774876

research-article2018
NSQXXX10.1177/0894318418774876Nursing Science QuarterlyKhatiban et al.

Article

Nursing Science Quarterly

Orem’s Self-Care Model With Trauma

2018, Vol. 31(3) 272­–278
© The Author(s) 2018
Reprints and permissions:
Patients: A Quasi-Experimental Study sagepub.com/journalsPermissions.nav
DOI: 10.1177/0894318418774876
https://doi.org/10.1177/0894318418774876
journals.sagepub.com/home/nsq

Mahnaz Khatiban, PhD,1 Fatemeh Shirani, MSN,1

Khodayar Oshvandi, PhD,1 Ali Reza Soltanian, PhD,1
and Ramin Ebrahimian, MD1

Abstract
To examine if the application of Orem’s self-care model could improve self-care knowledge, attitudes, practices, and
respiratory conditions of trauma patients with chest tubes, a quasi-experimental study was conducted. The participants were
assigned to two groups—namely, Orem’s model and routine care. Although the patients’ self-care knowledge, attitudes,
and practices were improved in both groups over the course of 3 days since the initial assessments, there was a greater
degree of improvement in the experimental group than that in the control group. However, there were no differences in
the improvement of the chest parameters between the two groups. Orem’s model was effective in improving self-care in
patients with chest tube.

Keywords
chest tubes, Iran, Orem self-care model, trauma

Chest trauma is one of the primary causes of morbidity and
mortality in developing countries (Demirhan, Onan, Oz, &
Halezeroglu, 2009). In the United Kingdom, the overall mor-
tality rate of patients with at least one chest injury is 18.7%
of 1,164 patients (Veysi, Nikolaou, Paliobeis, Efstathopoulos,
& Giannoudis, 2009). In Turkey, chest trauma, which resulted
from vehicular accidents, is 47.5% of 4,205 patients, and
72% of those were blunt injuries (Demirhan et al., 2009). In
the assessment and management of patients with blunt or
penetrating chest trauma, the level of respiratory function
should be considered and assessed (Mohammed, 2015).
Chest drainage system is a lifesaving procedure in the
management of chest trauma (Kesieme et al., 2012). In
Turkey, chest tube is the choice of treatment for 46% of
patients with chest trauma complicated with rib fractures and
hemopneumothorax (Demirhan et al., 2009). The caregiving
for such patients begins after the insertion of a chest tube
(Durai, Hoque, & Davies, 2010). Having a trained and com-
mitted therapeutic team, as well as knowledgeable patients,
is the key concept in providing the best respiratory caregiv-
ing practices.
For patients with chest tubes, it is important to prevent
atelectasis and stiffness of the shoulder joint mobility and to
improve respiratory conditions. These can all be achieved
through the patients’ awareness of self-care behaviors, sup-
port, and with encouragement to maintain such behaviors.
Self-care behaviors in such people are comprised of effective
coughing, deep breathing, incentive spirometer, and shoulder
joint exercise using their appropriate range of motion (Lewis,
Dirksen, Heitkemper, & Bucher, 2013). Persons who are
armed with sufficient knowledge and who demonstrate a pos-
itive attitude become consistent skilled performers of these
self-care behaviors. This, in turn, results in more positive out-
comes. Persons therefore should be taught and supported to
carry out the fundamentals of self-care practices to help them
for the early removal of their chest drainage system.
Self-care is the combination of behaviors and practices
that leads to survival, good health, and healing (Baker &
Denyes, 2008). It is a vital component of healthcare, and it
distinguishes nursing from other disciplines when used as
the basis for practice. It is often considered a nursing out-
come (Sidani, 2003). Orem presented her first self-care
deficit theory in 1959. In Orem’s conceptual framework,
everyone is a self-care agent who has the capacity to engage
in self-care behaviors. Self-care agency involves the indi-
vidual’s cognitive, physical, psychological, and behavioral
domains (Fawcett & Desanto-Madeya, 2012).
According to Orem’s theory, the nurse can help patients to
accomplish the self-care activities to maintain health, life,
and wellness. As patients have the ability to think intellectu-
ally and assume responsibilities, they are deemed able to
appropriately conduct self-care. In a supportive-educative
system, the nurse provides information and support while the
patient learns strategies to overcome self-care deficits
(Allison, 2007; Bernier, 2002). It has been emphasized that
self-care behaviors can lead to the achievement of desired
1
Hamadan University of Medical Sciences, Hamadan, Iran
Khatiban et al. 273
goals and increased patient satisfaction. It can also decrease
the risk of complications, reduce the rate of readmission, and
promote healing after surgery and illness. The increased feel-
ing of control, responsibility, independence, and autonomy
felt by patients improves their coping, decreases the burden
of chronic disease, and improves their sense of well-being,
performance, and quality of life. These improved outcomes,
in turn, help for better symptom management and diminish
healthcare costs (Sidani, 2003).
Background
Orem’s theory has been implemented in many studies.
The application of this self-care model has had positive
effects on patients with asthma (Altay & Cavusoglu, 2013;
Kaur, Behera, Gupta, & Verma, 2009), multiple sclerosis
(Afrasiabifar, Mehri, Sadat, & Shirazi, 2016; Shahdadi,
Dahmardeh, Salari, & Ahmadidaresima, 2017), myocardial
infarction (Mohammadpour, Rahmati Sharghi, Khosravan,
Alami, & Akhond, 2015), heart failure (Williams, 2015;
Zamanzadeh, Valizadeh, Howard, & Jamshidi, 2013), diabe-
tes (Bahramnezhad, Fathi, Shiri, & Asgari, 2015; Oshvandi
et al., 2014), and cystic fibrosis (Baker & Denyes, 2008).
However, we found no study that applied this model to acute
patients such as those with chest trauma. We assumed that
Orem’s model has the potential to assist trauma patients with
a chest drainage system to manage their respiratory function.
Aim and Hypothesis
The aim of this study is to examine the effectiveness of nurs-
ing care among trauma patients with chest tubes using
Orem’s self-care model. The hypothesis: Compared with
those in the control group, participants in the experimental
group will have statistically significant improvements in
self-care knowledge, attitudes, practices, and respiratory
conditions from baseline to 3 days after intervention.
Method
This study is a quasi-experimental double-blinded study,
with one experimental group receiving Orem’s self-care
model and a control group receiving care as usual. The out-
come measure was the effectiveness of Orem’s model in
improving self-care knowledge, attitudes, practices, and
respiratory conditions among trauma patients with chest
tubes.
Setting
Participants were recruited at three surgical wards of a pub-
lic tertiary hospital in Hamadan, Iran from December 2012
to May 2013. This hospital has the specialty and subspe-
cialty services for all patients, especially those with trau-
matic injuries.
Sample
There were 62 participants in total, and the sample size was
calculated to be 31 patients per group using 80% power with
a two-sided significance level of α = 0.05 and effect size of
0.70. All newly hospitalized patients with chest trauma with
chest tubes at the research setting were invited to take part in
the research.
In the research setting, there are either five or six mul-
tibed rooms in each of the three surgical wards. Thus, the
use of research randomizer software was not possible due to
contaminant bias. Accordingly, the randomization was cre-
ated by writing the names of the wards on opaque, equal-
sized papers, which were then folded and placed in a box.
An individual randomly drew them from the box. Of the
three surgical wards, two wards (A and B) were randomly
allocated to the control group, and the third ward (C) was
allocated to the experimental group. Through convenience
sampling, the patients for the study group were selected
from these three wards. The Figure shows the flowchart of
the study. The detailed selection criteria of the patients have
been adapted in a previous study published in Persian
(Khatiban, Shirani, Oshvandi, Soltanian, & Ebrahimiyan,
2014). In summary, the inclusion criteria were as follows:
ages from 18 to 65 years, no previous history of underlying
pulmonary disorders (asthma, chronic obstructive pulmo-
nary disease, empyema, or lung malignancy), and con-
sciousness with ability to respond to questions, no complete
bed rest, and no flail chest. The patients whose chest tubes
were suddenly removed or those who were candidates for
thoracotomy were excluded in our study.
The Interventions
The experimental group received a supportive-educative sys-
tem plus routine care. The supportive-educative system was
designed on the studies about Orem’s model (Alligood &
Marriner-Tomey, 2006; Bernier, 2002; Fawcett & Desanto-
Madeya, 2012; Manzini & Simonetti, 2009; Oshvandi et al.,
2014) and the chest tube care (Durai et al., 2010; Lewis et al.,
2013; Muslim et al., 2008). For each participant in the exper-
imental group, the nursing process was planned according to
the supportive-educative system of the Orem’s model. In this
study, self-care education, motivation, and support for the
following therapy were done via interaction and co-responsi-
bility between the patient and the nurse involved. To promote
participants’ self-care knowledge, attitudes, and practice,
multiple learning opportunities about the chest drainage sys-
tem and all its components (equipment like the connections
and bottle) were provided. Other self-care education pro-
vided included suitable positions, effects of walking and
duration of walks, proper usage of the spirometer, and the
dietary regimen. Furthermore, additional basic self-care
behaviors that are in accordance with the needs, such as per-
forming effective coughs, respiratory practices, avoiding
274 Nursing Science Quarterly 31(3)
stimulant agents and smoking, avoiding infectious condi-
tions, and exercising of limbs and shoulders, were also
taught, The patients were also instructed to report and inspect
for any abnormal chest tube conditions such as air or liquid
leakage. During all of these sessions, one of the participants’
family members was also educated to provide support and
incentive. They were encouraged and supported by the nurse
during the practices and demonstrations. In each session, the
nurse assured them of their skills by asking them to show the
self-care activities. Any and all possible questions were
explored and answered in accordance with the individual
needs. The sessions were scheduled in an accommodating
manner that was based on level of fatigue, doctor appoint-
ments, meal times, and pain levels. The duration and num-
bers of sessions varied depending on the understanding and
willingness to participate. These sessions continued until the
participants were able to master and demonstrate the self-
care techniques independently. They were also provided with
two educational pamphlets and one poster. To maintain con-
sistency, the same researcher delivered the intervention to all
the participants in the experimental group. The participants,
the nurse, and the physician who completed the research
checklists did not know to which group the participant had
been allocated.
In the control group, the participants only received rou-
tine nursing care, which consisted of patient education, nurs-
ing care, and inspection of the patient’s catheter site. The
content of the routine education focused on providing verbal
instructions for breathing and shoulder and arm exercises as
well as care for the chest tube. However, there was no sup-
portive care given for the participants and their family mem-
bers in terms of education and participation in care and
evaluating the self-care skills.
Data Collection
The data were collected on the first day of chest tube inser-
tion (baseline) and 3 days after (before the chest tube was
removed). The applied tools were three questionnaires and a
checklist according to the related literature, which were as
follows:
1. The Patient’s Demographic Characteristics Form,
including gender, educational level, employment sta-
tus, marital status, residency, smoking, and opium
abuse according to the related literature (Alligood &
Marriner-Tomey, 2006).
2. Self-care Knowledge, Attitudes, and Practice of
patients with chest tube (self-care KAP) question-
naires included three sections:
a. The self-care Knowledge questionnaire consisted
of 10 multiple choice questions, which assessed
the level of patients’ information on self-care.
This part of the questionnaire was derived from
medical and nursing literatures (Brunicardi, 2005;
Brunner, Smeltzer, Bare, Hinkle, & Cheever,
2010; Durai et al., 2010). The correct answer was
rated with a 1 score, and the incorrect answer was
rated 0. Therefore, the scores ranged from 0 to 10
(0 to 3 = fair; >3 to 6 = moderate; >6 to 10 = good
knowledge).
b. The self-care Attitude questionnaire consisted
of 10 questions based on the 5-point Likert-
type scale (1 = completely disagree to 5 =
completely agree). The questionnaire assessed
attitudes toward performing self-care behaviors
to achieve early improvement. At the head of
this part, some information was provided about
self-care activities for patients with chest tube,
such as positioning, walking, shoulder and limb
motion, coughing, deep breathing, and checking
the bottles and tubes. The scores ranged from 10
to 50 (10 to 23 = negative; >23 to 36 = neutral;
>36 to 50 = positive attitude). This part was also
developed according to the medical and nurs-
ing literatures (Chan, 1996; Haire-Joshu, Fisher,
Munro, & Wedner, 1993).
c. The self-care Practice of the patient with chest
tube questionnaire included 14 items that deter-
mined (in a yes or no format) the performance of
the self-care behaviors in the last 24 hours. The
scores ranged from 0 to 14 (0 to 4 = fair; >4 to
9 = mediocre; >9 to 14 = good practice). It was
also developed from the medical and nursing lit-
eratures (Brunicardi, 2005; Brunner et al., 2010;
Durai et al., 2010).
3. Respiratory Condition Checklist with 14 items
regarding the main criteria for improvement of the
respiratory condition. It consisted of the abnormali-
ties in the respiratory parameters developed accord-
ing to the Bates’ Guide to Physical Examination and
History Taking (Bickley & Szilagyi, 2012).
All study tools were developed based on relevant literature.
For the face and content validity and content validity index
(CVI) of the study tools, all of these study tools were given to
10 experts who are medical-surgical nursing faculty members,
thorax surgeons, and nurses in surgery wards. Then, the study
tools were refined according to their comments. The overall
CVI was estimated to be 91% for the Self-Care KAP question-
naires and 96% for the Respiratory Condition checklist.
For the reliability of the study tools, 10 patients of the same
population completed the Self-care KAP questionnaires, and a
researcher completed 10 Respiratory Condition Checklists for
the same set of patients. The results showed that the Self-care
KAP questionnaires and the Respiratory Condition Checklist
had desirable reliability—with Cronbach’s alpha values of
0.76, 0.70, 0.75, and 0.85, respectively. To eliminate researcher
Khatiban et al. 275
Figure.  Flowchart of the study.
bias, the Respiratory Condition Checklist was completed by
an external trained observer, and all patients’ chest radiographs
were confirmed by a physician with no information of the
sample groups.
All trauma patients with chest tube that were hospitalized
in the research setting were invited to participate in the
research. Once the patients provided their written consent,
the researcher completed the Patient’s Demographic
Characteristics Form via interviews at the beginning of the
study. Neither the participants nor the observers knew which
participants belonged to the control group or the experimen-
tal group. The self-care KAP questionnaires were completed
by the participants, whereas the Respiratory Condition
Checklist was completed by a nurse blinded to the groups. A
physician, who was also blinded to the groups, evaluated the
participants’ chest radiographs. The results of the question-
naires and checklist were gathered twice: on the first day of
the chest drainage system insertion and 3 days later.
Analysis
For the statistical analysis, the statistical software SPSS ver-
sion 16.0 for windows (SPSS Inc., Chicago, IL) was used.
The results were presented as mean ± standard deviation for
the quantitative variables and the demographic data, whereas
the outcome variables were summarized through descriptive
statistics. To compare the differences of the demographic
variables and the baseline scores of the study between the
experimental and control groups, Chi-Square test, Fisher’s
Exact test, and Mann–Whitney U test or independent sample
t test were used. Dependent sample t test or Wilcoxon test
was performed to examine the changes of the outcome vari-
able scores in each group over time. P values of 0.05 or less
were considered statistically significant.
Ethical Considerations
This study was approved by the Research Ethics Committee
and the Research Committee of Hamadan University
of Medical Sciences (number of approval document:
9107252645). All patients were assured that participation in the
study was voluntary and that they could opt out from the study
at any time without any negative consequences. Written
informed consent was obtained, and all of the data collected
were kept confidential. All of the educational materials were
also delivered to the control group after the third day.
Results
Of 82 patients evaluated for eligibility, 17 patients did not meet
the inclusion criteria, and three patients declined to participate.
Finally, 62 patients with chest tubes were selected. The figure
shows the recruitment and allocation of participants in this
research.
276 Nursing Science Quarterly 31(3)

Table 1.  Comparison of the Studied Demographic toward, and practices in self-care behaviors were enriched
Characteristics Between Groups (n = 62). in both groups. However, there was greater improvement
Experimental Control in participants who received Orem’s model than those in
Group Group the control group over the course of 3 days from the initial
(n = 31) (n = 31) assessments.
Variables F (%) F (%) p Value Comparison of participants’ respiratory well-being. With
Male gender 23 (74.2) 21 (67.7) 0.58 regard to respiratory status, the assessed respiratory parame-
Education level ters, including respiratory rates (p < .05), respiratory rhythms
 Illiterate 5 (16.7) 3 (9.7) 0.69 (p < .01), skin and cutaneous color (p < .01), respiratory effort
  Primary level 17 (54.8) 15 (48.4) (p < .05), and respiratory sounds (p < .05), were improved in
  Diploma degree and up 9 (28.1) 13 (42.0) both groups. However, the results illustrated a significantly
Employment state greater improvement in the experimental group than that in
 Employed 18 (58.1) 17 (54.8) 0.18 the control group. The chest symmetry, tactile fremitus, per-
 Unemployed 13 (41.9) 14 (45.2) cussion notes, ineffective cough, sputum, and chest radio-
Married 22 (71.0) 21 (67.7) 0.78 graph parameters similarly improved in both groups 3 days
Urban residency 25 (80.6) 26 (83.9) 0.93 after the insertion of the chest tube (p > .05). For both control
Cigarette smoking 13 (41.9) 11 (35.5) 0.43 and experimental groups, the results demonstrated a signifi-
Opium abuse 7 (22.6) 7 (22.6) 0.99 cant improvement in the patients’ dyspnea and chest wall
pain. The patients’ blood oxygen saturation levels decreased
in both groups; however, this problem was only noteworthy
Table 2.  Means and Standard Deviations in Patients’ Self-Care
Knowledge, Attitude, and Practices at Baseline and Posttest (n = 62).
(p < .05) in the control group (Table 3).

Experimental Control
Group Group Discussion
Item (n = 31) (n = 31) p Value To the best of our knowledge, our study was the first research
Knowledge (range = 0 to 10) ever to assess the value of Orem’s model to improve knowl-
  Before intervention 4.61 ± 2.47 4.39 ± 1.86 0.92 edge, attitudes, practices, and respiratory conditions of acute
  After intervention 8.65 ± 1.85 5.03 ± 1.70 <0.001 patients such as trauma patients who require a chest drainage
  p value <0.001 0.007   system. The demonstration of the beneficial effects of Orem’s
Attitude (range = 10 to 50) model for these patients is of great importance, as consider-
  Before intervention 37.52 ± 3.10 37.90 ± 3.30 0.636 ably frequent occurrences of chest traumas require chest tube
  After intervention 40.29 ± 3.71 38.16 ± 2.71 <0.012 insertion. According to the results, all study aspects, includ-
  p value <0.001 0.35   ing the self-care knowledge, attitudes, and practices, as well
Practices (range = 0 to 14) as the respiratory conditions, significantly improved after the
  Before intervention 8.61 ± 2.47 8.52 ± 2.11 0.87 application of Orem’s model.
  After intervention 12.74 ± 1.33 9.36 ± 2.09 <0.001 The effectiveness of Orem’s model in other patient sub-
  p value <0.001 0.062   groups has been well established. For example, the application
of Orem’s model in adolescents with asthma increased their
self-care skills (Altay & Cavusoglu, 2013) and decreased per-
Comparison of Sociodemographic and Self-Care ceived stress (Hemati, Abasi, Mosaviasl, Shakerian, & Kiani,
2016). It was also demonstrated in other studies that Orem’s
Requisites
model led to the improvement in the practices of the hyperten-
The participants were hospitalized due to vehicular accidents sive patients (Manzini & Simonetti, 2009). The results of yet
(59.3%), falls (23.7%), physical fights (12%), and building another study showed that the level of the self-care knowledge,
collapses (5%). The mean age of the patients was approxi- attitudes, and practices for patients with a diabetic foot greatly
mately similar for both groups (p = 0.43): 40.70 ± 14.44 improved (Bolourchifard, Neishabory, & AbedSaeedi, 2009). A
years in the experimental group and 37.77 ± 17.01 years in supportive-educative nursing system based on Orem’s theory
the control group. The other study demographic characteris- could improve the self-care knowledge, motivation, and skills
tics were also comparable between the experimental and of myocardial infarction patients (Mohammadpour et al., 2015).
control groups, as shown in Table 1. The fatigue of multiple sclerosis patients was significantly
decreased after applying Orem’s self-care model (Afrasiabifar
Comparison of Self-care KAP. The results of the three parts et al., 2016). An Orem’s self-care program improved the quality
of Self-care KAP questionnaire were presented in detail in of life in burn patients (Hashemi et al., 2014) as well as in
Table 2. In general, the patients’ knowledge of, attitudes patients with migraine (Zarandi, Raiesifar, & Ebadi, 2016).
Khatiban et al. 277

Table 3.  Comparison Between the Control and Experimental Despite the significant results, this study revealed some
Group According to the Respiratory Condition Variables at potential limitations. A small sample size and short follow-
Baseline and Posttest (n = 62). up period due to the nature of the condition are examples of
Experimental Control these limitations.
Group Group
Variables (n = 31) (n = 31) p Value

  1- Normal respiratory rate (12 to 20 per minute)

Relevance to Clinical Practice
  Before intervention 21 (67.7) 23 (74.2) 0.56 Orem’s model can be incorporated into routine care to facili-
  After intervention 28 (90.3) 25 (80.6) 0.28 tate the continuity of care in an acute and short-term situa-
  p value  0.016 0.69  
tion. Moreover, it can be provided by surgical nurses after
  2- Normal respiratory rhythm
  Before intervention 21 (67.7) 27 (87.1) 0.068 minimal education. The effectiveness of the supportive-edu-
  After intervention 31 (100) 31 (100) — cative system of nursing makes it meaningful to promote
  p value  0.002 0.13   professional nursing as well as to diminish the gap between
  3- Normal skin & cutaneous color theory and practice.
  Before intervention 21 (67.7) 20 (64.5) 0.56
  After intervention 31 (100) 25 (80.6) 0.010
  p value  0.031  0.062   Conclusion
  4- Normal respiratory efforts
  Before intervention 22 (71.0) 25 (80.6) 0.56 Many studies confirm the effectiveness of Orem’s model in
  After intervention 28 (90.3) 24 (77.4) 0.67 patients with chronic diseases. This study demonstrated that
  p value  0.031 0.45   this model is also valuable in patients with an acute condition.
  5- Normal chest shape and symmetric A supportive-educative nursing system of Orem’s model was
  Before intervention 29 (93.5) 29 (93.5) 1.000
effective in improving knowledge, attitudes, and performance
  After intervention 28 (90.3) 30 (96.8) 0.61
  p value 1.00 1.00  
regarding any self-care behaviors and respiratory conditions
  6- Normal tactile fremitus of patients with a chest tube for a short period of time. An
  Before intervention 24 (77.4) 25 (80.6) 0.76 educative and supportive nursing system is feasible and use-
  After intervention 29 (93.5) 27 (87.1) 0.39 ful in acute settings.
  p value  0.062 0.69  
  7- Normal percussion notes Declaration of Conflicting Interests
  Before intervention 24 (77.4) 29 (93.5) 0.07
  After intervention 29 (93.5) 28 (90.3) 1.000 The authors declared no potential conflicts of interest with respect
  p value 0.18  1.000   to the authorship and/or publication of this review.
  8- Normal respiratory sounds
  Before intervention 10 (16.1) 19 (38.7) 0.022 Funding
  After intervention 19 (61.73) 26 (83.9) 0.046
  p value  0.012  0.016   The authors disclosed receipt of the following financial support for
  9- Lack of dyspnea the research, authorship, and/or publication of this article: This
  Before intervention 1 (3.2) 0 (0.0) 1.000 study was based on a master’s thesis in critical care nursing, which
  After intervention 16 (51.6) 8 (25.8) 0.037 was approved and funded by the Vice-Chancellor for Research and
  p value  0.031  0.008   Technology of Hamadan University of Medical Sciences.
10- Lack of chest-wall pain
  Before intervention 1 (3.2) 2 (6.5) 1.000 References
  After intervention 16 (51.6) 10 (32.3) 0.12
  p value <0.001  0.008   Afrasiabifar, A., Mehri, Z., Sadat, S. J., & Shirazi, H. R. G. (2016).
11- Lack of ineffective cough The effect of Orem’s self-care model on fatigue in patients
  Before intervention 7 (22.6) 9 (29.0) — with multiple sclerosis: A single blind randomized clinical trial
  After intervention 5 (16.1) 6 (19.4) 0.74 study. Iranian Red Crescent Medical Journal, 18(8), e31955.
  p value 0.73 0.55   doi:10.5812/ircmj.31955
12- Lack of sputum Alligood, M. R., & Marriner-Tomey, A. (2006). Nursing theory:
  Before intervention 16 (51.6) 14 (45.2) 0.61 Utilization & application. St. Louis, MO: Mosby/Elsevier.
  After intervention 15 (48.4) 13 (41.9) 0.61 Allison, S. E. (2007). Self-care requirements for activity and rest:
  p value  1.000  1.000   An Orem nursing focus. Nursing Science Quarterly, 20(1), 68-
13- Normal chest x-ray parameters 76. doi:10.1177/0894318406296297
  Before intervention 12 (38.7) 14 (45.2) 0.80 Altay, N., & Cavusoglu, H. (2013). Using Orem’s self-care model
  After intervention 14 (45.2) 13 (41.9) 0.61 for asthmatic adolescents. Journal for Specialists in Pediatric
  p value 0.50  1.000   Nursing, 18(3), 233-242. doi:10.1111/jspn.12032
14- Normal oxygen saturation (SO2) Bahramnezhad, F., Fathi, A., Shiri, M., & Asgari, P. (2015). The
  Before intervention 31 (100) 31 (100) — effects of self-care training on self-perception in diabetic ado-
  After intervention 28 (90.3) 25 (80.6) 0.068 lescents. British Journal of Medicine and Medical Research,
  p value 0.25  0.031  
8(10), 855-862.
278 Nursing Science Quarterly 31(3)
Baker, L. K., & Denyes, M. J. (2008). Predictors of self-care in
adolescents with cystic fibrosis: A test of Orem’s theories of
self-care and self-care deficit. Journal of Pediatric Nursing,
23(1), 37-48. doi:10.1016/j.pedn.2007.07.008
Bernier, F. (2002). Applying Orem’s self-care deficit theory of nurs-
ing to continence care: Part 2. Urologic Nursing, 22(6), 384-390.
Bickley, L., & Szilagyi, P. G. (2012). Bates’ guide to physical
examination and history-taking. Philadelphia, PA: Lippincott
Williams & Wilkins.
Bolourchifard, F., Neishabory, M., & AbedSaeedi, Z. (2009). The
effects of group and individual education on the level of the
knowledge, attitude and practice of self care in patients with
diabetic foot ulcer. Iran Journal of Nursing, 22(59), 33-41.
Brunicardi, F. C. (2005). Schwartz’s principles of surgery. New
York, NY: McGraw-Hill.
Brunner, L.S., Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever,
K. H. (2010). Brunner & Suddarth’s textbook of medical-sur-
gical nursing (12 ed., Vol. 1). Philadelphia, PA: Lippincott
Williams & Wilkins.
Chan, C. S. Y. (1996). What do patients expect from consultations
for upper respiratory tract infections? Family Practice, 13(3),
229-235.
Demirhan, R., Onan, B., Oz, K., & Halezeroglu, S. (2009).
Comprehensive analysis of 4205 patients with chest trauma: A
10-year experience. Interactive Cardiovascular and Thoracic
Surgery, 9(3), 450-453. doi:10.1510/icvts.2009.206599
Durai, R., Hoque, H., & Davies, T. W. (2010). Managing a chest
tube and drainage system. AORN Journal, 91(2), 275-280;
281-273. doi:10.1016/j.aorn.2009.09.026
Fawcett, J., & Desanto-Madeya, S. (2012). Contemporary nursing
knowledge: Analysis and evaluation of nursing models and
theories. Philadelphia, PA: FA Davis.
Haire-Joshu, D., Fisher, E. B., Munro, J., & Wedner, H. J. (1993).
A comparison of patient attitudes toward asthma self-man-
agement among acute and preventive care settings. Journal of
Asthma, 30(5), 359-371.
Hashemi, F., Rahimi Dolatabad, F., Yektatalab, S., Ayaz, M., Zare,
N., & Mansouri, P. (2014). Effect of Orem self-care program
on the life quality of burn patients referred to Ghotb-al-din-
e-Shirazi Burn Center, Shiraz, Iran: A randomized controlled
trial. International Journal of Community Based Nursing and
Midwifery, 2(1), 40-50.
Hemati, Z., Abasi, S., Mosaviasl, F., Shakerian, B., & Kiani, D.
(2016). Effect of Orem’s self-care model on perceived stress
in adolescents with asthma referring the asthma and allergy
clinic, Isfahan, 2014. International Journal of Community
Based Nursing and Midwifery, 4(3), 247-255.
Kaur, S., Behera, D., Gupta, D., & Verma, S. K. (2009). Evaluation
of a ‘supportive educative intervention’ on self care in patients
with bronchial asthma. Nursing and Midwifery Research, 5(2),
124-132.
Kesieme, E. B., Dongo, A., Ezemba, N., Irekpita, E., Jebbin, N.,
& Kesieme, C. (2012). Tube thoracostomy: Complications and
its management. Pulmonary Medicine Journal, 2012, 256878.
doi:10.1155/2012/256878
Khatiban, M., Shirani, F., Oshvandi, K., Soltanian, A., &
Ebrahimiyan, R. (2014). Effect of supportive-educative nursing
system on self-care skills in trauma patients with chest drainage
system. Hayat, 20(1), 48-58.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L.
(2013). Medical-surgical nursing: Assessment and manage-
ment of clinical problems, single volume. St. Louis, MO:
Elsevier Health Sciences.
Manzini, F. C., & Simonetti, J. P. (2009). Nursing consultation
applied to hypertensive clients: Application of Orem’s self-
care theory. Revista Latino-Americana De Enfermagem, 17(1),
113-119.
Mohammadpour, A., Rahmati Sharghi, N., Khosravan, S., Alami,
A., & Akhond, M. (2015). The effect of a supportive educa-
tional intervention developed based on Orem’s self-care theory
on the self-care ability of patients with myocardial infarction:
A randomised controlled trial. Journal of Clinical Nursing,
24(11-12), 1686-1692.
Mohammed, H. M. (2015). Chest tube care in critically ill patient:
A comprehensive review. Egyptian Journal of Chest Diseases
and Tuberculosis, 64(4), 849-855.
Muslim, M., Bilal, A., Salim, M., Khan, M. A., Baseer, A., &
Ahmed, M. (2008). Tube thorocostomy: Management and
outcome in patients with penetrating chest trauma. Journal of
Ayub Medical College Abbottabad, 20(4), 108-111.
Oshvandi, K., Jokar, M., Khatiban, M., Keyani, J., Yousefzadeh,
M. R., & Sultanian, A. R. (2014). The effect of self care
education based on teach back method on promotion of self
care behaviors in Type II diabetic patients: A clinical trial
study. Iranian Journal of Diabetes and Metabolism, 13(2),
131-143.
Shahdadi, H., Dahmardeh, H., Salari, S., & Ahmadidaresima, S.
(2017). The effect of a self-care training program based on
Orem model on anxiety in patients with multiple sclerosis (MS).
Indian Journal of Public Health Research & Development,
8(1), 269-274.
Sidani, S. (2003). Self-care. In D. Doran & J. Almost (Eds.),
Nursing sensitive outcomes: The state of the science (pp. 65-
114). Toronto, Ontario, Canada: Jones & Bartlett Learning.
Veysi, V. T., Nikolaou, V. S., Paliobeis, C., Efstathopoulos, N., &
Giannoudis, P. V. (2009). Prevalence of chest trauma, associ-
ated injuries and mortality: A Level I trauma centre experience.
International Orthopaedics, 33(5), 1425-1433. doi:10.1007/
s00264-009-0746-9
Williams, N. M., II. (2015). The impact of self-care education
on heart failure patients with a high risk for readmission.
Unpublished capstone project for Doctorate of Nursing
Practice, Gardner-Webb University, Hunt School of Nursing.
Retrieved from https://digitalcommons.gardner-webb.edu/
nursing_etd/226/
Zamanzadeh, V., Valizadeh, L., Howard, A., & Jamshidi, F.
(2013). A supportive-educational intervention for heart
failure patients in Iran: The effect on self-care behaviours.
Nursing Research and Practice, 2013, 492729. doi:http://
dx.doi.org/10.1155/2013/ 492729
Zarandi, F. M., Raiesifar, A., & Ebadi, A. (2016). The effect of
Orem’s self-care model on quality of life in patients with
migraine: A randomized clinical trial. Acta Medica Iranica,
54(3), 159-164.