’s work the in men is accompanied by an explanatory section that includes specific role charts to categorize data, and plan for interventions at all levels. The nurse helps the client through primary, secondary, and tertiary prevention modes to adjust to environment stressors and maintain client system stability. In later writings, she stated that health is equated with optimal system stability that is the best possible wellness state.

Florence Nightingale237 There are ten basic assumptions underlying Neuman’s Conceptual Framework.  Though each individual client or group as a client system is unique, each system is a composite of common known factors or innate characteristics within a normal, given range of response contained within a basic structure.  The particular interrelationships of client variable physiological, psychological, sociocultural-developmental and spiritual at any point in time can affect the degree to which a client is protected by the flexible time of defense against possible reaction to a single stressor or a combination of stressors.  Each individual client/client system, over time, has evolved a normal range of response to the environment that is referred to as a normal line of defense, or usual wellness/stability state.  When the cushioning accordion like effect of the flexible line of defense is no longer capable of protecting the client system against an environment stressor, the stressor breaks through the normal line of defense.  The client, whether in state of wellness or illness is a dynamic composite of the interrelationships of variables physiological, psychological, sociocultural,

developmental and spiritual wellness is on a continuum of available energy to support the system in its optimal state.  Implicit within each client system is a state of internal resistance factors known as lines of resistance, which function to stabilize and return the client to the usual wellness state (normal line of defense) or possibly to a higher level of stability following an environmental stressor reaction.  Primary prevention relates to general knowledge that is applied in client assessment and intervention in identification and reduction or mitigation of risk factors associated with environmental stressor to prevent possible reaction.

Florence Nightingale238  Secondary prevention relates to symptomalogy following a reaction to stressors, appropriate ranking of intervention priorities and treatment to reduce their noxious effects.  Tertiary prevention relates to the adjustive processes taking place as reconstitution begins and maintenance factors move the client back in a circular manner toward primary prevention.  The client is in dynamic constant energy of change with the environment.

Conclusion Conceptual models are imperative to the development of nursing as a profession. Neuman’s total person approach to health care is one such model. In essence, she presents an approach to viewing the person’s perception of the stressors affecting the part of the whole individuals in constant interaction with the environment. In as much as the model emphasizes to total person it transcends the nursing model to become a health care model, applicable to all health care disciplines. Even though the model is interdisciplinary, it certainly has universal applicability to nursing. One of its greatest strengths is the clear direction it gives for interventions through primary, secondary and tertiary prevention. Nursing theory, nursing research and nursing practice, the applicability of the model to all health disciplines could foster a common perspective and thereby fail to point over the distinctive contribution of nursing or any other health disciplines to health care.

Florence Nightingale239 References  Erb, K., & Wilkinson, B. (1998). Fundamentals of Nursing: concepts, process and practice, (5th ed.). New Jersey: Upper Saddle River  George, J.B. (1990). Nursing Theories: the base for professional nursing practice, (3rd ed.). USA.  Jacob, A. (1997). Fundamentals of Nursing, (Vol. 1). India: Vikas Publishing House Pvt Ltd.

Nargis Qureshi Advance Concept of Nursing Theoretical Framework Mrs. Ruth K. Alam December , 2007

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A Brook and Showers O'er rocks and rills, From spills to spill, It wanders on it's way, While fairies dance, and raindrops prance, Upon it's waters gay The sun shines through, In misty hue, Upon the rippling stream. The fleecy clouds, In silver shrouds, Are clothed in fancies dream.
(Poem written by Martha Rogers, aged 16, on April 15, 1931, from the collection of Erline McGriff, photo courtesy of the late Joan Hoexter).

Florence Nightingale241 Topic: Theorist: Introduction According to my subject “Advance Concept of Nursing” I was assigned to explain Nursing Theorist and her conceptual framework. My theorist is “Martha E. Rogers.” Martha Elizabeth Rogers was born on May 12, 1914; sharing a birthday with Florence Nightingale. She began her academic career when she entered the University of Tennessee in Knoxville in 1931 where she remained for two years. She stated that: "I took the science-med course. It was more substantial than straight pre-med and included more science and maths. I took psychology, French, Zoology, Genetics, Embryology and many other courses" (Hektor, 1989). However, she didn’t complete the course, instead she entered nursing school at Knoxville General Hospital in September 1933. She received her nursing diploma in 1936 and her Bachelor of Science degree in Public Health Nursing form the George Peabody College in Nashville in 1937 and then became a public health nurse in rural Michigan where she stayed for two years before returning to further study. In 1945 she earned her master’s degree from Teacher’s College Columbia University, New York. She then became a public health nurse in Hartford, CT, advancing from staff nurse to acting Director of Education. After this she established and eventually became the Executive Director of the first Visiting Nurse Service in Phoenix. She left Arizona in 1951 and returned to school at the Johns Hopkins University, Baltimore. Rogers was appointed Head of the Division of Nursing at New York University in 1954. In about 1963 Martha edited a journal called Nursing Science. It was during that time that Rogers was beginning to formulate ideas about the publication of her third book An Introduction to the Theoretical Basis of Nursing (Rogers, 1970). Rogers officially retired as Professor and Head of the Division of Nursing in 1975 after 21 years of Theoretical Framework Martha E. Rogers

Florence Nightingale242 service. In 1979 she became Professor Emeritus and continued to have an active role in the development of nursing up until the time of her death on March 13, 1994. Early development of the conceptual framework, the Science of Unitary Human Beings, was first seen in Reveille in Nursing, Rogers’ second book, which was published in 1964. Six years later, in 1970, Rogers published her major work which was entitled An Introduction to the Theoretical Basis of Nursing. In the 20 years or so following the publication of An Introduction to the Theoretical Basis of Nursing, considerable changes have taken place within the conceptual framework to the Science of Unitary Human Beings (Rogers, 1980, 1983, 1986, 1990). It is beyond the scope of this section to chart these changes but it will give the reader the current definitions of the concepts subsumed under the Science of Unitary Human Beings, relating these to earlier definitions where appropriate. In 1970, Rogers formulated five basic assumptions that describe man and the life process in man (Rogers, 1970). These assumptions or "building blocks" underlay the conceptual framework and consist of the concepts of: Wholeness - in which the human being is regarded as a unified whole which is more than and different from the sum of the parts. Openness - where the individual and the environment are continuously exchanging matter and energy with each other. Unidirectionality - where the life process exists along an irreversible space time continuum. Pattern and Organization - which identifies individuals and reflects their innovative wholeness. Sentience and Thought - which states that of all life, human beings are the only ones capable of abstraction and imagery, language and thought, sensation and emotion. In terms of Health she stated that, “Positive health symbolizes wellness. It is a value term defined by the culture or individual. Health and illness are considered “to denote behaviors that are of high value and low value.” Nursing – a humanistic science dedicated to

Florence Nightingale243 compassionate concern with maintaining and promoting health, preventing illness, and caring for and rehabilitating the sick and disabled. Nursing seeks to promote symphonic interaction between the environment and the person, to strengthen the coherence and integrity of the human beings, and to direct and redirect patterns of interaction between the person and the environment for the realization of maximum health potential. A unified whole possessing integrity and manifesting characteristics that are more than and different from the sum of its parts; an organized pattern energy field that continually. The concept of Unitary Health Care emerged from the dynamic and innovative work of the nursing academic Professor Martha E Rogers during the 1950s in New York. She created the conceptual health care system that became known throughout the world as the Science of Unitary Human Beings. Many examples have been given of the direct application of the conceptual framework in nursing practice. In discussion and position papers and in those describing accounts of care delivery, Bradley (1987) and Hover-Kramer (1990) promote the importance of the concept of energy fields and its potential operationalization using techniques such as therapeutic touch (although the pioneering work of Dolores Krieger (1979), the foremost authority on therapeutic touch, should not be regarded as having directly evolved from the work of Rogers). Whelton (1979) presented a comprehensive and detailed but far from clear assessment and care plan based on the Science of Unitary Human Beings. It was shown to be useful in guiding nursing intervention and predicting outcomes in the examples given, that is, the care of a patient with decreased cardiac output, diabetes and hypertension and in the care of a patient with a recurrent meningioma. However, there is no evidence in the literature that this care plan has been used since it was first published. Another assessment tool to be used in nursing practice has been developed by Barrett (1988) who has also stated that nurses need to assess "pattern manifestation" and to promote "deliberative mutual patterning"

Florence Nightingale244 (Barrett, 1990). The nursing care of an adolescent with a "borderline personality disorder" has been described by Thompson (1990) who used the conceptual framework to describe the interpersonal processes of transference and counter-transference that existed. Further explorations of patient care scenarios using the Science of Unitary Human Beings are given by Meehan (1990) who described caring for a man with pain due to metastatic cancer, Madrid (1990) who gave a moving account of successful deliberative mutual patterning in the care of a patient who was in considerable discomfort due to pain, hospitalizations and gastrointestinal bleeding and Chapman (1994) who described an ICU incident. Analysis Purpose or intent of the analysis in part determines the criteria for analysis" and that the purpose can either be to "compare and contrast the cognitive processes used by the creators of the models" or "to determine the acceptability of a model by the nursing profession". An analysis using an explicit framework can reduce the possibility of bias occurring in the evaluation process and augments the potential for further theory refinement. In addition, it is important to perform an analysis in order to establish whether the work, in this instance the Science of Unitary Human Beings, is a suitable framework to use as the philosophical basis for a major piece of research. When considering this suitability, a consideration needs to made not only of the degree of internal consistency and development but also of its applicability to nursing from a United Kingdom perspective. Conclusion A critical analysis of the Science of Unitary Human Beings needs to be performed in order to: (a) judge how suitable the framework will be as a philosophical base or structure for the present research, (b) assess how well the Science of Unitary Human Beings meets criteria judging the internal suitability of the framework, (c) determine how applicable the Science of

Florence Nightingale245 Unitary Human Beings might be for nursing all over the world, and (d) clarify whether the framework is indeed a philosophy, model or theory. It is hoped that some of these issues can be addressed and questions can be answered following this session. These questions are: (1) How is people defined and described? (b) How is environment defined and described? (c) How is health defined and described? (d) How is nursing defined and described? (e) Goal?

Florence Nightingale246 References   George, J.B. (1990). The base for professional nursing practice, (3rd ed.). USA. Jacob, A. (1997). Fundamentals of Nursing, (Vol. 1). India: Vikas Publishing House Pvt Ltd.   Taylor, C. (1993). Fundaments of Nursing, (2nd ed.). Lippincott. An Article: Retrieved from www.medweb.uwcm.ac.ukmartha/ - 2k – on December 14, 2007.

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Yasmeen Naheed Advance Concept of Nursing Theoretical Framework Mrs. Ruth K. Alam December ,2007

Florence Nightingale248 Topic: Theorist: Introduction My subject is ‘Advance Concept of Nursing.’ Conceptual nursing theories or models were developed to provide a basis to help the nurse make decisions regarding which types of information and observations are essential to ensure accurate evaluative judgments. The term theory and conceptual framework are often used interchangeably in nursing literature. Strictly speaking, they differ in their levels of abstraction. My theorist is “Lydia E. Hall.” Lydia E. Hall received her basic nursing education at York Hospital, School of Nursing in York, Pennsylvania. Bother her BS in Public Health Nursing and MA in teaching Natural Sources are from Teachers College, Columbia University, New York. Lydia Hall was the first Director of the Loeb Center for Nursing and Rehabilitation and continued in that position until her death in 1969. Her experience in nursing spans the clinical, educational, research and supervisory components. Her publications include several articles on the definition of nursing and quality of care. Lydia Hall put firth what she considered a basic philosophy of nursing upon which the nurse may have patient care. This philosophy is still used as a working reality at the Loeb Center for Nursing. Her major theme of theory is three interlocking circles: care, cure and core. We will discuss here three components of the theoretical framework. Major theme, what is the main concept of the theory? What theorist said about her concept? Person: the recipient of nursing care (including individual, families, groups, and communities); what theorist explains about the person? Environment: the internal and external surrounding that effect the person. It may be home or hospital; what are my theorist’s concepts about environment. Theoretical Framework Lydia E. Hall

Florence Nightingale249 Theoretical Framework Major theme of Lydia E. Hall was nursing care consists of three interlocking circles: Care, cure and core.

Care – the care circle represents the nurturing. Component of nursing and is exclusive to nursing. Nurturing involves using the factors that make up the concept of mothering (care and comfort of the person) and provide for teaching-learning activities. When functioning in the care circle, the nurse applies knowledge of the natural and biological sciences to provide a strong theoretical base for nursing implementation. Core – the core circle is the therapeutic use of self or helping the patient to grow in self identity. The professional nurse, by use of the reflective technique (acting as a mirror for the patient), helps the patient look at and explore feeling regarding his or her current health status and related potential changes in the life style. Cure – is based in the pathological and therapeutic sciences, involves working with the patient and family in relation to the medical care, and is shared with other members of the health team. Although the concept of Hall is directly emphasizes on the health and related to the person’s health perception and the cognitive process. How a person, express his or her feeling about the health status, and lifestyle? How he or she perceived about an interpersonal relationship with the nurse? Person – the individual human who is sixteen years of age or older and past the acute stage of a long term illness is the focus of nursing care in Hall’s theoretic framework. The source of energy and motivation for healing is the individual

Florence Nightingale250 care recipient, not the health care provider. Hall emphasizes the importance of the individual as unique, capable of growth and learning, and requiring a total person approach. Environment – Hall’s concept of environment is deal within relation to the individual. Hall is credited with developing the concept of Loeb Centre because she assumed the hospital environment during treatment of acute illness creates a difficulty psychological experience for the ill individual. Loeb Center focuses on providing an environment that is conductive to self development. The focus of the action of nurses is the individual, so that any actions taken in relation to environment would be for the purpose of assisting the individual in attaining a personal goal. Conclusion Although Lydia Hall first presented her theory of nursing during the late 1950’s and early 1960’s, Loeb Center for Nursing and Rehabilitation is still using Hall’s theory to provide patient care. Hall’s theory of nursing involves three interlocking circles, each representing one aspect of nursing. The care aspect represents intimate bodily care of the person. The core aspect deals with the innermost feeling and motivation of the person. The cure aspect tells how the nurse helps the person and family through the medical aspect of care. The main tool, the nurse uses to help the person realize his or her motivations and to grow in self awareness is that of reflection. Hall presents a philosophical view of humans as having the energy and motivation for self awareness and growth. Definition of environment and person must be inferred. Lydia Hall’s theory may be used in the nursing process. The core, care and cure aspects are all applicable to each phase of the nursing process. The limitations of Hall’s theory illness orientation, age, family contact restrictions, and use of reflection only can e overcome by taking a broader view of care, core and cure and by emphasizing the aspect that is most appropriate for a particular situation. References

Florence Nightingale251   Crisp & Taylor (2001). Fundamentals of Nursing, (6th ed.). Singapore: Kyob. George, J.B. (1990). Nursing theories the base for professional nursing practice, (3rd ed.). USA.  Lydia Hall (1926-1969). Article. Retrieved from www.enursescribe.com/

Lydia_Hall.htm on December 9, 2007.

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Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Fair of Loneliness Advance Concept of Nursing-I Azra Nasreen Mrs. Ruth K. Alam

Florence Nightingale253 Introduction On September 3, 2007, I was deputed to Thoracic Medicine (Ward-12) to fulfill requirement of my BScN Year-I clinical requirement. On the first day, I met with the Head Nurse. She welcomed me and gave orientation of the ward. My goals for clinical are to assess the patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis During orientation, I observed that the ward is housed in well established building. One portion of it is being used as offices and minor procedures and other portion for indoor patients. During my clinical, I observed shortage of health care team workers. Cleanliness was up to the standard, but there is a lack of communication between health team members and patients. Similarly, I also found improper care of patients, lack of proper and prompt investigation facilities, etc. This may be due to the shortage of manpower and lack of communication between them. To achieve my goal that is to assess patients according to Gordon’s health pattern, I selected patients to prepare their care plan after necessary discussion with Head Nurse. Observation During my clinical, I observed that resources are not up to the task but Head Nurse and co-workers tried their best to do the needful for the patients’ care. Each of them was working according to the task given to them. I also discussed the problems related to patients, availability of medicine, equipment, shortage of staff, etc. One day, I saw a patient having being carried out for X-ray and Ultrasound diagnosis, but he is not will for the same. On inquiry it came into my notice that he is hospitalized first time. Besides his suffering of lungs obstruction, he is also having a fear that he will be left all alone by his family members. He is also not willing that his attendant left him alone.

Florence Nightingale254 Loneliness is an emotional state of dissatisfaction with the quality or quantity of relationships. Risk factors include schizophrenia, bipolar affective disorder, personality disorder, social isolation, inadequate social and relational skills, passivity, low self-esteem, hopelessness, powerlessness, anxiety or fear, inadequate leisure activity skills, inadequate resources for transportation or leisure activities, chronic illness or disability, etc. (Carson, 2000). Facilitating the client’s development of social, relationship and leisure activity skills; promoting the client’s self-esteem and identifying sources of social contact and support in the client’s living situation and community. These include interpersonal relationships, adopting a pet if the client is able to care for an animal, referral to supportive groups, placement in an appropriate group-living situation, identification of continued treatment resources, and so on. In addition, educating the client and significant others about loneliness, and teaching the client how to communicate needs for support and intimacy (e.g., helping the client learn how to tell others when he or she is feeling lonely, and helping the client’s significant others learn how to respond by listening or attending to the client) can be effective interventions. Keeping in view the above strategy and with the consent of Head Nurse, I counseled the client and built a trustworthy environment between the client and myself and then encourage the client to communicate his problem of fear of loneliness and hospitalization, as he is admitted in the hospital for the first time and also unaware of hospital environment. After spending some time with him, I made him understand that he is here for his own benefits of getting necessary health care investigations and treatment. He agreed with my views and gives his consent for the diagnostic procedures. The nurse needs to be aware of the risk for and situation of loneliness when working with clients in inpatient facilities, in partial treatment settings, and in the community. Facilitating the client’s development of social, relationship and leisure activity skills;

Florence Nightingale255 promoting the client’s self-esteem and identifying sources of social contact and support in the client’s living situation and community. These include interpersonal relationships, adopting a pet if the client is able to care for an animal, referral to supportive groups, placement in an appropriate group-living situation, identification of continued treatment resources, and so on. In addition, educating the client and significant others about loneliness, and teaching the client how to communicate needs for support and intimacy (e.g., helping the client learn how to tell others when he or she is feeling lonely, and helping the client’s significant others learn how to respond by listening or attending to the client) can be effective interventions. During my clinical visit, I had experienced many things like managing of ward with limited resources and shortage of staff. How to deal with patients suffering from anxiety and fear of hospitalization? etc. etc. In future, I try my best to provide special care to the patients having problems of not coping with the indoor situation and environment. Beside this special attention should be given to the condition that health care providers could visit each patient within a specific time period, so that any suffering of the patient come into the notice of the Head Nurse, which need immediate attention. Awareness to the attendant and the client should also be given to how to communicate and try to solve their problems by their own. Attention provided by the health care team works to the client during their hospitalization can solve many problems and facilitate them to provide a good care to the patients.

Florence Nightingale256 References  Carson, V.B. (2000). Mental health nursing. The nursing patient journey. 2nd Edition.  Kozier, B., Erb, G., Berman, A.J., & Burke, K. (2000). Fundamentals of nursing: concepts, process and practice. 6th Edition. New Jersey: Prentice Hall Health.  Scott, J. (2001). Cognitive therapy for depression. British Medical Bulletin; 57:101-113. Retrieved from http://www.google.com.pk/ on October 2, 2007.

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Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Communication Advance Concept of Nursing-I Irshad Akhter Mrs. Ruth K. Alam

Florence Nightingale258 Introduction Being a student of BScN Year-I, I had to complete my clinical requirement, therefore, my first placement was made at Medical Unit III (Ward-7). First week of my clinical was an orientation week. On the first day I met with the Head Nurse who is maintaining this unit in well organized way. She gives an orientation and told us that this unit consists of 50 beds, which are divided into two wings for male and female patients. My goals for clinical are to assess the patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis During orientation, I seen an emergency trolley that was usually considered or met for any sort of life saving emergency occurred. It was maintained properly. Record of drugs and other items was maintained in the register duly signed by the Charge Nurse and countersigned by the Head Nurse. Head Nurse assigned the work to each coworker, therefore, everyone know his work and expert in his routine work. The Head Nurse frequently visits the patients and was well aware of patients’ diseases, treatment and progress, etc. To achieve my goal that is assess patients according to Gordon’s health pattern, I selected patients to prepare their care plan after necessary discussion with Head Nurse. Observation During my clinical, I observed the routine work being carried out by the Head Nurse and sub-ordinates. I also discussed the problems related to patients, availability of medicine, equipment, shortage of staff, etc. One day when I was on my clinical routine work, I found a patient of known diabetes mellitus having a complaint about his diet. In his diet a fruit, Papaya was included, but he dislikes it and wants to have some other fruit, instead of Papaya.

Florence Nightingale259 Analysis I communicate with the client and tried to satisfy him about his dietary requirement being a known patient of Diabetes mellitus. I also requested to the Head Nurse to check the diet chart and exclude Papaya from his diet menu. Later on, I told the patient about his diet and no more Papaya is included in his diet menu. Communication refers to giving, receiving or sharing of ideas, knowledge and feelings, etc. It is also recognized as a permanent change in behavior through the process of training and experience. The primary purpose of communication is to help client come to know themselves in ways that allow them to recognize possibilities in their lives and to alter ineffective life pattern. The nurse’s role in the communication process is to help patients transform vague, tangential, or distorted statements into clear, concrete, workable statements that have common meaning to both. The nurse uses these mutually developed statements as the basis for therapeutic intervention. The nurse enlists the patients as collaborators in the process of self-discovery and uses words, actions and knowledge to help patients develop a more positive view of themselves and more adaptive ways of interacting in the world (Nancy, et al., 1998) Another problem I found there was shortage of staff due to which patients do not get quality care for which they were admitted for. I discussed the problem with the Head Nurse as an incidence was occurred last night that one of the patients was not feeling well and he tried to call staff member but nobody responded at the movement. The Head Nurse confirmed about complain and said that this was happened during night shift duty. She asked the patient that in future if he had any complain he should contact her. I analyzed that due to a good conduct and communication, the patient was satisfied. From this situation, I had learned that how can we manage and enhance our learning process

Florence Nightingale260 through critical thinking, effective health care of the client and as well as communicate effectively. The success of any organization depends on the good relation between team members and quality of communication. To achieve the purpose, a team leader should pay special attention to the quality of team relations and of communication as a means of maintaining good relations. During my stay in the ward, I tried my best to become a role model for others especially for the nurse student so that they should get awareness about their responsibilities and the care provided by them to the patient. This becomes a great source for me to observe the change in nurses’ behavior and attitude. In future, I also tried my best to emphasize on good communication between the health care providers and patients. This will facilitate client to focus on other people or interactions cyclic, which interrupted negative thoughts, moreover positive feedback increases the likelihood that the client will continue the good behavior.

Florence Nightingale261 References  Kozier, B., Erb, G., Berman, A.J., & Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  Nancy, R., Long, W.W., & Tierney, A. J. (1998). The element of nursing (4th ed). Singapore.

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Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Aseptic Measures Advance Concept of Nursing-I Khurshida Hussain Mrs. Ruth K. Alam

Florence Nightingale263 Introduction It was my first week as the clinical posting at the Department of Nephrology (Ward-22), Jinnah Postgraduate Medical Centre, Karachi. This clinical placement took place to fulfill my requirement of BScN Year-I Degree Program. First week of my clinical replacement is recognized as an orientation week and my goals are to assess patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis On the morning of September 3, 2007 at 08:15 AM, I reached at the Department of Nephrology and met with the Head Nurse. She welcomed me. As she was busy in managing ward routine work, she asked me to wait for a while and then she took me and gave orientation of the ward. The Department of Nephrology is housed in ground plus two floors with provision of lifts. It is reserved for the admission, diagnosis and treatment of the clients suffering from Kidney, ureter and urinary bladder diseases. The new facilities added recently include facility of dialysis for renal failure patients. Observation While orientation, I had discussed various matters with the Head Nurse and she answered my question up to my satisfaction. Although, I observed good management, but seen shortage of staff especially in the dialysis room, moreover, staff working in the dialysis room do not follow coming in and out with observing precaution measures, which is against the ethics of nursing profession and patient’s right. The more surprising thing which I had observed there is that no nursing staff was posted in the dialysis room. The staff nurses performing duties in the ward also provide care to the patients in the dialysis room. During my posting at the unit, I encountered a female patient, who was a case of chronic renal failure, while I was on my schedule duty at the department, it was time for the

Florence Nightingale264 injection dispensing to the client. The on duty nurse came and she attempted to pass the intravenous (I/V) cannula, without taking standardized aseptic techniques required as prerequisite to pass I/V Canula. I witnessed that the duty nurse had handled the tip of I/V cannula by placing her fingers on it, so making the cannula contaminated with microorganisms, which might be present on her hands. After observing the non-sterilized technique of I/V cannulization by the nurse on duty, I immediately interrupted the duty nurse, to not to pass that I/V cannula and discard it. I also asked her to use other I/V cannula by adopting proper sterilized technique to pass I/V line. She obeyed my instruction as directed by me. According to Hauswirth and Sherk (2007), Aseptic technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens. Crow (1989) stated that, “Aseptic technique is the effort taken to keep patients as free from hospital microorganisms as possible”. The founder of the technique is considered to be Joseph Lister. It is a method used to prevent contamination of wounds and other susceptible sites by organisms that could cause infection. This can be achieved by ensuring that only sterile equipment and fluids are used during invasive medical and nursing procedures. Ayliffe et al. (2000) suggest that there are two types of asepsis: medical and surgical asepsis. Medical or clean asepsis reduces the number of organisms and prevents their spread; surgical or sterile asepsis includes procedures to eliminate micro-organisms from an area and is practised by nurses in operating theatres and treatment areas. Aseptic technique is employed to maximize and maintain asepsis, the absence of pathogenic organisms, in the clinical setting. The goals of aseptic technique are to protect the patient from infection and to prevent the spread of pathogens. Often, practices that clean (remove dirt and other impurities), sanitize (reduce the number of microorganisms to safe

Florence Nightingale265 levels), or disinfect (remove most microorganisms but not highly resistant ones) are not sufficient to prevent infection. The Centers for Disease Control and Prevention (CDC) estimates that over 27 million surgical procedures are performed in the United States each year. Surgical site infections are the third most common nosocomial (hospital-acquired) infection and are responsible for longer hospital stays and increased costs to the patient and hospital. Aseptic technique is vital in reducing the morbidity and mortality associated with surgical infections. In addition to environmental safety, a major concern of health practitioners is the danger of spreading microorganisms from person to person and from place to place. Microorganisms are naturally present in the environment. Some are beneficial and some are not. Some are harmless to most people, and others are harmful to many people. Still others are harmless, except in certain circumstances. In future, I will emphasis on providing awareness of standardized aseptic techniques because in the medical management of the clients the aseptic techniques are necessary to avoid the unnecessary secondary infection and hospital acquired infection, which increases the mortality and morbidity of the clients. Similarly the secondary infections during hospitalization cause the extra burden on the hospital budget, which may be used on other areas of health management.

Florence Nightingale266 References  Hauswirth, K. & Sherk, S.D. (2007). Aseptic technique forum: A guideline for patients and caregivers. Retrieved from www.google.com.pk on October 4, 2007.  Kozier, B., Erb, G., Berman, A.J., & Burke, K. (2000). Fundamentals of nursing: concepts, process and practice. 6th Edition. New Jersey: Prentice Hall Health.  www.google.com.pk/Aseptic technique retrieved from Wikipedia on October 4, 2007.

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Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Professional Responsibility Advance Concept of Nursing-I Nargis Bashir Mrs. Ruth K. Alam

Florence Nightingale268 Introduction On September 10, 2007, when I reached College of Nursing, Jinnah Postgraduate Medical Centre, Karachi, it came into my notice that I was deputed in Gynecology and Obstetrics (Ward-8) for first clinical to fulfill requirement of my BScN Year-I Degree Program. First week is an orientation week and my goals are to assess patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis I and one of my classmates reached there and reported to the Head Nurse, who welcomed both of us and gave us orientation of the ward. Gynecology and Obstetrics is a housed in two storied building comprising facilities for admitting indoor patients, having 150 beds. Ground floor consists of offices, ward, and ICU. During orientation, I had observed many problems which include lack of communication between health care provider team and patients, unsatisfactory sanitation condition of the ward. I also observed that patients also come from the rural areas of Sindh Provinces, who faced difficulty in conveying their problems due to language differences. One of the major issues, which I had observed was shortage of staff. This problem can be observed in each and every public sector hospitals, which resulted in negative thinking and concept of people. According to WHO’s nurse/patient ratio must be 1/10 but this is not achieved yet and that is why we are still unable to provide good and reasonable nursing care. Observation Once, during my clinical round, I observed a postoperative patient is suffering from severe pain, but no one is there to provide her relief from pain. Being a nurse, I immediately provide care to the patient and also spent some time with her while communication. This will help the client to divert her attention. When I observed that she is now relaxed, I went to the Head Nurse and asked for the patient condition.

Florence Nightingale269 According to the Head Nurse, the client had delivered a baby two days back after Cesarean section, due to sudden rise in her blood pressure she was operated in emergency and so she delivered her first baby. Postoperative pain is a natural phenomenon; therefore she needs counseling, more attention and care. We had given awareness to the attendant of the patient, that how can she cope with such a situation. It is the responsibility of a nurse to take care of such patients especially postoperative patients, as we have more opportunities to communicate and interact with the clients and therefore it is our responsibility to provide special care to those clients who are critically ill or need postoperative care. According to Jammerson (1987), “Responsibility denotes an obligation to accomplish a task.” Delegation is the process by which the responsibility for performing a task, function, activity, or decision is transferred to another individual who accept that responsibility. On the other hand, “Responsibility is transferred and accountability is shared.” As s nurse we should perform those tasks for which we are responsible (Adcock, 1971). Rob (1901), suggested that “Nurse should always make her it rule to think of every client as an individual human bean being, whose, fancies and peculiarities for her all the considerations possible at her hand.” I discussed the matter with the Head Nurse regarding responsibilities of Nurses while performing her duties. She agreed with me and we decided to observe student nurses that how they communicate with patients and care was provided by them. I also arranged a session for giving them some awareness in respect to there responsibilities toward clients. During my last day of clinical, I observed change in the behavior and attitude of nurses and they were showing a very responsible behavior. I was very much surprised and satisfied. The reason of this change was that the Head Nurse now trying her bests to manager the ward with well planned manner. She gives task to each and every team work and takes round of the ward.

Florence Nightingale270 I had learned lot from this clinical placement. Being a nurse we are responsible for many things while providing health care facilities to the clients. We have to administer medication on time, we not only maintain I/V line but also have to take care either I/V line is working properly, how we are interacting with the clients and coworkers, etc. The main thing which I like to be adopted in my future is that I will use all my efforts to manage a ward with limited resources. I also give awareness to the clients and their attendant how to manage pain, if health care provider was not available. In addition to the above, I also adopt such policies and encourage each member of health care provider team to be sincere with their work and during duty hours should work with responsibility for the task given to them.

Florence Nightingale271 References  Ellis, J.R., & Harley, C. (2001). Managing and coordinating nursing care (3rd ed) USA.  Hickkey, J.R., & Venegonsi, S.L. (1993). Advanced practice nursing (2nd ed.) USA: Lippincot.  Nancy, R., Long, W.W., & Tierney, A. J. (1998). The element of nursing (4th ed). Singapore.  Rowe, J.A. (2000). Accountability: The fundamental component of nursing practice. British Journal of Nursing, 9(9), 249-252.

Florence Nightingale272

Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Culture Difference Advance Concept of Nursing-I Nargis Qureshi Mrs. Ruth K. Alam

Florence Nightingale273 Introduction On September 3, 2007, I was deputed to Ward-13 to fulfill requirement of my BScN Year-I clinical requirement. On the first day, I met with the Head Nurse. She welcomed me and later on gave orientation of the ward. My goals for clinical are to assess the patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis During orientation, I observed that the ward is housed in two rooms, which are not well ventilated. Patients are suffering from air pollution and unhygienic conditions. Other factors which I had observed there are shortfall of staff members, improper communication between health caregivers and patients, improper care of patients, etc. To achieve my goal that is assess patients according to Gordon’s health pattern, I selected patients to prepare their care plan after necessary discussion with Head Nurse. Observation During my clinical, I observed that resources are not up to the task but Head Nurse and co-workers tried their best to do the needful for the patients’ care. I also discussed the problems related to patients, availability of medicine, equipment, shortage of staff, etc. One day when I was on my clinical round, I observed a patient is not willing to administer injection. On inquiry, it came to my not that he is admitted first time in the hospital therefore, he is afraid. Moreover, he does not understand Urdu and he is also facing difficulty in communication due to language differences. To solve the problem I used critical thinking and to communicate between the client and health caregivers, I called one of the relative of another patient.

Florence Nightingale274 By obtaining assistance of another person well worse with client’s language, I communicate with the patient and counsel him and also make him understand for the purpose of administering injection to him. The patient agreed to have injection. Nurses function in a health care environment that mirrors the diversity and cultural complexities of the larger society. The diversity of clients is varied and related to gender, age, socioeconomic status, education, physical and mental disabilities, regional locations, sexual life-style, and racial and ethnic backgrounds. The essential role of the nurse in cultural transactions within health care, and proposes an approach to cultural inclusiveness crafted from the nursing process. In addition to a fundamental approach to care, nurses must bring the will and commitment to change. Culture is dynamic. Its changes are usually gradual, but always constant. Culture is one of the few attributes important enough that no one was left out. We all have at least one; many of us have more than one. It includes values, beliefs, attitudes, customs, rituals, and behaviors. It will vary within the group by age, gender, religion, and social class. Nurses must recognize the process of continually cultural change through acculturation or assimilation. Once the dynamism of cultures is accepted, a static description of behaviors or the naming of specific cultural attributes has limited utility (Dennis & Small, 2003). Another problem I found there was shortage of staff due to which patients do not get quality care for which they were admitted for. I discussed the problem with the Head Nurse, she told about the shortage of staff especially in night shift. She had made several requests but no action was taken so far. The unhygienic condition of the ward is one of the other problems, as there is no permanent cleaner was deputed. During my stay in the ward, I tried my best to become a role model for others. I felt no hesitation to take assistance of other so that communication link between patients and health care worker could be continued and proper counsel could be also done.

Florence Nightingale275 In future, I may use communication skill and to cope with the daily requirement and management of ward asked for proper equipment and staff. This will facilitate to provide proper care to the clients admitted for their treatment.

Florence Nightingale276 References  Dennis, B.P., & Small, E.B. (2003). Incorporating cultural diversity in nursing care: an action plan. ABNF Journal.  Kozier, B., Erb, G., Berman, A.J., & Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  Nancy, R., Long, W.W., & Tierney, A. J. (1998). The element of nursing (4th ed). Singapore.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Critical Thinking Advance Concept of Nursing-I Naeema Mrs. Ruth K. Alam

Florence Nightingale277

Florence Nightingale278 Introduction To fulfill first clinical requirement of my BScN Year-I Degree Program, I was deputed to Department of Gynecology and Obstetric (Ward-8). On the morning at 08:15 AM of September 3, 2007, I reached to Ward-8. First week is an orientation week and my goals are to assess patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis After reaching at Ward-8, I met to the Head Nurse, and told her my purpose of being present there. She welcomed me and after distributing work tasks between the coworkers, she gave me orientation of the department and later on of the ward. Department of Gynecology and Obstetrics is a housed in two storied building comprising facilities for indoor patients, having 150 beds. It was further divided into two wards. Ward-8 at ground floor consists of offices, ward, and ICU, etc. and ward-9 on the first floor with all the same facilities. Both ward have high bed occupancy rate, this is due to patients coming for treatment not only from Karachi but also from far flung areas of Provinces of Sindh and Balochistan. Due to high occupancy rate, work load was increased manifold, which resulted in shortage of staff and burden on other facilities. During orientation, I had observed many problems which include lack of communication between health care provider team and patients, this may cause due to heavy work load and shortage of staff, unsatisfactory sanitation condition of the ward as only two cleaners were present. One of the major issues, was shortage of staff and this issue was found in each and every public sector hospitals. According to WHO’s nurse/patient ratio must be 1/10 but this is not achieved yet and that is why we are still unable to provide good and reasonable nursing care to the patients.

Florence Nightingale279 Observation During my clinical round, an incidence was occurred that one of the Student Nurse is trying to maintain I/V line of the patient, but patient is not willing to let her do so. When I enquired about the reasons, the Student Nurse told me that she cannot understand my language and is afraid of administering medication via I/V line. I observed that patient belong to rural area of the Sindh and cannot talk or understand Urdu. I critical think about the situation and to solve the issue search for a patient attendant who can understand Urdu and can be helpful to communicate with both of us. I was successful to find one of them. I asked her to communicate with both of us and make the patient understand that to maintain I/V line is important for her and can improve her condition. After spending some time with both of them, I succeed to make the patient understand the reasons and purposes of maintaining I/V line. Later on I called the Student Nurse and asked her to do the needful. Critical thinking is the process of examining underlying assumptions, interpreting and evaluating arguments, imagining and exploring alternative and developing a reflective criticism for the purpose of reaching a reasoned conclusion that can be justified. According to Field (1987), critical thinking is a process highly sensitive to content the emotional and rational dimension. Kemp (1985) stated that, “Critical thinking is an attitude of inquiry involving the use of facts, principles, theories, observations, deductions, interpretations and evaluation.” We had adopted such a profession in which have to face many critical situations. Critical thinking competency, general thinking competency, specific critical thinking competencies in clinical situations and special critical thinking competency in nursing helped us out to solve the problem while bold and prompt decision. Therefore, Head Nurses are

Florence Nightingale280 expected to use knowledge from various disciplines to solve problems of patients, staff and the organization as well as problems in their own personal and professional lives. In nursing, it is common to equal critical thinking with problem solving, analyzes of data, clinical decision making or judgment and use of the nursing process. It helps in anticipating problem to bring change and understanding each other and identifying actual or potential problems and its helps to make decision about an action plan. During my stay at my clinical placement, I had learned lot of things, which I will apply whenever, I got opportunity. The main things, which I had learned are that how to manage a ward with limited resources, how to depute coworker so that each task can be met and completed within time. I will use all my efforts to manage a ward with limited resources. I also encourage to coworker to learn additional languages especially Urdu, as they can be posted at any part of the country. In addition to the above, I also adopt such policies and encourage each member of team to work sincerely and with responsibility as the care of the patient while hospitalization lies on their shoulder. Little bit of negligence can cause problems for the others.

Florence Nightingale281 References  Hickkey, J.R., & Venegonsi, S.L. (1993). Advanced practice nursing (2nd ed.) USA: Lippincot.  Kozier, B., Erb, G., Berman, A.J., & Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. New Jersey: Prentice Hall Health.  Nancy, R., Long, W.W., & Tierney, A.J. (1998). The element of nursing. 4th Edition. Singapore.  Sullivan, E.J., & Decker, P.J. (1990). Effective Management in Nursing. 3rd Edition.

Rowe, J.A. (2000). Accountability: The fundamental component of nursing practice. British Journal of Nursing, 9(9), 249-252.

Florence Nightingale282

Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Gastrostomy Tube Care Advance Concept of Nursing-I Shamshad Begum Mrs. Ruth K. Alam

Florence Nightingale283 Introduction On September 3, 2007, I was deputed to Ward-4 to fulfill requirement of my BScN Year-I clinical requirement. The ward is also recognized by the name of Cancer Ward. On the first day, I met with the Head Nurse. She welcomed me and gave orientation of the ward. My goals for clinical are to assess the patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis During orientation, I observed that the ward is housed in an old barrack, which was renovated several times. Being a Cancer Ward standard of ventilation is not found satisfactory. Patients are suffering from pollution due to environmental conditions. Other factors which I had observed there are shortage of staff members, improper cleanliness, improper communication between health team members and patients, improper care of patients, lack of proper and prompt investigation facilities, etc. To achieve my goal that is to assess patients according to Gordon’s health pattern, I selected patients to prepare their care plan after necessary discussion with Head Nurse. Observation During my clinical, I observed that resources are not up to the task but Head Nurse and co-workers tried their best to do the needful for the patients’ care. I also discussed the problems related to patients, availability of medicine, equipment, shortage of staff, etc. One day when I saw a patient having gastrostomy tube passed, but no proper care was taken about taking hygienic procedure to protect the wound or gastrostomy tube. Patient was also feeling uncomfortable while sitting or in spine position on the bed. I inquired from the Head Nurse about the condition and treatment being given to the patient. She told me that patient was suffering from stomach cancer and after gastrostomy, tube was inserted for further treatment and care. After taking consent from the Head Nurse, I examined the patient

Florence Nightingale284 thoroughly and arranging necessary material and antiseptics, I changed dressing and also clean the tube by taking necessary precaution measures. Gastrostomy refers to a surgical opening into the stomach. Creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression. Typically this would include an incision in the patient's epigastrium as part of a formal operation. It can be performed through surgical approach or percutaneous endoscopic gastrostomy (PEG). The opening may be used for feeding, such as with a gastrostomy tube (Wikipedia, 2007). To take care of gastrostomy feeding tube, dressing should be changed every 1 to 2 days, clean around tube with hydrogen peroxide, apply antibiotic ointment to skin around tube, dress with gauze pads and tape, and position tube so it does not kink. While taking shower, cover dressing with a double layer of plastic wrap and tape edges. Remove plastic wrap and change dressing after you shower (Golzarian, et al.). Other problems I found there was shortage of staff, due to which patients do not get quality care, unhygienic condition of the ward and environmental factors. I discussed these problems with the Head Nurse, she agreed with me and said that we had asked for more staff but our requirement was not fulfilled, yet. Regarding unsatisfactory sanitary conditions she added that we have no regular or permanent Sanitary Worker. Administration sends one of them who work for few hours and thereafter go back whenever they received call from their superiors. During my clinical, I learned lot of thing which included how to manage a ward especially with shortage of staff. How one can communicate with the patients and team workers, how to take care of patients to who tubes were passed. Moreover, how to provide patients better facilities with limited resources.

Florence Nightingale285 In future, I may try my best to provide special care to the patients having nasogastric tube or gastrostomy tube passed. Special antiseptic measures should be taken and cleanliness of tube should be checked after every food intake. Awareness regarding how to take care of gastrostomy tube should be given to the attendant of the patient and patient too. On the other hand necessary measures should also be taken with the Administration for deputing enough trained staff, which can cope with the requirement of Cancer patients and for cleanliness of the ward proper arrangements should be made. Rectifying of these problems may improve the care given to the clients admitted.

Florence Nightingale286 References  Golzarian, J., Sun, S., Sharafuddin, M., & Mimura, H. How to care for your feeding tube (Gastrostomy Tube)? Retrieved on October 2, 2007.  Kozier, B., Erb, G., Berman, A.J., & Burke, K. (2000). Fundamentals of Nursing: Concepts, Process and Practice. 6th Edition. Prentice Hall Health New Jersey.  www.google.com.pk/wikipedia Gastrostomy. Retrieved on October 2, 2007.

Florence Nightingale287

Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Session 2007-2009 Reflection Log: Privacy Advance Concept of Nursing-I Yasmeen Naheed Mrs. Ruth K. Alam

Florence Nightingale288 Introduction On September 3, 2007, I went to Medical ICU for my first clinical to fulfill requirement of my BScN Year-I degree program. First week is an orientation week and my goals are to assess patient according to Gorden’s Health Pattern and develop a care plan according to patient’s actual problem. Analysis I met to the Head Nurse, who welcomed me and later gave orientation of the ward. Medical ICU is a 20 bedded ward where health care was provided to those patients suffering from critical medical illness. During my clinical I came to known that mortality rate was at higher side, this is due to the admission of such a critical ill patients who required immediate attention and need more medical care facilities. One of the major problems which I had observed is that there was no interaction between doctors and nurses. This might be due to over load as everyone was busy with their own work. The time I spent for my clinical, I had learned how to assess patient according to functional health pattern of Gorden. During head to toe assessment applied physical assessment techniques, I have learned more during my first placement in clinical area. I had selected different diseased patients for assessment and to develop their care plan according to their actual problems. Interaction between the health workers and patients is one of the important elements of health care settings. Being a Nurse, we are more attached to the patients. Attention towards the patient and listening their conversation with full concentration will be more beneficial for client and also for nurses. Secondly, maintaining patients’ privacy is our fundamental role and basic ethical principle. During my clinical days, I come across with one situation that still irritating me. One patient, who was in very critical condition and suffering from ascities, Doctor came to him to conduct catheterization procedure without adopting any privacy method. Only one bed sheet

Florence Nightingale289 was spread around, which was not enough to provide complete privacy. Patient felt hesitation and refused to catheterize. Doctor left the patient and attends other patients. When I asked the doctor about this patient, he replied that I haven’t found screen for privacy of this patient. Later on I talked to patient about refusing for the procedure as it is necessary for him. He replied that, “is it a way to expose anyone in front of all people especially in front of ladies and you tell me that this sheet is enough for my privacy. In this situation, I never give permission to attend me.” These were patient’s feeling about his basic right, which is privacy. I went to the Ward Manager and asked for screen, which I found from the neighbored Ward-7. I screened the patient and counsel the patient that now you are in privacy and then he agreed for catheterization procedure. Being a nurse it was important for me that I have to maintain patient’s privacy because it is patient’s right to have privacy. Whenever, I recall this incidence, I always get anxious. The whole situation came in front of me and a question arises in my mind that isn’t privacy a patient’s right and what would be patient’s feelings at that time? I have been taught and emphasized from beginning in our training to maintain privacy before doing any procedure. But it has been observed that at most of the times, privacy of the patient was ignored or not maintained. There may be many reasons for this ignorance; one of them could be a large number of patients and lack of resources. According to Paraland (2000), practical difficulties in hospital such as lack of resource may make it difficult for patient privacy. It can cause conflicts for nurses whose aim to maintain patient’s privacy.” Gabbie (2001) stated, “It is the responsibility of every professional nurse to understand the critical importance of the principles of privacy.” In future, when I will be back in my respective institute, I will respect patient and pride to maintain their privacy. I will try to bring change by giving awareness to the health providers about patient’s privacy and its importance. Finally, I must say that respect patient’s

Florence Nightingale290 privacy. It is a good practice and is patient’s basic right. No matter health care provider is a nurse or a doctor. References  Gebbie, K.M. (2001). Privacy: the patient’s right. American journal of nursing. 101(6):73.  Paraland, J.M., et al. (2000). Autonomy and clinical practice 2: patient privacy and nursing practice. British journal of nursing. 9(9):567.

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