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APPLICATION OF BETTY NEUMAN'S SYSTEMS MODEL
LAST UPDATED ON
10/29/2008
OBJECTIVES:
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to assess the patient condition by the various
methods explained by the nursing theory
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to identify the needs of the patient
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to demonstrate an effective communication and
interaction with the patient.
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to select a theory for the application according
to the need of the patient
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to apply the theory to solve the identified
problems of the patient
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to evaluate the extent to which the process was
fruitful.
INTRODUCTION
SYSTEM MODEL- BETTY
NEUMAN
A theory is a
group of related concepts that propose action
that guide practice. A nursing theory is a set
of concepts, definitions, relationships, and
assumptions or propositions derived from nursing
models or from other disciplines and project a
purposive, systematic view of phenomena by
designing specific inter-relationships among
concepts for the purposes of describing,
explaining, predicting, and /or prescribing.
The Neuman’s system model has two major components
i.e. stress and reaction
to stress. The client in the Neuman’s 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 lifespan.
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:
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Intrapersonal
- occur within person, e.g. emotions and
feelings
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Interpersonal
- occur between individuals, e.g. role
expectations
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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.
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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.
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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.
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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:
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Physical/Physiological
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Psychological
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Socio-cultural
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Developmental
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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.
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The
internal environment exists within the
client system.
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The
external environment exists outside
the client system.
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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 energyis
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:
Neuman’s 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 client’s and
caregiver’s 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.
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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)
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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.
WHIPPLE’S 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.
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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
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Have you experienced a similar problem?
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The fatigue is similar to that of previous
hospitalization (after the surgery of the BPH)
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Severity of pain was some what similar in the
previous time of surgery i.e. TURP.
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Was psychologically disturbed during the
previous surgery i.e. TURP.
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What helped then- family members psychological
support helped him to over come the crisis
situation
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Anticipation of the future
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Concerns about the healthy and speedy recovery.
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Anticipation of changes in the lifestyle and
food habits
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Anticipating about the demands of modified life
style
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Anticipating the needs of future follow up
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What doing to help himself?
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Talking to his friends and relatives
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Reading the religious materials i.e. reading the
Bible
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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
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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
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Trying to accept the reality etc..
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What is expected of others?
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Family members visiting the patient and spending
some time with him will help to a great extent
to relieve his tension.
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Convey a warm and accepting behaviour towards
him.
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Family members will help him to meet his own
personal needs as much as possible.
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Involve the patient also in taking decisions
about his own care, treatment, follow up etc
STRESSORS AS PERCEIVED BY THE CARE GIVER.
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Major stress areas
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Persistent fatigue
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Massive weight loss i.e.( 8 kg of body weight
with in 4 months)
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History of BPH and its surgery
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Persistence of urinary symptoms (difficulty in
initiating the stream of urine) and edema of the
lower extremities
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Persistent disease- chronic hypertensive since
last 28 years
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Depressive ideations and negative thoughts
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Present circumstances differing from the usual
pattern of living
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