Application of Betty Neuman's System Model

This page was last updated on January 4, 2011

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OBJECTIVES

to assess the patient condition by the various methods explained by the nursing theory

to identify the needs of the patient

to demonstrate an effective communication and interaction with the patient.

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

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

to evaluate the extent to which the process was fruitful.

INTRODUCTION

SYSTEM MODEL- BETTY NEUMAN

The Neumans system model has two major components:stress and reaction to stress.

The client in the Neumans system model is viewed as an open system in which repeated
cycles of input, process, out put and feed back constitute a dynamic organizational
pattern.

The client may be an individual, a group, a family, a community or an aggregate.

In the development towards growth and development open system continuously become
more differentiated and elaborate or complex.

As they become more complex, the internal conditions of regulation become more
complex.

Exchange with the environment are reciprocal, both the client and the environment may
be affected either positively or negatively by the other.

The system may adjust to the environment to itself.

The ideal is to achieve optimal stability.

 As an open system the client, the client system has propensity to seek or maintain a
balance among the various factors, both with in and out side the system, that seek to
disrupt it. Neuman seeks these forces as stressors and views them as capable of having
either positive or negative effects.

Reaction to the stressors may be possible or actual with identifiable responses and
symptom.

MAJOR CONCEPTS

I. PERSON VARIABLES

Each layer, or concentric circle, of the Neuman model is made up of the five person variables.
Ideally, each of the person variables should be considered simultaneously and comprehensively.

1. Physiological - refers of the physicochemical structure and function of the body.

2. Psychological - refers to mental processes and emotions.

3. Sociocultural - refers to relationships; and social/cultural expectations and activities.

4. Spiritual - refers to the influence of spiritual beliefs.

5. Developmental - refers to those processes related to development over the life span.

II. CENTRAL CORE

The basic structure, or central core, is made up of the basic survival factors that are
common to the species (Neuman, 1995, in George, 1996).

These factors include: system variables, genetic features, and the strengths and
weaknesses of the system parts. Examples of these may include: hair color, body
temperature regulation ability, functioning of body systems homeostatically, cognitive
ability, physical strength, and value systems.

The person's system is an open system and therefore is dynamic and constantly changing
and evolving.

Stability, or homeostasis, occurs when the amount of energy that is available exceeds that
being used by the system.

A homeostatic body system is constantly in a dynamic process of input, output, feedback,

and compensation, which leads to a state of balance.

III. FLEXIBLE LINES OF DEFENSE-

 The flexible line of defense is the outer barrier or cushion to the normal line of defense,
the line of resistance, and the core structure.

If the flexible line of defense fails to provide adequate protection to the normal line of
defense, the lines of resistance become activated.

The flexible line of defense acts as a cushion and is described as accordion-like as it

expands away from or contracts closer to the normal line of defense.

The flexible line of defense is dynamic and can be changed/altered in a relatively short
period of time.

IV. NORMAL LINE OF DEFENSE

The normal line of defense represents system stability over time.

It is considered to be the usual level of stability in the system.

The normal line of defense can change over time in response to coping or responding to
the environment. An example is skin, which is stable and fairly constant, but can thicken
into a callus over time.

V. LINES OF RESISTANCE

The lines of resistance protect the basic structure and become activated when environmental
stressors invade the normal line of defense. Example: activation of the immune response after
invasion of microorganisms. If the lines of resistance are effective, the system can reconstitute
and if the lines of resistance are not effective, the resulting energy loss can result in death.

VI. RECONSTITUTION-

Reconstitution is the increase in energy that occurs in relation to the degree of reaction to the
stressor. Reconstitution begins at any point following initiation of treatment for invasion of
stressors. Reconstitution may expand the normal line of defense beyond its previous level,
stabilize the system at a lower level, or return it to the level that existed before the illness.

VII. STRESSORS

The Neuman Systems Model looks at the impact of stressors on health and addresses stress and
the reduction of stress (in the form of stressors). Stressors are capable of having either a positive
or negative effect on the client system. A stressor is any environmental force which can
potentially affect the stability of the system: they may be:

Intrapersonal - occur within person, e.g. emotions and feelings

 Interpersonal - occur between individuals, e.g. role expectations

Extra personal - occur outside the individual, e.g. job or finance pressures

The person has a certain degree of reaction to any given stressor at any given time. The nature of
the reaction depends in part on the strength of the lines of resistance and defense. By means of
primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or
maintain the stability of the system.

VII. PREVENTION

As defined by Neuman's model, prevention is the primary nursing intervention. Prevention

focuses on keeping stressors and the stress response from having a detrimental effect on the
body.

Primary -Primary prevention occurs before the system reacts to a stressor. On the one hand, it
strengthens the person (primarily the flexible line of defense) to enable him to better deal with
stressors, and on the other hand manipulates the environment to reduce or weaken stressors.
Primary prevention includes health promotion and maintenance of wellness.

Secondary-Secondary prevention occurs after the system reacts to a stressor and is provided in
terms of existing systems. Secondary prevention focuses on preventing damage to the central
core by strengthening the internal lines of resistance and/or removing the stressor.

Tertiary -Tertiary prevention occurs after the system has been treated through secondary
prevention strategies. Tertiary prevention offers support to the client and attempts to add energy
to the system or reduce energy needed in order to facilitate reconstitution.

NURSING METAPARADIGM

A. PERSON

The person is a layered multidimensional being. Each layer consists of five person variables or
subsystems:

Physical/Physiological

Psychological

Socio-cultural

Developmental

Spiritual
The layers, usually represented by concentric circle, consist of the central core, lines of
resistance, lines of normal defense, and lines of flexible defense.

The basic core structure is comprised of survival mechanisms including: organ function,
temperature control, genetic structure, response patterns, ego, and what Neuman terms 'knowns
and commonalities'.

Lines of resistance and two lines of defense protect this core. The person may in fact be an
individual, a family, a group, or a community in Neuman's model.

The person, with a core of basic structures, is seen as being in constant, dynamic interaction with
the environment.

Around the basic core structures are lines of defense and resistance (shown diagrammatically as
concentric circles, with the lines of resistance nearer to the core.

The person is seen as being in a state of constant change and-as an open system-in reciprocal
interaction with the environment (i.e. affecting, and being affected by it).

B. THE ENVIRONMENT-

The environment is seen to be the totality of the internal and external forces which surround a
person and with which they interact at any given time. These forces include the intrapersonal,
interpersonal and extra personal stressors which can affect the person's normal line of defense
and so can affect the stability of the system.

The internal environment exists within the client system.

The external environment exists outside the client system.

Neuman also identified a created environment which is an environment that is created and
developed unconsciously by the client and is symbolic of system wholeness.

C. HEALTH-

Neuman sees health as being equated with wellness. She defines health/wellness as "the
condition in which all parts and subparts (variables) are in harmony with the whole of the
client (Neuman, 1995)".

As the person is in a constant interaction with the environment, the state of wellness (and
by implication any other state) is in dynamic equilibrium, rather than in any kind of
steady state.

Neuman proposes a wellness-illness continuum, with the person's position on that

continuum being influenced by their interaction with the variables and the stressors they
encounter.
 The client system moves toward illness and death when more energy is needed than is
available. The client system moves toward wellness when more energy is available than
is needed.

D. NURSING

Neuman sees nursing as a unique profession that is concerned with all of the variables
which influence the response a person might have to a stressor.

The person is seen as a whole, and it is the task of nursing to address the whole person.

Neuman defines nursing as actions which assist individuals, families and groups to
maintain a maximum level of wellness, and the primary aim is stability of the
patient/client system, through nursing interventions to reduce stressors.

Neuman states that, because the nurse's perception will influence the care given, then not
only must the patient/client's perceptions be assessed, but so must those of the caregiver
(nurse).

The role of the nurse is seen in terms of degrees of reaction to stressors, and the use of
primary, secondary and tertiary interventions.

Neuman envisions a 3-stage nursing process:

1. Nursing Diagnosis - based of necessity in a thorough assessment, and with

consideration given to five variables in three stressor areas.

2. Nursing Goals - these must be negotiated with the patient, and take account of patient's
and nurse's perceptions of variance from wellness

3. Nursing Outcomes - considered in relation to five variables, and achieved through

primary, secondary and tertiary interventions.

NURSING PROCESS BASED ON SYSTEM MODEL

Assessment: Neumans first step of nursing process parallels the assessment and nursing
diagnosis of the six phase nursing process. Using system model in the assessment phase
of nursing process the nurse focuses on obtaining a comprehensive client data base to
determine the existing state of wellness and actual or potential reaction to environmental
stressors.

Nursing diagnosis- the synthesis of data with theory also provides the basis for nursing
diagnosis. The nursing diagnostic statement should reflect the entire client condition.
 Outcome identification and planning- it involves negotiation between the care giver
and the client or recipient of care. The overall goal of the care giver is to guide the client
to conserve energy and to use energy as a force to move beyond the present.

Implementation nursing action are based on the synthesis of a comprehensive data

base about the client and the theory that are appropriate to the clients and caregivers
perception and possibilities for functional competence in the environment. According to
this step the evaluation confirms that the anticipated or prescribed change has occurred.
Immediate and long range goals are structured in relation to the short term goals.

Evaluation evaluation is the anticipated or prescribed change has occurred. If it is not

met the goals are reformed.

ASSESSMENT

PATIENT PROFILE

1. Name- Mr. AM

2. Age- 66 years

3. Sex-Male

4. Marital status-married

5. Referral source- Referred from ------- Medical College, -------

STRESSORS AS PERCEIVED BY CLIENT

(Information collected from the patient and his wife)

Major stress area, or areas of health concern

Patient was suffering from severe abdominal pain, nausea, vomiting, yellowish
discolorations of eye, palm, and urine, reduced appetite and gross weight loss(8kg with in
4 months)

Patient is been diagnosed to have Periampullary carcinoma one week back.

Patient underwent operative procedure i.e. WHIPPLES PROCEDURE- Pancreato

duodenectomy on 27/3/08.

Psychologically disturbed about his disease condition- anticipating it as a life threatening

condition. Patient is in depressive mood and does not interacting.
 Patient is disturbed by the thoughts that he became a burden to his children with so many
serious illnesses which made them to stay with him at hospital.

Patient has pitting type of edema over the ankle region, and it is more during the evening
and will not be relieved by elevation of the affected extremities.

He had developed BPH few months back (2008 January) and underwent surgery TURP
on January 17. Still he has mild difficulty in initiating the stream of urine.

Patient is a known case of Diabetes since last 28 years and for the last 4 years he is on
Inj. H.Insulin (4U-0-0). It is adding up his distress regarding his health.

Life style patterns

patient is a retired school teacher

cares for wife and other family members

living with his son and his family

active in church

participates in community group meeting i.e. local politics

has a supportive spouse and family

taking mixed diet

no habits of smoking or drinking

spends leisure time by reading news paper, watching TV, spending time with family
members and relatives

Have you experienced a similar problem?

The fatigue is similar to that of previous hospitalization (after the surgery of the BPH)

Severity of pain was somewhat similar in the previous time of surgery i.e. TURP.

Was psychologically disturbed during the previous surgery i.e. TURP.

What helped then- family members psychological support helped him to overcome the
crisis situation
Anticipation of the future

Concerns about the healthy and speedy recovery.

Anticipation of changes in the lifestyle and food habits

Anticipating about the demands of modified life style

Anticipating the needs of future follow up

What doing to help himself?

Talking to his friends and relatives

Reading the religious materials i.e. reading the Bible

Instillation of positive thoughts i.e. planning about the activities to be resume after
discharge, spending time with grand children, going to the church, return back to the
social interactions etc

Avoiding the negative thoughts i.e. diverts the attentions from the pain or difficulties, try
to eliminate the disturbing thoughts about the disease and surgery etc

Trying to accept the reality etc..

What is expected of others?

Family members visiting the patient and spending some time with him will help to a great
extent to relieve his tension.

Convey a warm and accepting behaviour towards him.

Family members will help him to meet his own personal needs as much as possible.

Involve the patient also in taking decisions about his own care, treatment, follow up etc

STRESSORS AS PERCEIVED BY THE CARE GIVER.

Major stress areas

Persistent fatigue

Massive weight loss i.e.( 8 kg of body weight with in 4 months)

 History of BPH and its surgery

Persistence of urinary symptoms (difficulty in initiating the stream of urine) and edema of
the lower extremities

Persistent disease- chronic hypertensive since last 28 years

Depressive ideations and negative thoughts

Present circumstances differing from the usual pattern of living

Hospitalization

acute pain ( before the surgery patient had pain because of the underlying pathology and
after the surgery pain is present at the surgical site)

nausea and vomiting which was present before the surgery and is still persisting after the
surgery also

anticipatory anxiety concerns the recovery and prognosis of the disease

negative thoughts that he has become a burden to his children

Anticipatory anxiety concerning the restrictions after the surgery and the life style
modifications which are to be followed.

Clients past experience with the similar situations

Patient verbalized that the severity of pain, nausea, fatigue etc was similar to that of
patients previous surgery. Counter checked with the family members that what they
observed.

Psychologically disturbed previously also before the surgery. (collected from the patient
and counter checked with the relatives)

Client perceived that the present disease condition is much more severe than the previous
condition. He thinks it is a serious form of cancer and the recovery is very poor. So
patient is psychologically depressed.

Future anticipations

Client is capable of handling the situation- will need support and encouragement to do so.
 He has the plans to go back home and to resume the activities which he was doing prior
to the hospitalization.

He also planned in his mind about the future follow up ie continuation of chemotherapy

What client can do to help himself?

Patient is using his own coping strategies to adjust to the situations.

He is spending time to read religious books and also spends time in talking with others

He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope.

He sets his major goal i.e. a healthy and speedy recovery.

Client's expectations of family, friends and caregivers

he sees the health care providers as a source pf information.

He tries to consider them as a significant members who can help to over come the stress

He seeks both psychological and physical support from the care givers, friends and
family members

He sees the family members as helping hands and feels relaxed when they are with him.

Evaluation/ summary of impressions-

There is no apparent discrepancies identified between patients perception and the care
givers perceptions.

INTRAPERSONAL FACTORS

1. Physical examination and investigations

Height- 162 cm

Weight 42 kg

TPR- 37o C, 74 b/m, 14 breaths per min

BP- 130/78 mm of Hg
 Eye- vision is normal, on examination the appearance of eye is normal. Conjunctiva is
pale in appearance. Pupils reacting to the light.

Ear- appearance of ears normal. No wax deposition. Pinna is normal in appearance and
hearing ability is also normal.

Respiratory system- respiratory rate is normal, no abnormal sounds on auscultation.

Respiratory rate is 16 breaths per min.

Cardiovascular system- heart rate is 76 per min. on auscultation no abnormalities

detected. Edema is present over the left ankle which is non pitting in nature.

GIT- patient has the complaints of reduced appetite, nausea; vomiting etc. food intake is
very less. Mouth- on examination is normal. Bowel sounds are reduced. Abdomen could
not be palpated because of the presence of the surgical incision. Bowel habits are not
regular after the hospitalization

Extremities- range of motion of the extremities are normal. Edema is present over the left
ankle which is non pitting in nature. Because of weakness and fatigue he is not able to
walk with out support

Integumentary system- extremities are mild yellowish in color. No cyanosis. Capillary

refill is normal.

Genitor urinary system- patient has difficulty in initiating the urine stream. No complaints
of painful micturation or difficulty in passing urine.

Self acre activities- perform some of his activities, for getting up from the bed he needs
some other persons support. To walk also he needs a support. He do his personal care
activities with the support from the others

Immunizations- it is been told that he has taken the immunizations at the specific periods
itself and he also had taken hepatitis immunization around 8 years back

Sleep . He told that sleep is reduced because of the pain and other difficulties. Sleep is
reduced after the hospitalization because of the noisy environment.

Diet and nutrition- patient is taking mixed diet, but the food intake is less when compared
to previous food intake because of the nausea and vomiting. Usually he takes food three
times a day.

Habits- patient does not have the habit of drinking or smoking.

 Other complaints- patient has the complaints of pain fatigue, loss of appetite, dizziness,
difficulty in urination, etc...

2. Psycho- socio cultural

Anxious about his condition

Depressive mood

Patient is a retired teacher and he is Christian by religion.

Studied up to BA

Married and has 4 children(2sons and 2 daughters)

Congenial home environment and good relationship with wife and children

Is active in the social activities at his native place and also actively involves in the
religious activities too.

Good and congenial relationship with the neighbors

Has some good and close friend at his place and he actively interact with them. They also
very supportive to him

Good social support system is present from the family as well as from the neighborhood

3. Developmental factors

Patient confidently says that he had been worked for 32 years as a teacher and he was a
very good teacher for students and was a good coworker for the friends.

He told that he could manage the official and house hold activities very well

He was very active after the retirement and once he go back also he will resume the
activities

4. Spiritual belief system

Patient is Christian by religion

He believes in got and used to go to church and also an active member in the religious
activities.
 He has a personal Bible and he used to read it min of 2 times a day and also whenever he
is worried or tensed he used to pray or read Bible.

He has a good social support system present which helps him to keep his mind active.

INTERPERSONAL FACTORS

has supportive family and friends

good social interaction with others

good social support system is present

active in the agricultural works at home after the retirement

active in the religious activities.

Good interpersonal relationship with wife and the children

Good social adjustment present

EXTRAPERSONAL FACTORS

All the health care facilities are present at his place

All communication facilities, travel and transport facilities etc are present at his own
place.

His house at a village which is not much far from the city and the facilities are available
at the place.

Financially they are stable and are able to meet the treatment expenses.

Summary

Physiological- thin body built pallor of extremities, yellowish discoloration of the mucus
membrane and sclera of eye. Nausea, vomiting, reduced appetite, reduced urinary out put.
Diagnosed to have periampullary carcinoma.

Psycho socio cultural factors- patient is anxious abut his condition. Depressive mood. Not
interacting much with others. Good support system is present.

Developmental no developmental abnormalities. Appropriate to the age.

 Spiritual- patients belief system has a positive contribution to his recovery and
adjustment.

CLINICAL FEATURES

pain abdomen since 4 days

Discoloration of urine

Complaints of vomiting

Fatigue

Reduced appetite

on and off fever

Yellowish discoloration of eye, palms and nails

Complaints of weight loss

Edema over the left leg

Investigations Values

Hemoglobin(13-19g/dl) 6.9

HCT (40-50%) 21.9

WBC (4000-11000 12200

cells/cumm)

Neutrophil (40-75%) 77.2

Lymphocyte (25-45%) 10.5

Monocyte (2-10%) 4.5

Eosinophil (0-10%) 2.6

Basophil (0-2%) .2

Platelet (150000-400000 345000

cells/cumm)

ESR (0-10mm/hr) 86

RBS (60-150 mg/dl) 148

Pus C/S _

USG USG shows mild diffuse cell growth at the Ampulla of Vater which
suggests peri ampullary carcinoma of Grade I with out metastasis and
gross spread.

Urea (8-35mg/dl) 28

Creatinine (0.6-1.6 1.8

mg/dl)

Sodium (130-143 136

mEq/L)

Potassium (3.5-5 mEq/L) 4

PT (patient)(11.4-15.6 12.3
sec)
APTT- patient (24- 32.4 26.4
sec)

Blood group A+

HIV Negative

HCV Negative

HBsAg Negative

Urine Protein (negative) Negative

Urine WBC (0-5 Nil

cells/hpf)

RBC (nil ) Nil

Initial Treatment Post operative period (immediate post op)

Patient got admitted to ---- Medical college Inj Pethedine 1mg SOS
for 3 days and the symptoms not relieved. So
they asked for discharge and came to ---this Inj Phenargan SOS
hospital. There he was treated with:
Inj Pantodac 40 mg IV OD
Inj Tramazac IV SOS

IV fluids DNS
Inj Clexane 0.3 ml S/C OD

Treatment at this hospital... Inj Vorth P 40 mg IM Q12H

Pre operative period
Inj calcium Gluconate 10 ml over 10
 min

IV fluids DNS

Late post op period after 3 days of surgery)

Inj H Insulin S/C 6-0-6U

Tab Pantodac 40 mg 1-0-0

Tab Clovipas 75 mg 0-1-0

Cap beneficiale 0-1-0

Tab Monotrate 1-0-1

Tab Clovipas 75 mg 0-1-0

Tab Metalor XL 1-0-0

Tab Monotrate 1-0-1

Inj H Insulin S/C 6-0-6U

Tab Metalor XL 1-0-0

Inj Tramazac 50 mg IV Q8H

Other instructions
Inj Emset 4 mg Q8H

Tab Pantodac 40 mg 1-0-0

Incentive
spirometry
Cap beneficiale 0-1-0

Syp Aristozyme 1-1-1

Steam
K bind I sachet TID

Surgical management

Patient underwent Whipples procedure (pancreato inhalation

duodenectomy)

Eearly
ambulation
Diabetic diet

NURSING PROCESS

I. NURSING DIAGNOSIS

Acute pain related to the presence of surgical wound on abdomen secondary to

periampullary carcinoma
Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and
verbalization.
Primary Prevention
Assess severity of pain
by using a pain scale
Check the surgical site
for any signs of
infection or
complications
Support the areas with
extra pillow to allow
the normal alignment
and to prevent strain
Handle the area gently.
Avoid unnecessary
handling as this will
affect the healing
process
lean the area around
the incision and do
surgical dressing at the
site of incision to
prevent any form of
infections
Provide non-
pharmacological
measures for pain
relief such as
diversional activity
which diverts the
patients mind.
Administer the pain
medications as per the
prescription by the
pain clinics to relieve
Nursing Actions
secondary Prevention Tertiary Prevention
Teach the patient educate the client
about the relaxation about the importance
techniques and make of cleanliness and
him to do it encourage him to
maintain good
Encourage the patient personal hygiene.
to divert his mind
from pain and to Involve the family
engage in pleasurable members in the care
activities like taking of patient
with others
Encourage relatives
Do not allow the to be with the client in
patient to do order provide a
strenuous activities. psychological well
And explain to the being to patient .
patient why those
activities are Educate the family
contraindicated. members about the
pain management
Involve the patient in measures.
making decisions
about his own care Provide the primary
and provide a positive and secondary
psychological support preventive measures
to the client whenever
Provide the primary necessary.
preventive care when
ever necessary.
 the severity of pain.

Keep the patients body

clean in order to avoid
infection

Evaluation patient verbalized that the pain got reduced and the pain scale score also was zero. His facial expression also
reveals that he got relief from pain.

II. NURSING DIAGNOSIS

Activity intolerance related to fatigue secondary to pain at the surgery site, and dietary restrictions

Outcome/ goals: Client will develop appropriate levels of activity free from excess fatigue, as evidenced by normal vital
signs & verbalized understanding of the benefits of gradual increase in activity & exercise.

Nursing actions
Primary prevention Secondary prevention Tertiary prevention

Adequately oxygenate Instruct the client to Encourage the client to

the client avoid the activities do the mobility
which causes extreme exercises
Instruct the client to fatigue.
avoid the activities Tell the family
which causes extreme Advice the client to members to provide
fatigue perform exercises to nutritious diet in a
strengthen the frequent intervals
Provide the necessary extremities&
articles near the promote activities Teach the patient and
patients bed side. the family about the
Tell the client to importance of
Assist the patient in avoid the activities psychological well
early ambulation such as straining at being in recovery.
stool etc
Monitor clients Provide the primary
response to the Teach the client and secondary level
activities in order to about the importance care if necessary.
reduce discomforts. of early ambulation
and assist the patient
Provide nutritious diet in early ambulation
to the client.
Teach the mobility
Avoid psychological exercises appropriate
for the patient to
 distress to the client. improve the
Tell the family circulation
members to be with
him.

Schedule rest periods

because it helps to
alleviate fatigue

Evaluation patient verbalized that his activity level improved. He is able to do some of his activities with assistance.
Fatigue relieved and patient looks much more active and interactive.

NURSING DIAGNOSIS-III

Impaired physical mobility related to presence of dressing, pain at the site of surgical incision

Outcomes/goals: Patient will have improved physical mobility as evidenced by walking with minimum support and doing
the activities in limit.

Nursing actions
Primary prevention Secondary prevention Tertiary prevention

Provide active and Provide positive Educate and

passive exercises to reinforcement for reeducate the client
all the extremities to even a small and family about
improve the muscle improvement to the patients care
tone and strength. increase the and recovery
frequency of the
Make the patient to desired activity. Support the patient,
perform the and family towards
breathing exercises Teach the mobility the attainment of
which will exercises the goals
strengthen the appropriate for the
respiratory muscle. patient to improve
Coordinate the care
the circulation and
activities with the
Massage the upper to prevent
contractures family members and
and lower
extremities which other disciplines
help to improve the Mobilize the patient like physiotherapy.
circulation. and encourage him
to do so whenever Teach the
Provide articles near possible importance of
to the patient and psychological well
encourage doing Motivate the client being which
 to involve in his own influence indirectly
care activities the physical
activities within recovery
limits which Provide primary
promote a feeling of preventive measures Provide primary
well being. whenever necessary preventive
measures whenever
necessary

CONCLUSION

The Neumans system model when applied in nursing practice helped in identifying the interpersonal, intrapersonal and
extra personal stressors of Mr. AM from various aspects. This was helpful to provide care in a comprehensive manner. The
application of this theory revealed how well the primary, secondary and tertiary prevention interventions could be used for
solving the problems in the client.
 Hydatidiform Mole

Background:

Gestational trophoblastic disease encompasses several disease processes that originate in

the placenta. These include complete and partial moles, placental site trophoblastic tumors,
choriocarcinomas, and invasive moles.

Pathophysiology:

A complete mole contains no fetal tissue. Ninety percent are 46,XX, and 10% are 46,XY. All
chromosomes are of paternal origin. An enucleate egg is fertilized by a haploid sperm
(which then duplicates its chromosomes), or the egg is fertilized by 2 sperm. In a complete
mole, the chorionic villi have grapelike (hydatidiform) swelling, and there is trophoblastic
hyperplasia.

With a partial mole, fetal tissue is often present. The chromosomal complement is 69,XXX or
69,XXY. This results from fertilization of a haploid ovum and duplication of the paternal
haploid chromosomes or from dispermy. As in a complete mole, there is hyperplastic
trophoblastic tissue and swelling of the chorionic villi.

Frequency:

In Western countries, 1 per 1000-1500 pregnancies is affected. Hydatiform mole is

an incidental finding in approximately 1 per 600 therapeutic abortions.

In Asian countries, the rate is as much as 15 times higher than in the United States.
Japan has a reported rate of 2 cases per 1000 pregnancies. In the Far East, some
sources estimate the rate as high as 1 case per 120 pregnancies.

Mortality/Morbidity:

Of patients with hydatidiform mole, 20% develop a trophoblastic malignancy. After a

complete mole develops, uterine invasion occurs in 15% of patients, and metastasis occurs
in 4%. No cases of choriocarcinoma have been reported after a partial mole, although 4% of
patients with partial moles develop persistent nonmetastatic trophoblastic disease requiring
chemotherapy.

Race:

Molar pregnancy has no racial or ethnic predilection, although Asian countries show a rate
15 times higher than the US rate. Asian women living in the United States do not appear to
have a different rate of molar pregnancies than other ethnic groups.
Age:

Hydatidiform mole is more common at the extremes of reproductive age. Women in the
early teens or the perimenopausal years are most at risk. Women older than 35 years have
a 2-fold increase in risk. Women older than 40 years experience a 7-fold increase in risk
compared to younger women. Parity does not affect the risk.

CLINICAL PRESENTATION

History:

Complete mole

o Vaginal bleeding: The most common symptom of a complete mole is vaginal

bleeding. Molar tissue separates from the decidua, causing bleeding. The
uterus may become distended by large amounts of blood, and dark fluid may
leak into the vagina. This symptom occurs in 97% of cases.

o Hyperemesis: Patients may also complain of severe nausea and vomiting. This
is due to extremely elevated human chorionic gonadotropin (HCG) levels.

o Hyperthyroidism: Approximately 7% of patients may present with

tachycardia, tremor, and warm skin.

Partial mole

o Patients with partial mole do not have the same clinical features as those with
complete mole. These patients usually present with signs and symptoms
consistent with an incomplete or missed abortion.

o Vaginal bleeding

o Absence of fetal heart tone

Physical
Examination:

Complete mole

o Size inconsistent with gestational age: A uterine enlargement

greater than expected for gestational age is a classic sign of a
complete mole. Unexpected enlargement is caused by excessive
trophoblastic growth and retained blood. However, a similar
frequency of patients present with size-appropriate
enlargement or smaller-than-expected enlargement.
 o Preeclampsia: Approximately 27% of patients with complete
mole develop toxemia characterized by hypertension (BP
>140/90 mm Hg), proteinuria (>300 mg/d), and edema with
hyperreflexia. Convulsions rarely occur.

o Theca lutein cysts: These are ovarian cysts greater than 6 cm

in diameter and accompanying ovarian enlargement. These
cysts are usually not palpated on bimanual examination but are
identified by ultrasound. Patients may complain of pressure or
pelvic pain. Because of the increased ovarian size, there is a
risk of torsion. These cysts develop in response to high levels of
beta-HCG and spontaneously regress after the mole is
evacuated.

Partial mole

o Uterine enlargement and preeclampsia is reported in only 3% of

patients.

o Theca lutein cysts, hyperemesis, and hyperthyroidism are rare.

Twinning with a complete mole and a fetus with a normal placenta has
been reported. Cases of healthy infants in these circumstances have
been reported.

Causes: A diet deficient in animal fat and carotene may be a risk factor.

DIFFERENTIAL DIAGNOSIS

Hyperemesis Gravidarum
Hypertension
Hypertension, Malignant
Hyperthyroidism

Quantitative beta-HCG: HCG levels greater than 100,000 mIU/mL indicates

exuberant trophoblastic growth and raises suspicion that a molar pregnancy should
be excluded. A molar pregnancy may have a normal HCG level.

Complete blood count with platelets: Anemia is a common medical complication, as

is the development of a coagulopathy.
 Test clotting function to exclude the development of a coagulopathy or to treat one if
discovered.

Liver function tests

BUN and creatinine studies

Thyroxin: Although women with molar pregnancies are usually clinically euthyroid,
plasma thyroxin is usually elevated above normal pregnancy range. Hyperthyroidism
may be the presenting complaint.

Imaging Studies:

Ultrasound is the criterion standard for identifying both complete and partial molar
pregnancies. The classic image is of a snowstorm pattern indicating hydropic
chorionic villi.

Chest x-ray: Once a molar pregnancy is diagnosed, a baseline chest film should be
taken. The lungs are a primary site of metastasis for malignant trophoblastic tumors.

Histologic Findings:

Complete mole: Fetal tissue is absent, severe trophoblastic proliferation, hydropic

villi, and chromosomes 46,XX or 46,XY are present. Additionally, complete moles
show overexpression of several growth factors, including c-myc, epidermal growth
factor, and c-erb B-2, compared to normal placenta.

Partial mole: Fetal tissue is often present as well as amnion and fetal red blood cells.
Hydropic villi and trophoblastic proliferation are also observed.

TREATMENT

Medical Care:

Stabilize the patient.

Transfuse for anemia.

Correct any coagulopathy.

Treat hypertension.
Surgical Care:

Evacuation of the uterus by dilation and curettage is always necessary.

Prostaglandin or oxytocin induction is not recommended because of the increased

risk of bleeding and malignant sequelae.

Intravenous oxytocin should be started with the dilation of the cervix and continued
postoperatively to reduce the likelihood of hemorrhage. Consideration of using other
uterotonic formulations (eg, Methergine, Hemabate) is also warranted.

Respiratory distress is often observed at the time of surgery. This may be due to
trophoblastic embolization, high-output congestive heart failure caused by anemia,
or iatrogenic fluid overload. Distress should be aggressively treated with assisted
ventilation and monitoring, as required.

Activity:

Patients may resume activity as tolerated.

Pelvic rest is recommended for 4-6 weeks after evacuation of the uterus, and the
patient is instructed not to become pregnant for 12 months. Adequate contraception
is recommended during this period.

Monitor serial beta-HCG values to identify the rare patient who develops malignant
disease. Should a pregnancy occur, the elevation in beta-HCG would be confused
with development of malignant disease.

MEDICATION

Prophylactic chemotherapy for hydatidiform mole is controversial. Most women are cured by
evacuation of the mole.

FOLLOW-UP

Further Outpatient Care:

Serial quantitative beta-HCG levels should be determined.

o Draw the first level 48 hours after evacuation and then every 2 weeks until
the levels are within reference ranges.
 o Levels should consistently drop and should never increase.

o Once levels have reached reference ranges, check them each month for a
year.

o Any rise in levels should prompt a chest x-ray and pelvic examination to
facilitate early detection of metastases.

Contraception is recommended for 6 months to a year after evacuation.

Patients with a prior complete or partial molar pregnancy have a 10-fold risk of a
second mole in a future pregnancy. Evaluate all future pregnancies early with
ultrasound.

Complications:

Perforation of the uterus during suction curettage sometimes occurs because the
uterus is large and boggy. If perforation is noted, the procedure should be completed
under laparoscopic guidance.

Hemorrhage is a frequent complication during the evacuation of a molar pregnancy.

For this reason, intravenous oxytocin should be started prior to beginning the
procedure. Methergine and/or Hemabate should also be available. The patient should
be typed and crossed and have blood readily available.

Malignant trophoblastic disease develops in 20% of molar pregnancies. For this

reason, quantitative HCG should be serially followed for 1 year postevacuation until
results are negative.

Disseminated intravascular coagulation (DIC): Factors released by the molar tissue

have fibrinolytic activity. All patients should be screened for coagulopathy.

Trophoblastic embolism is believed to cause acute respiratory insufficiency. The

greatest risk factor is a uterus larger than that expected for a gestational age of 16
weeks. The condition may be fatal.

Prognosis:

Because of early diagnosis and appropriate treatment, the current mortality from
hydatidiform mole is essentially zero. Approximately 20% of women with a complete
mole develop a trophoblastic malignancy. Gestational trophoblastic malignancies are
100% curable.

The risk of recurrence is 1-2%.

MISCELLANEOUS
MedicalPitfalls:

Failure to consider the diagnosis in a patient who presents with hyperemesis: Many
patients with molar gestations develop intractable nausea and vomiting due to the
high levels of circulating HCG.

Failure to explain the importance of close follow-up care after evacuation of the
mole: Approximately 20% of patients with molar gestations develop trophoblastic
malignancy.

Failure to recognize the significance of plateauing beta-HCG levels: If beta-HCG

levels plateau, serious consideration must be given to the possibility of persistent or
malignant disease. A chest x-ray should be performed for metastasis. If metastatic
disease is found, staging by CT scan of the abdomen, pelvis and brain should be
performed, and the patient should be treated based on those findings.

Failure to consider the diagnosis in a patient who presents with preeclampsia before
24 weeks' gestation: Twenty-seven percent of patients with a complete mole develop
preeclampsia.