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APPLICATION OF ROY’S ADAPTATION MODEL
IN NURSING PRACTICE
Last updated on
06-03-09
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Outline
INTRODUCTION
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Born at Los Angeles on October 14, 1939 as the 2nd
child of Mr. and Mrs. Fabien Roy
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At age 14 she began working at a large general
hospital, first as a pantry girl, then as a maid, and finally as a
nurse's aid.
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She entered the Sisters of Saint Joseph of
Carondelet.
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she earned a Bachelor of Arts with a major in
nursing from Mount St. Mary's College, Los Angeles in 1963.
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a master's degree program in pediatric nursing at
the University of California ,Los Angeles in 1966.
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She also earned a master’s & PhD in Sociology in
1973 & 1977 ,respectively
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Sr. Callista had the significant opportunity of
working with Dorothy E. Johnson
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Johnson's work with focusing knowledge for the
discipline of nursing convinced Sr. Callista of the importance of
describing the nature of nursing as a service to society and
prompted her to begin developing her model with the goal of
nursing being to promote adaptation.
Sister Callista Roy
(1984), Introduction to Nursing: An Adaptation Model (2nd
ed)
ASSUMPTIONS OF ROY’S ADAPTATION MODEL
Scientific
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Systems of matter and energy progress to
higher levels of complex self-organization
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Consciousness and meaning are constitutive
of person and environment integration
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Awareness of self and environment is
rooted in thinking and feeling
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Humans by their decisions are accountable
for the integration of creative processes
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Thinking and feeling mediate human action
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System relationships include acceptance,
protection, and fostering of interdependence
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Persons and the earth have common patterns
and integral relationships
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Persons and environment transformations
are crated in human consciousness
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Integration of human and environment
meanings results in adaptation
Philosophical
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Persons have mutual relationships with the
world and God
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Human meaning is rooted in an omega point
convergence of the universe
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God is intimately revealed in the
diversity of creation and is the common destiny of creation
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Persons use human creative abilities of
awareness, enlightenment, and faith
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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
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Described as a whole comprised of parts
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Functions as a unity for some purpose
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Includes people as individuals or in
groups (families, organizations, communities, nations, and
society as a whole)
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An adaptive system with cognator and
regulator subsystems acting to maintain adaptation in the four
adaptive modes: physiologic-physical, self-concept-group
identity, role function, and interdependence
ENVIRONMENT
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All conditions, circumstances, and
influences surrounding and affecting the development and
behavior of persons and groups with particular consideration of
mutuality of person and earth resources
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Three kinds of stimuli: focal, contextual,
and residual
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Significant stimuli in all human
adaptation include stage of development, family, and culture
HEALTH AND ADAPTATION
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Health: a state and process of being and
becoming integrated and whole that reflects person and
environmental mutuality
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Adaptation: the process and outcome
whereby thinking and feeling persons, as individuals and in
groups, use conscious awareness and choice to create human and
environmental integration
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Adaptive Responses: responses that
promotes integrity in terms of the goals of the human system,
that is, survival, growth, reproduction, mastery, and personal
and environmental transformation
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Ineffective Responses: responses that do
not contribute to integrity in terms of the goals of the human
system
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Adaptation levels represent the condition
of the life processes described on three different levels:
integrated, compensatory, and compromised
NURSING
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Nursing is the science and practice that
expands adaptive abilities and enhances person and environment
transformation
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Nursing goals are to promote adaptation
for individuals and groups in the four adaptive modes, thus
contributing to health, quality of life, and dying with dignity
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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
System-a
set of parts connected to function as a whole for some purpose.
Stimulus-something
that provokes a response, point of interaction for the human
system and the environment
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Focal Stimuli-internal
or external stimulus immediately affecting the system
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Contextual Stimulus-all
other stimulus present in the situation.
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Residual Stimulus-environmental
factor, that effects on the situation that are unclear.
Regulator Subsystem-automatic
response to stimulus (neural, chemical, and endocrine)
Cognator Subsystem-responds
through four cognitive responds through four cognitive-emotive channels (perceptual and
information processing, learning, judgment, and emotion)
Behavior
-internal or external actions and reactions under specific
circumstances
Physiologic-Physical Mode
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Behavior pertaining to the physical
aspect of the human system
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Physical and chemical processes
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Nurse must be knowledgeable about normal
processes
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5 needs (Oxygenation, Nutrition,
Elimination, Activity & Rest, and Protection)
Self Concept-Group Identity
Mode
The composite of beliefs and feelings
held about oneself at a given time. Focus on the psychological and
spiritual aspects of the human system. Need to know who one is, so
that one can exist with a state of unity, meaning, and
purposefulness of 2 modes (physical self, and personal self)
Role function Mode
Set of expectations about how a person
occupying one position behaves toward a occupying another
position. Basic need-social integrity, the need to know who one is
in relation to others
Interdependence Mode
Behavior pertaining to interdependent
relationships of individuals and groups. Focus on the close
relationships of people and their purpose. Each relationship
exists for some reason. Involves the willingness and ability to
give to others and accept from others. Balance results in feelings
of being valued and supported by others. Basic need - feeling of
security in relationships
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A problem solving approach for gathering
data, identifying the capacities and needs of the human adaptive
system, selecting and implementing approaches for nursing care,
and evaluation the outcome of care provided
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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
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Assessment of Stimuli:
the second step of
the nursing process which involves the identification of
internal and external stimuli that are influencing the person’s
adaptive behaviors. Stimuli are classified as: 1) Focal- those
most immediately confronting the person; 2) Contextual-all other
stimuli present that are affecting the situation and 3)
Residual- those stimuli whose effect on the situation are
unclear.
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Nursing Diagnosis: step three of the
nursing process which involves the formulation of statements
that interpret data about the adaptation status of the person,
including the behavior and most relevant stimuli
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Goal Setting: the forth step of the
nursing process which involves the establishment of clear
statements of the behavioral outcomes for nursing care.
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Intervention: the fifth step of the
nursing process which involves the determination of how best to
assist the person in attaining the established goals
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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.
DEMOGRAPHIC DATA
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Name
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Age
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Sex
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IP number
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Education
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Occupation
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Marital status
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Religion
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Informants
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Date of admission
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Mr. NR
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53 years
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Male
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-----
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Degree
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Bank clerk
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Married
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Hindu
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Patient and Wife
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21/01/08
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FIRST LEVEL ASSESSMENT
PHYSIOLOGIC-PHYSICAL MODE
Oxygenation:
Stable process of ventilation and stable
process of gas exchange. RR= 18Bpm. Chest normal in shape. Chest
expansion normal on either side. Apex beat felt on left 5th
inter-costal space mid-clavicular line. Air entry equal
bilaterally. No ronchi or crepitus. NVBS. S1& S2
heard. No abnormal heart sounds. Delayed capillary refill+.
JVP0. Apex beat felt- normal rhythm, depth and rate.
Dorsalis pedis pulsation of affected limp is not palpable. All
other pulsations are normal in rate, depth, tension with regular
rhythm. Cardiac dull ness heard over 3rd ICS near to
sternum to left 5ht ICS mid clavicular line. S1& S2
heard. No abnormal heart sounds. BP- Normotensive. .
Peripheral pulses felt-Normal rate and rhythm, no clubbing or
cyanosis.
Nutrition
He is on diabetic diet (1500kcal).
Non vegetarian. Recently his Weight
reduced markedly (10 kg/ 6 month). He has stable digestive
process. He has complaints of anorexia and not taking adequate
food. No abdominal distension. Soft on palpation. No tenderness.
No visible peristaltic movements. Bowel sounds heard. Percussion
revealed dullness over hepatic area. Oral mucosa is normal. No
difficulty to swallow food
Elimination:
No signs of infections, no pain during
micturation or defecation. Normal bladder pattern. Using urinal
for micturation. . Stool is hard and he complaints of
constipation.
Activity and rest:
Taking adequate rest.
Sleep pattern disturbed at night due unfamiliar surrounding. Not
following any peculiar relaxation measure. Like movies and
reading. No regular pattern of exercise. Walking from home to
office during morning and evening. Now, activity reduced due to
amputated wound. Mobility impaired. Walking with crutches. Pain
from joints present. No paralysis. ROM is limited in the
left leg due to wound. No contractures present. No swelling over
the joints. Patient need assistance for doing the activities.
Protection:
Left lower fore foot is amputated. Black discoloration present
over the area. No redness, discharge or other signs of infection.
Nomothermic. Wound healing better now. Walking with the use of
left leg is not possible. Using crutches. Pain form knee and hip
joint present while walking. Dorsalis pedis pulsation, not present
over the left leg. Right leg is normal in length and size. Several
papules present over the foot. All peripheral pulses are present
with normal rate, rhythm and depth over right leg.
Senses:
No pain sensation from the wound site.
Relatively, reduced touch and pain sensation in the lower
periphery; because of neuropathy. Using spectacle for reading.
Gustatory, olfaction, and auditory senses are normal.
Fluids and electrolytes:
Drinks approximately 2000ml of water. Stable
intake out put ratio. Serum electrolyte values are with in normal
limit. No signs of acidosis or alkalosis. Blood glucose elevated
Neurological function:
He is conscious and oriented.
He is anxious about the disease condition. Like to go home as
early as possible. Showing signs of stress. Touch and pain
sensation decreased in lower extremity. Thinking and memory is
intact.
Endocrine function
He is on insulin. No signs and
symptoms of endocrine disorders, except elevated blood sugar
value. No enlarged glands.
SELF CONCEPT MODE
Physical self:
He is anxious about changes in body image,
but accepting treatment and coping with the situation. He deprived
of sexual activity after amputation.
Belongs to a Nuclear
family. 5 members. Stays along with wife and three children. Good
relationship with the neighbours. Good interaction with the
friends. Moderately active in local social activities
Personal self:
Self esteem disturbed because of financial
burden and hospitalization. He believes in god and worshiping
Hindu culture.
ROLE PERFORMANCE MODE:
He was the earning member in the family. His
role shift is not compensated. His son doesn’t have any work. His
role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship
with the neighbours. Good interaction with the friends relatives.
But he believes, no one is capable of helping him at this moment.
He says ”all are under financial constrains”. 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- 4 week. A wound first found on the
junction between first and second toe-4 month back. The wound was
non-healing and gradually increased in size with pus collected
over the area.
He first showed in
a local (---) hospital. From there, they referred to ----
medical college; where he was admitted for 1 month and 4 days. During
hospital stay great and second toe amputated. But surgical wound
turned to non- healing with pus and black colour. So the physician
suggested for below knee amputation. That made them to come to
---Hospital,
---. He underwent a plastic surgery 3 week before.
CONTEXTUAL
STIMULI:
Known case DM for
past 10 years. Was on oral hypoglycemic agent for initial 2 years,
but switched to insulin and using it for 8 years now. Not wearing
foot wear in house and premises.
RESIDUAL
STIMULI:
He had TB attack
10 year back, and took complete course of treatment. Previously,
he admitted in ---Hospital for leg pain about 4 year back.
. Mother’s brother had DM. Mother had history
of PTB. He is a graduate in humanities, no special knowledge on
health matters.
CONCLUSION
Mr.NR who was suffering with diabetes
mellitus for past 10 years. Diabetic foot ulcer and
recent amputation made his life more stressful. Nursing care of
this patient based on Roy's adaptation model provided had a dramatic
change in his condition. Wound started healing and he planned to discharge on
25th april. He studied how to use crutches and mobilized at least
twice in a day. Patient’s anxiety reduced to a great extends by
proper explanation and reassurance. He gained good knowledge on
various aspect of diabetic foot ulcer for the future self care
activities.
NURSING CARE PLAN
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ASSESS. OF BEHAVIOUR |
ASSESSMENT OF STIMULI |
NURSING DIAGNOSIS |
GOAL |
INTERVENTION |
EVALUATION |
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Ineffecitive protection
and sense in physical-physiological mode
(No pain
sensation from the wound site.)
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Focal stimuli:
Non-healing wound after
amputation of great and second toe of left leg- 4 week
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1.
Impaired skin integrity related to fragility of the skin
secondary to vascular insufficiency
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Long-term objective:
1.
amputated area will be completely healed by 20/5/08
2.Skin will
remain
intact with
no ongoing ulcerations.
Short-Term Objective:
i. Size of wound
decreases to 1x1 cm within 24/4/08.
ii. No signs of infection over
the wound within 1-wk
iii. Normal WBC values within 1-wk
iv. Presence of healthy granular tissues in the wound site
within 1-wk |
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Maintain the wound
area clean as contamination affects the healing process.
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Follow sterile
technique while providing cares to prevent infection and delay
in healing.
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Perform wound
dressing with betadine which promote healing and growth of new
tissue.
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Do not move the
affected area frequently as it affects the granulation tissue
formation.
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Monitor for signs
and symptoms of infection or delay in healing.
§
Administer the
antibiotics and vitamin C supplementation which will promote
the healing process. |
Short
term goal:
Met: size of wound decreased to less
than 1x1 cms.
WBC
values became normal on 24/4/08
Long
term goal:
Partially Met: skin partially intact
with no ulcerations.
Continue
plan Reassess goal and interventions
Unmet: not achieved complete healing
of amputated area. Continue plan Reassess goal and
interventions |
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Impaired activity in physical-physiological mode |
Focal stimuli:
During
hospital stay great and second toe amputated. But surgical
wound turned to non- healing with pus and black colour. |
2.
Impaired
physical mobility related to amputation of the left forefoot
and presence of unhealed wound
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Long term Objective:
Patient
will attain maximum possible physical mobility with in 6
months.
Short
term objective:
i.
Correct use of
crutches with in 22/4/08
ii.
walking with
minimum support-22/4/08
iii.
He will be self
motivated in activities- 20/4/08.
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§
Assess the level
of restriction of movement
§
Provide
active and passive exercises to all the extremities to improve
the muscle tone and strength.
§
Make the
patient to perform the ROM exercises to lower extremities
which will strengthen the muscle.
§
Massage the upper
and lower extremities which help to improve the circulation.
§
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.
§
Measures for pain
relief should be taken before the activities are initiated as
pain can hinder with the activity. |
Short
term goal:
Met: used crutches correctly on
22/4/08.
he is self
motivated in doing minor excesses
Partially Met: walking with minimum
support.
Long
term goal:
Unmet: not attained maximum possible
physical mobility- Continue plan Reassess goal and
interventions
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Alteration in Physical self in Self-concept mode
(He is
anxious about changes in body image)
Change in Role performance mode.
(He was the earning member in the family. His role shift is
not compensate)
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Contextual stimuli:
Known case
DM for past 10 years and on treatment with insulin for 8
years.
Residual stimuli: no special
knowledge in health matters |
3.
Anxiety related to hospital
admission and unknown Outcome of the disease and financial
constrains. |
Long term Objective:
The client will remain free from
anxiety
Short
term objective:
i.
demonstrating appropriate range
effective coping in the treatment
ii.
Being able to rest and
iii.
Asking fewer questions
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§
Allow and encourage the client
and family to ask questions. Bring up common concerns.
§
Allow the client and family to
verbalize anxiety.
§
Stress that frequent assessment
are routine and do not necessarily imply a deteriorating
condition.
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Repeat information as necessary
because of the reduced attention span of the client and family
§
Provide
comfortable quiet environment for the client and family |
Short
term goal:
Met:
demonstrated appropriate range effective coping
with treatment
He is able to rest quietly.
Long
term goal:
Unmet: client not completely
remained free from anxiety due to financial constrains-
Continue plan Reassess goal and interventions
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|
------ |
Contextual stimuli:
Known case
DM for past 10 years and on treatment with insulin for 8
years.
Residual stimuli: no special
knowledge in health matters |
4.
deficient knowledge regarding the foot care, wound care,
diabetic diet, and need of follow up care.
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Long term Objective:
Patient
will acquire adequate knowledge regarding the t foot care,
wound care, diabetic diet, and need of follow up care and
practice in their day to day life.
Short
term objective:
i.
Verbalization and
demonstration of foot care.
ii.
Strictly following
diabetic diet plan
iii.
Demonstration of
wound care. |
§
Explain the
treatment measures to the patient and their benefits in a
simple understandable language.
§
Explain about the
home care. Include the points like care of wounds, nutrition,
activity etc.
§
Clear the doubts
of the patient as the patient may present with some matters of
importance.
§
Repeat the
information whenever necessary to reinforce learning.
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Short
term goal:
Met: Verbalization and demonstration
of foot care.
Strictly following diabetic diet
plan
Unmet: Demonstration of wound care.
Long
term goal:
Unmet: not completely acquired and
practiced the required knowledge. Continue plan Reassess goal
and interventions
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REFERENCE
1)
Marriner TA, Raile AM. Nursing theorists and their work. 5th
ed. St Louis: Mosby;
2005
2)
George BJ,
Nursing Theories- The Base for Nursing
Practice.3rd ed. Chapter 8. Lobo ML. Behavioral System Model.
St Louis: Mosby; 2005
3)
Alligood MR “Nursing Theory Utilization and Application”
5th ed. St Louis: Mosby;
2005
4) Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th
ed. Philadelphia: Elsevier Mosby; 2006.
5)
Brunner LS, Suddharth DS. Text book of Medical Surgical
Nursing. 6th ed. London: Mosby; 2002
6)
Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s
principle and practices of medicine. 20th ed. London:
Churchill Livingstone Elsevier; 2006.
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