1.

THEORY APPLICATION
INTRODUCTION The history of professional nursing begins with Florence nightingale. She envisioned nurses as a body of educated women, when women were neither educated nor employed in the public services. Later in last century nursing began with a strong emphasis on practice. Following that came the curriculum era which addressed the questions about what the nursing students should study in order to achieve the required standard of nursing. As more and more nurses began to pursue higher degrees in nursing, there emerged the research era. Later graduate education and masters education was given much importance. The application of the theory to provide a nursing care is given much of importance. Many a nursing schools and colleges have developed their curriculum based on a theory and so only the students apply the theory in the patient care. As a part of my advanced nursing practice ,I have selected one patient for providing care based on the Orems Self Care Theory. The main objectives of this process were: to assess the patient condition by the various methods explained by the nursing theory to identify the needs of the patient to demonstrate an effective communication and interaction with the patient. to select a theory for the application according to the need of the patient to apply the theory to solve the identified problems of the patient to evaluate the extent to which the process was fruitful.

Demographic data Name Age Sex Education Occupation Marital status Religion War d Hospital No. Address

Mr. Basavaraj B.K 60 years Male 8th standard Coolie Married Hindu Casuality 02111033 Nelavagilu Kumarapatanam P.O Rannebennur T.Q Haveri(dist) Type 2 D.M ,Meningo-encephalitis

Diagnosis

Presenting history of Client brought to the hospital with complaint of body pain ,fever, disorientation, and decreased food illness Presenting signs and intake on 16/1/2011. Patient has urine output is symptoms reduced and blood glucose level is 211mg/dl. Catheter and ryles tube is inserted. 40% of oxygen administration given and antibiotics started .To correct blood sugar 40 units of Human Actrapid 40 ml of Normal Saline is infused at rate of 1ml/hr as per GRBS.On 18.1.2011. patient became restless, non verbalizing and unconscious. So patient is intubated and connected to ventilator on SIMV mode due to desaturation.Patient is also having renal failure now and RFT values are elevated.So they are planning to do dialysis.

Past health history

He had past history of DM and was on OHA for past 20 years. His family is a joint family .He is living with his son.

Family history

Socio-economic status

Poor economic status. He is the earning member of the family. He was taking a mixed diet.. He had bad habbits of chewing tobacco.But stopped 1 year back. Married.

Personal history

Marital/ sexual history

Physical Examination Region Remarks

General Unconscious,moderately built ,now inadequate nutrition. appearanc e Skin Skin has the changes as in normal old age, with slight loss of elasticity. Mild edema present over ankle region. Eyes Hearing Neck & Throat Mouth Pupil reaction is normal. Pallor of conjunctiva is noted. No signs of infection. Ears are normal without any discharge. No nodules or ulcers palpated over the pinna. Mild distension of neck veins present. Normal thyroid glands. Tonsils are normal with no signs of inflammation.ET tube present. Oral hygiene is maintained. Slight coating of the tongue present. Discolouration of the tooth present, no loss of tooth. Dental caries present. Respiratory Rate: 20 breath per minute. Symmetrical chest expansion. Crackles present. S1 and S2 heard normally. No murmurs or other abnormal heart sounds heard. Peripheral pulses were feeble. No varicosities present. Peripheral pulses are feebly palpable. Mild pallor present. Abdomen is distended , hepatomegaly present. Bowel sounds are sluggish. He is unconscious .Some involuntary movement o extremities poresent.No fracture or joint abnormality present.

Respiratio n Heart Sounds Vascular System Abdomen Musculos keletal

System Reflexes: Genitourinary system

All the deep tendon reflexes and superficial reflexes were poor. Bladder is catheterized. urine output is less. No urinary infection.

Application of Orems theory of Self care deficit

The theory of self care deficit was proposed by Dorothea.E. Orem. She was born in Maryland in 1914. She completed her basic nursing education from Washington in 1930s. She received her Bachelors and Masters of sciences in nursing education in 1939 and 1945 consecutively. The self care deficit theory proposed by her is a combination of three theories, i.e. theory of self care, theory of self care deficit and the theory of nursing systems. In the theory of self care, she explains self care as the activities carried out by the individual to maintain their own health. The self care agency is the acquired ability to perform the self care and this will be affected by the basic conditioning factors such as age, gender, health care system, family system etc. Therapeutic self-care demand is the totality of the self care measures required. The self care is carried out to fulfill the self-care requisites. There are mainly 3 types of self care requisites such as universal, developmental and health deviation self care requisites. Whenever there is an inadequacy of any of these self care requisite, the person will be in need of self care or will have a deficit in self care. The deficit is identified by the nurse through the thorough assessment of the patient. Once the need is identified, the nurse has to select required nursing systems to provide care: wholly compensatory, partly compensatory or supportive and educative system. The care will be provided according to the degree of deficit the patient is presenting with. Once the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get an idea about whether the mutually planned goals are met or not. Thus the theory could be successfully applied into the nursing practice.

In case of Mr. Basavaraj with Meningoencephalites and on ventilator is not able to do the ADL by himself. Thus, the nursing system is wholly compensated. Theory of self-care deficit was applied to this patient to provide a comprehensive need based care to the patient. The application and evaluation of the theory is as follows.

BASIC CONDITIONING FACTORS: Age Gender Health status

60 yrs male Meningoencephalites .Now on ventilator due to unconsciousness and desaturation.

Development state Socio cultural issues

Adult male He had formal education till 8th std and was working as a coolie worker.

Health care system Family system Patterns of living

Institutional health care Married. Joint family with wife and son.

Living with family members, not sedentary living.

Environment

Rural area.

Resources UNIVERSAL SELFCARE REQUISITES:

He is the bread winner of the family.

 Air Water

No spontaneous breathing. Patient is connected to mechanical ventilator on SIMV mode. Patient is on I.V. fluids - NS and DNS.

Food

Ryles tube feeding. The diet was mainly fluid diet rich in protein, calories ,vitamins and minerals to protect from bacterial infection and to promote easy recovery.Sugar is restricted as he is diabetic. His 24 hrs urine output 350ml . His daily living activities were restricted since patient is unconscious and on mechanical ventilator. Chest physio and limb & ROM exercises done.

Elimination Activity/rest

Social interaction

No social interaction.

Prevention hazards

Side rails of the cot are raised to protect from of hazards. Patient is also restrained to prevent the accidental self injuries and removal of tubings. Reassured the client relatives that they should carry out their role or function and meet ADL of patient and support the patient to return to his normal level of living.

Promotion of human functioning

DEVELOPEMENTAL SELFCARE REQUISITES: Maintenance of Not able to feed self and performing the mouth care ,toileting, bathing and other self care

developmental environment

activities.

Patient relatives seek medical facilities when they feel he is disoriented, food intake & Prevention/management activities are decreased and his temperature is of the conditions threatening the normal increased. development

HEALTH DEVIATION SELF CARE REQUISITES

Patient relatives report the problems to the Adherence to medical physician when in the hospital and sometimes neglects and try to manage the problem by self. regimen They cooperate with the medication. Not much aware about the use and side effects of medicines. Not aware about the actual disease process. Not aware about the side effects of the Awareness of potential problem associated with medications and complications of disease process. the regimen Relatives have adapted to the illness and inability of patient to carry out daily living activities . Modification of self image to incorporates changes in health status Finding difficulty in adjusting with the patients Adjustment of lifestyle illness and hospitalization and role changes in to accommodate family. changes in the health status and medical regimen

MEDICAL PROBLEM AND PLAN

Physicians perspective of the condition: Diagnosed with Meningoencephalites, Pyogenic meningitis, Type 2 Diabetes Mellitus.Now he is on ventillator due to unconsciousness & desaturation. He is getting the following medications: Inj. Monocef 2g IV BD Inj. Ampicillin 2gm IV BD Tab. Doxy 100mg BD Inj. Rezat 120mg IV OD Inj. Pan 40mg IV OD Inj. Dalacin 600mg IV TID Neb. With Asthalin QID Inj. Dopamine @ 5ml/hr IV Infusion IVF.DNS/NS with Optineuron @ 75ml/hr IVF. 40ml NS with 40units of Human Actrapid infusion @1ml/hr as per GRBS . Investigations: RBS 211 mg/dl(60-150) (elevated) BUN 135 mg/dl(8- 35)(elevated) S.Creatinine 2.8 mg/dl(0.6-1.6)(elevated) Sodium 135mEq/l(135-145) Potassium 5.7 mEq/l (3.5- 4.5)(elevated) Medical Diagnosis: Meningoencephalites, Pyogenic meningitis, Type 2 Diabetes Mellitus. Medical Treatment: Medication ,ventilator support, respiratory therapy and physiotherapy. AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF SELF-CARE DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING DIAGNOSIS. Air Water Food Elimination Activity/ Rest Solitude/ Interaction Prevention of hazards Promotion of normal function Maintain a developmental environment.

Prevent or manage the developmental threats Maintenance of health status Awareness and management of the disease process Adherence to the medical regimen Awareness of potential problem Modify self image Adjust life style to accommodate health status changes and medical regimen. Thus in the patient Mr. Basavaraj the areas that need assistance were Air Water Food Elimination Activity/ Rest Prevention of hazards Promotion of normalcy Maintenance of health status Awareness and management of the disease process. Adherence to the medical regimen Awareness of potential problem. Adjust life style to accommodate health status changes and medical regimen

Problems identified and prioritized nursing diagnosis:

1.Ineffective airway clearance related to inability to raise secretions as evidenced by diminished breath sounds and cough reflex. 2.Fluid volume excess related to reduced renal function and decreased urine output. 3. Altered body temperature, Hyperthermia related to infectious process. 4. Imbalanced nutrition less than body requirement related to inability to take food secondary to loss of consciousness. 5. Self-care deficit eating, bathing, grooming etc related to altered level of consciousness secondary to brain infection 6. Impaired physical mobility related to loss of consciousness. 7. Anxiety (family members) related to abrupt change in health status of family member, hospital environment, role changes and uncertain future.

8.Deficient knowledge (family members) about the disease process, its management and complications. 9. Risk for complications increased ICP related to increase in body temperature and cerebral metabolic demands. 10.Risk for impaired skin integrity related to immobility and prolonged bed rest secondary to unconsciousness

NURSING PROCESS ACCORDING TO OREMS THEORY OF SELF CARE DEFICIT NURSING DIAGNOSIS (diagnostic prescription) OUTCOMES AND PLAN (Prescriptive operations) IMPLEMENTATION (Control operations) EVALUATION. (Regulatory operations)

THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: Air ADEQUACY OF SELF CARE AGENCY: Inadequate 1. Ineffective airway clearance related to inability raise secretions as evidenced by diminished breath sounds and cough reflex. The patient will maintain normal airway clearance as evidenced by ease of breathing and ability to bring out secretions.

Wholly compensatory and supportive educative nursing system

Assess for the patency of airway. Auscultate breath sounds noting the areas of decreased ventilation and presence of

The patient is maintaining clear airway as evidenced by normal respiratory rate 20/mtand SpO2 95% and absence of

adventitious secretions. breath sounds . Place the patient in a slightly head end up position. Remove secretions by suctioning to clear airway. Maintain humidification of the oxygen. Provide chest physiotherapy and postural drainage. Provide nebulisation with duolin respules.

THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: Water ADEQUACY OF SELF CARE AGENCY: Inadequate 2.Fluid volume Patient will excess,hypervolemia related maintain to reduced renal function normal fluid and decreased urine output . volume as evidenced by output in proportion with the input. Assess for fluid excess by checking intake output chart,BP and for edema. Check for jugular vein distension and orbital edema. Maintain hourly Patients urine output is less when compared to intake.Output is 350ml/day.

intake output chart. Administer diuretics as per doctors order. Routinely check BUN and S.creatinine levels.

THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: Promotion of normal function ADEQUACY OF SELF CAREAGENCY:Inadequate will 3.Altered body temperature, Patient Hyperthermia related to maintain normal body infectious process. temperature as evidenced by absence of infection. Assess the vital signs every second hourly. Provide well ventilated room. Apply tepid sponging. Increase fluids to replace fluids lost through increased metabolism and diaphoresis as per intake output chart. Administer antipyretics as per physicians order. Administer antibiotics as per Patients fever has decreased to 98.8F from 101.2 F

order. Maintain aseptic precaution while giving suctioning and during other procedure. Remove secretions by suctioning ,chest physiotherapy, and postural drainage to prevent infections. Provide catheter care. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: Food ADEQUACY OF SELF CAREAGENCY:Inadequate 4. Imbalanced nutrition less than body requirement related to inability to take food secondary to loss of consciousness. The patient will maintain normal nutritional status as evidenced by adequate intake of food and normal intake and output chart Assess the patients nutritional status. Monitor fluids administered through I.V route and Ryles tube and calculate daily caloric intake to determine adequacy of caloric intake. Select nutritional Patients nutritional status inadequate evidenced inability take food self as patient is ventilator.

is as by to by the on

supplements to provide additional calories, iron, protein, and fluids. Maintain intake and output chart. Educate the patient family about prescribed diet that will maintain nutrition. Provide small and frequent, easily digestable fluid diet. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: Activity ADEQUACY OF SELF CAREAGENCY:Inadequate 5. Self-care deficit eating, bathing,toileting, grooming etc. related to altered level of consciousness secondary to brain infection. The patient will achieve self care activities within normal limit as evidenced by normal level of consciousness and ability to perform ADLs. Assess the patients level of consciousness and ability to perform the activities of daily living. Meet patients activities of daily living such as(giving sponge bath, mouth care, hair care). The patient is unable to perform self care activities and he is still on ventilator.

Meet the patients nutritional needs by giving food through ryles tube. Encourage family members to assist in meeting patients self care activities. Change the position every second hourly and give back care and massage.

Evaluation of the Application of Self Care Deficit Theory The theory of self care deficit when applied, could identify the self care requisites of Mr.Basavaraj from various aspects. This was helpful to provide care in a comprehensive manner. Patient was unconscious and family members were very cooperative. The application of this theory revealed how well the wholly compensatory and supportive and educative system could be used for solving the problems of unconscious patients who are on ventilator.

2.THEORY APPLICATION
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 Neumans system model has two major components i.e. stress and reaction to stress. The client in the Neumans system model is viewed as an open system in which repeated cycles of input, process, out put and feed back constitute adynamic 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 optimalstability. 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 whenenvironmental stressors invade the normal line of defense. Example: activation ofthe immune response after invasion of microorganisms. If the lines of resistanceare effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death. VI. RECONSTITUTION

Reconstitution is the increase in energy that occurs in relation to the degree of reaction to the stressor. Reconstitution begins at any point following initiation of treatment for invasion of stressors. Reconstitution may expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness. VII. STRESSORS The Neuman Systems Model looks at the impact of stressors on health and addresses stress and the reduction of stress (in the form of stressors). Stressors are capable of having either a positive or negative effect on the client system. A stressor is any environmental force which can potentially affect the stability of the system: they may be: Intrapersonal - occur within person, e.g. emotions and feelings Interpersonal - occur between individuals, e.g. role expectations Extra personal - occur outside the individual, e.g. job or finance pressures The person has a certain degree of reaction to any given stressor at any given time. The nature of the reaction depends in part on the strength of the lines of resistance and defense. By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system . VIII. PREVENTION As defined by Neuman's model, prevention is the primary nursing intervention. Prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body.

Primary -Primary prevention occurs before the system reacts to a stressor. On the one hand, it strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors, and on the other hand manipulates the environment to reduce or weaken stressors. Primary prevention includes health promotion and maintenance of wellness. Secondary-Secondary prevention occurs after the system reacts to a stressor and is provided in terms of existing systems. Secondary prevention focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor. Tertiary -Tertiary prevention occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution. NURSING METAPARADIGM A. PERSON The person is a layered multidimensional being. Each layer consists of five person variables or subsystems:Physical/Physiological, Psychological, Socio-cultural, Developmental,Spiritual. The layers, usually represented by concentric circle, consist of the central core, lines of resistance, lines of normal defense, and lines of flexible defense. The basic core structure is comprised of survival mechanisms including: organ function, temperature control, genetic structure, response patterns, ego, and what Neuman terms 'knowns and commonalities'. Lines of resistance and two lines of defense protect this core. The person may in fact be an individual, a family, a group, or a community in Neuman's model. The person, with a core of basic structures, is seen as being in constant, dynamic interaction with the environment. Around the basic core structures are lines of defense and resistance (shown diagrammatically as concentric circles) with the lines of resistance nearer to the core. The person is seen as being in a state of constant change and-as an open system-in reciprocal interaction with the environment (i.e. affecting, and being affected by it).

B. THE ENVIRONMENT

The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time. These forces include the intrapersonal, interpersonal and extra personal stressors which can affect the person's normal line of defense and so can affect the stability of the system.The internal environment exists within the client system. The external environment exists outside the client system. Neuman also identified a created environment which is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness. C. HEALTH Neuman sees health as being equated with wellness. She defines health/wellness as "the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Neuman, 1995)". As the person is in a constant interaction with the environment, the state of wellness (and by implication any other state) is in dynamic equilibrium, rather than in any kind of steady state. Neuman proposes a wellness-illness continuum, with the person's position on that continuum being influenced by their interaction with the variables and the stressors they encounter. The client system moves toward illness and death when more energy is needed than is available. The client system moves toward wellness when more energy is available than is needed. D. NURSING Neuman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor. The person is seen as a whole, and it is the task of nursing to address the whole person. Neuman defines nursing as actions which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors. Neuman states that, because the nurse's perception will influence the care given, then not only must the patient/client's perceptions be assessed, but so must those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of reaction to stressors, and the use of primary, secondary and tertiary interventions. Neuman envisions a 3-stage nursing process: 1. Nursing Diagnosis - based of necessity in a thorough assessment, and with consideration given to five variables in three stressor areas. 2. Nursing Goals - these must be negotiated with the patient, and take account of patient's and nurse's perceptions of variance from wellness 3. Nursing Outcomes - considered in relation to five variables, and

achieved through primary, secondary and tertiary interventions. NURSING PROCESS BASED ON SYSTEM MODEL Assessment: Neumans first step of nursing process parallels the assessment and nursing diagnosis of the six phase nursing process. Using system model in the assessment phase of nursing process the nurse focuses on obtaining a comprehensive client data base to determine the existing state of wellness and actual or potential reaction to environmental stressors. Nursing diagnosis- the synthesis of data with theory also provides the basis for nursing diagnosis. The nursing diagnostic statement should reflect the entire client condition. Outcome identification and planning- it involves negotiation between the care giver and the client or recipient of care. The overall goal of the care giver is to guide the client to conserve energy and to use energy as a force to move beyond the present. Implementation nursing action are based on the synthesis of a comprehensive data base about the client and the theory that are appropriate to the clients and caregivers perception and possibilities for functional competence in the environment. According to this step the evaluation confirms that the anticipated or prescribed change has occurred. Immediate and long range goals are structured in relation to the short term goals. Evaluation evaluation is the anticipated or prescribed change has occurred. If it is not met the goals are reformed. ASSESSMENT PATIENT PROFILE 1. Name - Mr.Kenchappa 2. Age - 75 years 3. Sex Male 4.Hospital No. - 02066670 5. Marital status married. 6.DOA:15/1/11 6.Diagnosis Scrub Typhus, Thrombocytopaenia and ARF. STRESSORS AS PERCEIVED BY CLIENT (Information collected from the patient and his Daughter) Major stress area, or areas of health concern:

Patient was suffering from severe fever associated with chills and body ache for the past 8 days. Now he is having fatigue and weakness of body, loss of appetite, nausea and vomiting, decreased urine output.His bladder is catheterised and is giving Ryles tube feed. Patient is been diagnosed to have Scrub typhus, thrombocytopaenia and ARF. 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. He had history of herniorrhaphy 5 yrs back. He has no history of any disease like DM ,HTN,BA and TB. Life style patterns: Patients occupation is agriculture.He cares for wife and other family members. Living with his son and his family. Participates in community group meeting i.e. local politics.Has a supportive spouse and family .Taking mixed diet. Has habits of smoking and occational drinking. Spends leisure time by reading news paper, watching TV, spending time with family members and relatives. Past expereiences He has no previous experience of hospitalization with similar disease. But he was hospitalized after herniorraphy. Accordng to him the present disease condition is much more severe than the previous condition. So he is psychologically depressed. Anticipation of the future: Concerns about the healthy and speedy recovery. Anticipation of changes in the lifestyle and food habits. Anticipating about the demands of modified life style. Anticipating the needs of future follow up. The things going to help himself

 Talking to his friends and relatives while they come to visit him. Instillation of positive thoughts i.e. planning about the activities to be resume after discharge, spending time with grand children, going to the temple , return back to the social interactions etc. Avoiding the negative thoughts i.e. diverts the attentions from the pain or difficulties and try to eliminate the disturbing thoughts about the disease and hospitalization and trying to accept the reality etc. He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope. He sets his major goal i.e. a healthy and speedy recovery. He sees the health care providers as a source of information.He tries to consider them as a significant members who can help to overcome the stress He seeks both psychological and physical support from the care givers, friends and family members. He sees the family members as helping hands and feels relaxed when they are with him. The things expected of others Family members visiting the patient and spending some time with him will help to a great extent to relieve his tension. Convey a warm and accepting behaviour towards him. Family members will help him to meet his own personal needs as much as possible. Involve the patient also in taking decisions about his own care, treatment, follow up etc. STRESSORS AS PERCEIVED BY THE CARE GIVER. Major stress areas: Altered body temperature ,Fever. Fatigue, Nausea and vomiting ,Decreased appetite. Decreased urine ouput. Hospitalization .Present circumstances differing from the usual pattern of living. Anxiety regarding ryles tube feeding and catheterisation of bladder. Anticipatory anxiety concerns the recovery and prognosis of the disease negative thoughts that he has become a burden to his children. Anticipatory anxiety concerning the restrictions of diet and the life style modifications which are to be followed.

Clients past experience with the similar situations He has no previous experience of hospitalization with similar disease. But he was hospitalized after appendicectomy and herniorraphy Client perceived that the present disease condition is much more severe than the previous condition. So patient is psychologically depressed.

Future anticipations Client is capable of handling the situation- will need support and encouragement to do so. He has the plans to go back home and to resume the activities which he was doing prior to the hospitalization. He also planned in his mind about the future follow up . The things the client can do to help himself Patient is using his own coping strategies to adjust to the situations. He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope. He sets his major goal i.e. a healthy and speedy recovery. Client's expectations of family, friends and caregivers. He sees the health care providers as a source pf information. He tries to consider them as a significant members who can help to over come the stress He seeks both psychological and physical support from the care givers, friends and family members He sees the family members as helping hands and feels relaxed when they are with him. Evaluation/ summary of impressions There is no apparent discrepancies identified between patients perception and the care givers perceptions. INTRAPERSONAL FACTORS Physical examination : Vital Signs T- 102F, P 100/mt , R 30/mt. BP- 120/80 mm of Hg.

General Appearance Patient is conscious and oriented,moderately build , now the nutrition is inadequate due to illness. Head and face: Hairs are normally distributed Face is bilaterally symmetrical. Eyes: Eye lashes: equally distributed Eye lids: no styes or blepheritis Conjunctiva: pale Sclera: white in color Pupils: equally reacting to light No squint or strabismus present.

Ears : Pinna: no abnormalities and is in straight line with the outer canthus of the eyes. No wax collection or ear discharge Hearing acuity: normal Nose: No nasal deviation No nasal discharges. No polyps or obstruction present. Ryles tube present. Mouth: Tongue: Normal Tooth : Dental carries present. Gum: No gum bleeding or gingivitis present Uvula: in midline Throat and Neck: Throat: No swallowing difficulty or tonsillitis Neck stiffness present. Neck: Trachea is in position. No thyroid gland or lymph node enlargement. Range of motion: Normal . Chest: Respiratory system:

Respiratory rate: 30 breaths per minute. Percussion: Normal sounds. Palpation: No palpable mass present . Auscultation: Breath sounds normal.

Cardiovascular system: Heart rate: 100 beat per minute Heart sounds: Normal, no murmurs present. Gastrointestinal system: Inspection : Normal Auscultation: Sluggish bowel sounds. Palpation : soft to touch , no organomegaly. Percussion :Normal. Appetite is decreased ,he has nausea and vomiting.

Genitourinary system: Bladder is catheterised, urine output is less compared to intake. No haematuria present. Musculoskeletal system There are no congenital deformities. Range of motion: normal. Neurological system: Alert, conscious and oriented. No sluttering or other speech problems. Reflexes are normal. 2.Personal system Immunizations - It is been told that he has taken the immunizations at the specific periods itself . Sleep He told that sleep is reduced because of the pain and other difficulties. Sleep is reduced after the hospitalization because of the noisy environment. Diet and nutrition- Patient is taking mixed diet, but the food intake is less when compared to previous food intake because of fever , decreased appetite, nausea and vomiting . Usually he takes food three times a day. Habits- patient does not have the habit of drinking or smoking.

 Other complaints - Patient has the complaints of body pain , fatigue and weakness of body, loss of appetite, nausea and vomiting, decreased urine output. Bladder is catheterised and ryle,s tube feeding is giving.

3.Psycho- socio cultural system. Anxious about his condition Depressive mood Patients occupation is agriculture and he is Hindu by religion. Studied up to 9th standard. Married and has 4 children(2sons and 2 daughters) Congenial home environment and good relationship with wife and children Is active in the social activities at his native place and also actively involves in the religious activities too. Good and congenial relationship with the neighbors Has some good and close friend at his place and he actively interact with them. They also very supportive to him. Good social support system is present from the family as well as from the Neighbourhood. 4. Developmental factors Patient has his own agricultural fields and now also he is working there.He told that he could manage the house hold activities very well. He was very active and once he go back also he will resume the activities. 5. Spiritual belief system Patient is Hindu by religion. He believes in god and used to go to temple and also an active member in the religious activities. He has a good social support system present which helps him to keep his mind active. INTERPERSONAL FACTORS Has supportive family and friends. God social interaction with others. Good social support system is present. Active in the agricultural works and household activities at home . Active in the religious activities. Good interpersonal relationship with wife and the children. Good social adjustment present. EXTRAPERSONAL FACTORS All the health care facilities are present at his place All communication facilities, travel and transport facilities etc are present at

his own place. His house at a village which is not much far from the city and the facilities are available at the place. Financially they are stable and are able to meet the treatment expenses. Investigation Values: Haemoglobin(13-19gm/dl) 11.7gm/dl (decreased) WBC (4000-11000 cells/mm3) - 20,000 cells/mm3(increased) Platelet (1,50000 4,00000 cells/mm3) - 99,000cells/mm3 (decreased) ESR (0-10mm/hr) - 86mm3 (increased) RBS (60-150 mg/dl) - 128mg/dl Urea (8-35mg/dl) - 48 mg/dl (increased) Creatinine (0.6-1.6mg/dl) 1.7 mg/dl Sodium (130-143 mEq/L) 141 mEq/L Potassium (3.5-5 mEq/L) 4.1 mEq/L Peripheral smear report Normocytic normochromic anaemia thrombocyotopaenia. Medications: Inj Monocef 2 gm IV Q12H Inj.Pan 40 mg IV BD T .Dolo 650 mg TID IVF DNS @ 60ml/hr with 1 amp. MVI NURSING DIAGNOSIS AND CARE PLAN 1. Altered body temperature, Hyperthermia related to infectious process. 2. Fluid volume excess, hypervolemia related to reduced renal function and decreased urine output . 3. Imbalanced nutrition less than body requirement related loss of appetite, nausea and vomiting. 4. Activity intolerance related to fatigue and weakness of body. 5. Anxiety related to abrupt change in health status and hospitalization. 6. eficient knowledge about the disease process, its management and complications. 7. Risk for complications increased ICP related to increase in body temperature and cerebral metabolic demands. 8. Risk for impaired skin integrity related to decreased level of activity and strict bed rest.

with

CONCLUSION The Neumans system model when applied in nursing practice helped in identifying the interpersonal, intrapersonal and extra personal stressors of Mr.Kenchappa from various aspects. This was helpful to provide care in a comprehensive manner. The application of this theory revealed how well the primary, secondary and tertiary prevention interventions could be used for solving the problems in the client. REFERENCES 1. Alligood M R, Tomey A M. Nursing Theory: Utilization & Application . (3rd ed). Missouri:Elsevier Mosby Publications; 2002. 2. Tomey AM, Alligood MR. Nursing theorists and their work. (5th ed.).Philadelphia: Mosby publications ;2002.p. 3. George JB. Nursing Theories: The Base for Professional Nursing Practice . (5th ed). NewJersey : Prentice Hall;2002. 4.Jacqueline F. Analysis and evaluation of conceptual models of nursing. (3rd ed). Philadelphia:FA Davis Company:1995.

CARE PLAN

ASSESSMENT DIAGNOSIS Subjective data: Patient says that I am feeling cold. Objective data: T- 102F P 100/mt R 30/mt Body is hot to touch . Patient looked fatigue. Diagnosis is meningo encephalitis. 1.Altered body temperature, Hyperthermia related to infectious process.

GOAL

PLAN OF ACTION

IMPLEMENTATION

EVALUATION

Patient maintains normal body temperature as evidenced by reduction in temperature to normal level .

SECONDARY PREVENTION: Monitor vital signs. Give tepid sponge. Provide a well ventillated room. Administer antipyretics. Administer antibiotics as advised. Administer fluids through ryles tube as per doctors order. Maintains aseptic technique during IV injections.

Monitored vital signs Temperature became normal to 2nd hourly. 99F. Gave tepid sponge. Provided a well ventillated room. Administered antipyretics(T.Dolo 650 TID). Administer antibiotics as advised(inj. Pipzo 4.5 gm IV ) Administer fluids through ryles tube as per doctors order. Maintained aseptic technique during IV injections.

Subjective data:Patient says that now I am passing only small amount of urine. Objective data: I/O = 2000/780 RFT is elevated Appetite is decreased. Fatigue present.

2)Fluid volume excess related to failure of kidneys to produce urine.

Patient will achieve and maintain balance in fluid volume state as evidenced by normal I/O and RFT values.

SECONDARY PREVENTION: Assess general condition of the patient Maintain I/O chart Check weight daily. Restrict intake of sodium and potassium Teach patient regarding importance of maintaining prescribed fluid restriction. Watch for signs of fluid overload; hypertension, pulmonary edema Administer diuretics. TERTIARY PREVENTION Maintain I/O chart. Check weight daily. Restrict intake of sodium and potassium. Teach patient Assessed general condition of the patient. Maintained I/O chart Restricted intake of sodium and potassium. Taught patient regarding importance of maintaining prescribed fluid restriction. Watched for signs of fluid overload; hypertension, pulmonary edema. Urine output increased to 860ml with intake of 1800ml.RFT values are not normal.

regarding importance of maintaining prescribed fluid restriction. Watch for signs of fluid overload; hypertension. Prevent and treat infections promptly. Check RFT values intermittently. Subjective data: Patient says that he feels fatigue as not eating anything. Objective data: Appetite is decreased. Nausea and vomiting present. Getting only IV fluids and ryles tube 3.Imbalanced nutrition less than body requirement related to nausea, vomiting, decreased fatigue and fever. Patient maintains adequate nutrition as evidenced by absence of nausea and adequate food intake. SECONDARY PREVENTION: Check the nutritional status . Give ryles tube feed as per doctors order. Provide IV fluids as per order. Avoid situations that stimuiate vomiting. Provide mouth care. Maintain intake-output chart. Checked the nutritional status .Its inadequate. Gave ryles tube feed, 150ml Q2H. Provided IV fluids as per order. Avoided situations that stimulate vomiting. Provided mouth care. Maintained intakeoutput chart . Nausea and vomiting is decreased. Nutrition is inadequate as patient is still continuing ryle,s tube feed.

feed. He has fever. He looked fatigue . Subjective data: Patient asks that whether my condition is improving and when I can start taking food. Objective data: Patient has facial expression of anxiety. Patient is repeatedly asking questions regarding his condition. He is less attentive to speech. SECONDARY 4.Anxiety Patient PREVENTION: related to remains Explain treatment abrupt change free from measures to the patient in health anxiety as and their benefits in a status and evidenced simple understandable hospitalizatio by language. n. verbalisatio Clarify the doubts of n and facial the patient . expression. Repeat the information whenever necessary to remove fear. Convey a calm and empathic environment. Provide clear information of daily improvement in condition. Verbalised Explained the treatment measures to reduction in anxiety. the patient and their benefits in a simple understandable language. Clarified the doubts of the patient . Repeated the information whenever necessary to remove fear. Conveyed a calm and empathic environment. Provided clear information of daily improvement in condition . Allowed family members to visit the patient and to give

support. Assessed general condition of the patient Inspected skin for evidence of skin breakdown; assessed skin turgor Turned patient every second hour Provided back care and back massage. Provided wrinkle-free bed. Monitored I/O chart. Provided ryles tube feed 150ml Q2H.

Objective data: Strict bed rest. Having fever. Inadequate nutririon. Fatigue present.

5.Risk for impaired skin integrity related to decreased level of activity and strict bed rest.

Patient will maintain intact skin as evidenced by absence of bedsores or skin breakdown

PRIMARY PREVENTION Assess general condition of the patient. Inspect skin for evidence of skin breakdown; assess skin turgor. Turn patient every second hour. Provide back care and back massage. Make wrinkle-free bed Monitor I/O chart. Give water bed. Provide adequate nitrition.

Skin is intact. Patient did not develop skin breakdown.

BETTY NEUMANS MODEL: