The Roy adaptation model and care of persons with Alzheimer's disease.

Roy's Nursing Model and Nursing Care of the Alzheimer's Patient Sister Calista Roy described a model for nursing practice based on the concept of adaptation. The five major concepts of nursing elaborated in the model, according to Stein (2003), are: the person, the goal of nursing, nursing activities, health and the environment. Each concept is interrelated to the larger construct of adaptation, which views the persona as having available four specific adaptation modes: physiologic, self-concept, role function, and interdependence modes (Stein, 2003). This brief report will examine this nursing model and apply it to care of the patient with Alzheimer's Disease, a progressive, debilitating and chronic condition that imposes significant care burdens on family members and healthcare professionals while simultaneously limiting the capacity of the affected patient to cope with activities of daily living (ADL) (Newman, 1997).

ASSUMPTIONS OF ROY¶S ADAPTATION MODEL Scientific

y y y y y y y y y

Systems of matter and energy progress to higher levels of complex self-organization Consciousness and meaning are constitutive of person and environment integration Awareness of self and environment is rooted in thinking and feeling Humans by their decisions are accountable for the integration of creative processes Thinking and feeling mediate human action System relationships include acceptance, protection, and fostering of interdependence Persons and the earth have common patterns and integral relationships Persons and environment transformations are crated in human consciousness Integration of human and environment meanings results in adaptation

Philosophical

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Persons have mutual relationships with the world and God Human meaning is rooted in an omega point convergence of the universe God is intimately revealed in the diversity of creation and is the common destiny of creation Persons use human creative abilities of awareness, enlightenment, and faith Persons are accountable for the processes of deriving, sustaining, and transforming the universe

PERSONS AND RELATING PERSONS

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An adaptive system with coping processes

meaning. and Protection) Self Concept-Group Identity Mode y The composite of beliefs and feelings held about oneself at a given time. and emotion) Behavior -internal or external actions and reactions under specific circumstances Physiologic-Physical Mode y y y y Behavior pertaining to the physical aspect of the human system Physical and chemical processes Nurse must be knowledgeable about normal processes 5 needs (Oxygenation. use conscious awareness and choice to create human and environmental integration Adaptive Responses: responses that promotes integrity in terms of the goals of the human system. family. survival. point of interaction for the human system and the environment Focal Stimuli-internal or external stimulus immediately affecting the system Contextual Stimulus-all other stimulus present in the situation. that is. organizations. Focus on the psychological and spiritual aspects of the human system. Need to know who one is. nations. Regulator Subsystem-automatic response to stimulus (neural. Activity & Rest. and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources Three kinds of stimuli: focal. Residual Stimulus-environmental factor. Elimination. learning. and compromised NURSING y y y Nursing is the science and practice that expands adaptive abilities and enhances person and environment transformation Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes. compensatory. reproduction. judgment. self-concept-group identity. growth. Stimulus-something that provokes a response. chemical. and personal and environmental transformation Ineffective Responses: responses that do not contribute to integrity in terms of the goals of the human system Adaptation levels represent the condition of the life processes described on three different levels: integrated. and personal self) . thus contributing to health. communities.y y y y Described as a whole comprised of parts Functions as a unity for some purpose Includes people as individuals or in groups (families. that effects on the situation that are unclear. and culture HEALTH AND ADAPTATION y y y y y Health: a state and process of being and becoming integrated and whole that reflects person and environmental mutuality Adaptation: the process and outcome whereby thinking and feeling persons. so that one can exist with a state of unity. as individuals and in groups. and interdependence ENVIRONMENT y y y All conditions. and residual Significant stimuli in all human adaptation include stage of development. 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 ROY ADAPTATION MODEL (RAM) ±TERMS y y y y y y y y System-a set of parts connected to function as a whole for some purpose. role function. mastery. circumstances. Nutrition. contextual. and purposefulness of 2 modes (physical self. and society as a whole) An adaptive system with cognator and regulator subsystems acting to maintain adaptation in the four adaptive modes: physiologic-physical. and endocrine) Cognator Subsystem-responds through four cognitive responds through four cognitive-emotive channels (perceptual and information processing. quality of life.

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.Role function Mode y Set of expectations about how a person occupying one position behaves toward a occupying another position. 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. identifying the capacities and needs of the human adaptive system. Basic needsocial integrity.those most immediately confronting the person. Ineffective Responses-neither promote not contribute to the integrity of the human system Copping Process-innate or acquired ways innate or of interacting with the changing of environment NURSING PROCESS A problem solving approach for gathering data.feeling of security in relationships Adaptive Responses-promote the integrity of the human system. Basic need . 2) Contextual-all other stimuli present that are affecting the situation and 3) Residual. Each relationship exists for some reason. Stimuli are classified as: 1) Focal. 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. 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. DEMOGRAPHIC DATA Name Age Sex IP number Education Occupation Marital status Religion Informants Date of admission Mr. the need to know who one is in relation to others Interdependence Mode y Behavior pertaining to interdependent relationships of individuals and groups. Balance results in feelings of being valued and supported by others.those stimuli whose effect on the situation are unclear. NR 53 years Male ----Degree Bank clerk Married Hindu Patient and Wife 21/01/08 . Focus on the close relationships of people and their purpose. Nursing Diagnosis: step three of the nursing process which involves the formulation of statements that interpret data about the adaptation status of the person. Involves the willingness and ability to give to others and accept from others.

Activity and rest: Taking adequate rest. Non vegetarian. Showing signs of stress. Walking with the use of left leg is not possible. Dorsalis pedis pulsation of affected limp is not palpable. No tenderness. Peripheral pulses felt-Normal rate and rhythm. No signs of acidosis or alkalosis. Now.normal rhythm. S1& S2 heard. Walking from home to office during morning and evening. reduced touch and pain sensation in the lower periphery. Thinking and memory is intact. Air entry equal bilaterally. Nomothermic. discharge or other signs of infection. . Touch and pain sensation decreased in lower extremity. Sleep pattern disturbed at night due unfamiliar surrounding. rhythm and depth over right leg. Black discoloration present over the area. Like to go home as early as possible. Pain from joints present. ROM is limited in the left leg due to wound. Stool is hard and he complaints of constipation. Patient need assistance for doing the activities. No regular pattern of exercise. Serum electrolyte values are with in normal limit. Oral mucosa is normal. JVP0. No visible peristaltic movements. Using urinal for micturation. Endocrine function y He is on insulin. tension with regular rhythm. He has stable digestive process. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line. Not following any peculiar relaxation measure. except elevated blood sugar value. Protection: Left lower fore foot is amputated. Mobility impaired. No enlarged glands. Blood glucose elevated. No signs and symptoms of endocrine disorders. Neurological function: y He is conscious and oriented. No difficulty to swallow food Elimination: No signs of infections. . All peripheral pulses are present with normal rate. No ronchi or crepitus. NVBS. Gustatory. not present over the left leg. Several papules present over the foot. Delayed capillary refill+. Normal bladder pattern. Using crutches. Stable intake out put ratio. He deprived of sexual activity after amputation. All other pulsations are normal in rate. He is anxious about the disease condition. Walking with crutches. Apex beat felt. Wound healing better now. RR= 18Bpm. no clubbing or cyanosis. Chest normal in shape. Dorsalis pedis pulsation. No abnormal heart sounds. No abnormal heart sounds. No redness. no pain during micturation or defecation. Bowel sounds heard. because of neuropathy. Apex beat felt on left 5th inter-costal space mid-clavicular line. No abdominal distension. Using spectacle for reading. Senses: No pain sensation from the wound site. Like movies and reading. depth and rate. olfaction. S1& S2 heard. He has complaints of anorexia and not taking adequate food. No paralysis. Soft on palpation. Relatively. No contractures present. Chest expansion normal on either side. Fluids and electrolytes: Drinks approximately 2000ml of water. Percussion revealed dullness over hepatic area. Pain form knee and hip joint present while walking.FIRST LEVEL ASSESSMENT PHYSIOLOGIC-PHYSICAL MODE Oxygenation: Stable process of ventilation and stable process of gas exchange. activity reduced due to amputated wound. SELF CONCEPT MODE Physical self: y He is anxious about changes in body image. Recently his Weight reduced markedly (10 kg/ 6 month). Nutrition He is on diabetic diet (1500kcal). No swelling over the joints. Right leg is normal in length and size. and auditory senses are normal. BPNormotensive. but accepting treatment and coping with the situation. depth. .

ROLE PERFORMANCE MODE: y He was the earning member in the family. he admitted in ---Hospital for leg pain about 4 year back. CONCLUSION Mr. That made them to come to ---Hospital.medical college. WBC values became normal on 24/4/08 . He underwent a plastic surgery 3 week before. But he believes. . Mother¶s brother had DM. So the physician suggested for below knee amputation. Mother had history of PTB. He is a graduate in humanities. He gained good knowledge on various aspect of diabetic foot ulcer for the future self care activities. But surgical wound turned to non. CONTEXTUAL STIMULI: Known case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years. Good interaction with the friends. He believes in god and worshiping Hindu culture.4 week.Maintain the wound area clean as contamination affects the healing process. RESIDUAL STIMULI: He had TB attack 10 year back. He was moderately active in local social activities SECOND LEVEL ASSESSMENT FOCAL STIMULUS: Non-healing wound after amputation of great and second toe of left leg. Previously. His role shift is not compensated. Diabetic foot ulcer and recent amputation made his life more stressful. Not wearing foot wear in house and premises. Good interaction with the friends relatives. ---. His role clarity is not achieved. The wound was non-healing and gradually increased in size with pus collected over the area. . A wound first found on the junction between first and second toe-4 month back. OF BEHAVIOUR Ineffecitive protection and sense in physicalphysiological mode ASSESSMENT OF STIMULI Focal stimuli: Non-healing wound after amputation of great and second toe of left leg.y Belongs to a Nuclear family. Stays along with wife and three children.Follow sterile technique while providing cares to prevent infection and EVALUATION Short term goal: Met: size of wound decreased to less than 1x1 cms. 5 members. Impaired skin integrity related to fragility of the skin secondary to vascular insufficiency GOAL Long-term objective: 1. they referred to ---. Wound started healing and he planned to discharge on 25th april. where he was admitted for 1 month and 4 days. Nursing care of this patient based on Roy's adaptation model provided had a dramatic change in his condition. His son doesn¶t have any work. He studied how to use crutches and mobilized at least twice in a day. but switched to insulin and using it for 8 years now. Patient¶s anxiety reduced to a great extends by proper explanation and reassurance.Skin will remain intact with no ongoing INTERVENTION . During hospital stay great and second toe amputated. no special knowledge on health matters. Good relationship with the neighbours. Moderately active in local social activities Personal self: y Self esteem disturbed because of financial burden and hospitalization. amputated area will be completely healed by 20/5/08 2.NR who was suffering with diabetes mellitus for past 10 years. He says ´all are under financial constrains´. INTERDEPENDENCE MODE: y He has good relationship with the neighbours.healing with pus and black colour. NURSING CARE PLAN ASSESS.4 NURSING DIAGNOSIS 1. He first showed in a local (---) hospital. From there. no one is capable of helping him at this moment. and took complete course of treatment.

Presence of healthy granular tissues in the wound site within 1-wk delay in healing.Measures for pain relief should be taken before the activities are initiated as pain can hinder with the activity. 3. No signs of infection over the wound within 1-wk iii. Administer the antibiotics and vitamin C supplementation which will promote the healing process. Short term goal: Met: used crutches correctly on 22/4/08. Normal WBC values within 1-wk iv.Make the patient to perform the ROM exercises to lower extremities which will strengthen the muscle. .Do not move the affected area frequently as it affects the granulation tissue formation. he is self motivated in doing minor excesses Partially Met: walking with minimum support.Massage the upper and lower extremities which help to improve the circulation. . . .Assess the level of restriction of movement . 2. walking with minimum support22/4/08 iii. ii.Provide active and passive exercises to all the extremities to improve the muscle tone and strength.) week ulcerations. Short term objective: i. Impaired physical mobility related to amputation of the left forefoot and presence of unhealed wound Long term Objective: Patient will attain maximum possible physical mobility with in 6 months. He will be self motivated in activities. Continue plan Reassess goal and interventions Impaired activity in physicalphysiological mode Focal stimuli: During hospital stay great and second toe amputated. Monitor for signs and symptoms of infection or delay in healing. Long term Objective: The client will remain free from anxiety Short term objective: .20/4/08.Perform wound dressing with Betadine which promote healing and growth of new tissue. .Provide articles near to the patient and encourage performing activities within limits which promote a feeling of well being.Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity. . . Correct use of crutches with in 22/4/08 ii. . But surgical wound turned to nonhealing with pus and black colour. Long term goal: Unmet: not attained maximum possible physical mobilityContinue plan Reassess goal and interventions Alteration in Physical self in Self-concept mode (He is anxious about changes in Contextual stimuli: Known case DM for past 10 years and on treatment with insulin for 8 years. .Stress that Short term goal: Met: demonstrated appropriate range effective coping with treatment He is able to rest quietly. Anxiety related to hospital admission and unknown Outcome of the disease and financial constrains. Size of wound decreases to 1x1 cm within 24/4/08. Continue plan Reassess goal and interventions Unmet: not achieved complete healing of amputated area. Short-Term Objective: i. Bring up common concerns. .Allow and encourage the client and family to ask questions. . Long term goal: Partially Met: skin partially intact with no ulcerations.Allow the client and family to verbalize anxiety.(No pain sensation from the wound site.

3rd ed. Strictly following diabetic diet plan iii. demonstrating appropriate range effective coping in the treatment ii. His role shift is not compensate) Residual stimuli: no special knowledge in health matters i. London: Churchill Livingstone Elsevier. Chapter 8. Davidson¶s principle and practices of medicine.Explain the treatment measures to the patient and their benefits in a simple understandable language. deficient knowledge regarding the foot care. . Behavioral System Model. Keene AM. Being able to rest and iii. and need of follow up care. Asking fewer questions frequent assessment are routine and do not necessarily imply a deteriorating condition. 2005 Black JM.Repeat information as necessary because of the reduced attention span of the client and family . Short term objective: i. . ii. Walker BR. 6th ed. Long term goal: Unmet: not completely acquired and practiced the required knowledge. .Clear the doubts of the patient as the patient may present with some matters of importance.Provide comfortable quiet environment for the client and family Long term goal: Unmet: client not completely remained free from anxiety due to financial constrainsContinue plan Reassess goal and interventions Contextual stimuli: Known case DM for past 10 years and on treatment with insulin for 8 years. (He was the earning member in the family. diabetic diet. 2005 George BJ.Explain about the home care. -----Residual stimuli: no special knowledge in health matters 4. Text book of Medical Surgical Nursing. 2005 Alligood MR ³Nursing Theory Utilization and Application´ 5th ed. and need of follow up care and practice in their day to day life. Demonstration of wound care. Brunner LS. 2002 Boon NA. . Philadelphia: Elsevier Mosby. . Hawks JH. Continue plan Reassess goal and interventions REFERENCE y y y y y y Marriner TA. Medical surgical nursing. Nursing theorists and their work. diabetic diet. Strictly following diabetic diet plan Unmet: Demonstration of wound care. Suddharth DS. . London: Mosby. Include the points like care of wounds. Raile AM. 20th ed. 6th ed. St Louis: Mosby. Verbalization and demonstration of foot care. St Louis: Mosby. wound care.body image) Change in Role performance mode. Colledge NR. activity etc. Lobo ML. 2006. Short term goal: Met: Verbalization and demonstration of foot care. Nursing Theories. Long term Objective: Patient will acquire adequate knowledge regarding the t foot care. nutrition. St Louis: Mosby. Hunter JAA. wound care. 2006. 5th ed.Repeat the information whenever necessary to reinforce learning.The Base for Nursing Practice.