Nursing Theories and Conceptual Frameworks

Concepts
Abstract ideas or mental images of phenomena or reality
Often called the building blocks of theories (e.g. mass, energy, ego, id)

Conceptual Framework
Group of related ideas, statements or concepts often used interchangeably
with the terms conceptual model and grand theories (e.g. Freuds
structure of the mind id, ego, superego)
o Id - me, myself and I
o Ego self-consciousness
o Superego conscience

Paradigm
A pattern of shared understanding and assumptions about reality and the
world include notions of reality that are largely unconscious or taken for
granted derived from cultural beliefs (e.g. time, space)

Metaparadigm
Concepts that can be superimposed on other concepts
Four major metaparadigms in nursing
o Person
o Environment
o Health
o Nursing

Theory
Supposition or system of ideas proposed to explain a given phenomenon
Attempt to explain relationships between concepts
Offer ways to conceptualize central interests of a discipline (e.g Freuds
theory of the unconscious)

Purpose of Nursing Theory

Link among nursing theory, education, research and clinical practice
Contributes to knowledge development
May direct education, research and practice

Theory in the Sicences and Practice Disciplines

Natural Sciences
o Theories provide a foundation and direction for research
o Often produce tangible results (e.g. knowledge that can be used to
control nature, disease and foreign threats
Practice Discipline
o Theories work like lenses to interpret the world of interest
o Usefulness comes from helping to interpret phenomenon from unique
perspectives
 o Building new understandings, relationships, possibilities
Use of Theory to Understand Clinical
Debates about the role of theory in practice provide evidence that nursing is
maturing

Nursing Process
Systematic, rational method of planning and providing individualized nursing
care

Assessing
Collect data
Organize data
Validate data
Document data

Diagnosing
Analyze data
Identify health problems, risks and strengths
Formulate diagnostic statements

Planning
Prioritize problems/diagnoses
Formulate goals/desired outcomes
Select nursing interventions
Write nursing orders

Implementing
Reassess the client
Determine the nurses need for assistance
Implement the nursing interventions
Supervise delegated case
Document nursing activities

Evaluating
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
Continue, modify or terminate the clients care plan

Assessment collecting, organizing and communicating/recording client data; to

establish data base about the clients response to health concerns or illness and the
ability to manage health care needs
Purpose: to establish a database
Activities:
o Obtain health history
o Perform physical assessment
 o Review records, e.g. laboratory records, other health care records
o Interview support persons
o Review literature
o Validate assessment data
Data Collection process of gathering information about the clients health
status
o Types of data:
Subjective data also referred to as symptoms or covert data;
apparent only to the person affected and can be described or
verified only by that person (e.g. itching pain, feelings of worry)
Includes clients sensations, feelings, values, beliefs,
attitudes and perception of personal health status and life
situations
Objective data also referred to as signs or overt data;
detectable by an observer or can be tested against an accepted
standard; can be seen by observation or physical examination
(e.g. discoloration of the skin, BP reading)
o Sources of Data
Primary source client
Secondary sources indirect sources (family members, support
people, client records)
Methods of Data Collection:
o Observing using five senses; using organized approach
o Interview planned communication or conversation with a purpose
Two Approaches
o Direct interview highly structured and elicit specific information by
asking closed questions that call for a specific amount of data
o Non-directive the nurse allows the client to control the purpose,
subject matter and pacing
Rapport is the understanding between two or more people
Kinds of Interview questions
o Closed questions restrictive and generally require only short answers
giving specific information
o Open-ended questions lead or invite clients to explore their thoughts
or feelings; allow clients the freedom to talk
Assessment Tools: Gordons Functional Health Pattern Framework
Review of Systems the goal is to gather subjective data from the client in
each of the major body systems

Nursing Diagnosis
Statement of the clients health status
Clinical judgment about individual, family or community responses to actual
and potential health problems/life processes
Provides the basis for selections of nursing interventions to achieve outcomes
for which the nurse is accountable
Types of Nursing Diagnosis
o Actual
o Potential
 Problem Statement describes the clients health problem or response for
which nursing therapy is given
Qualifiers added words to give additional meaning to the diagnostic
statement
o Altered change from baseline
o Impaired made worse, weakened, damaged
o Decreased smaller in size, amount or degree
o Ineffective not producing the desired effect
o Acute severe or of short duration
o Chronic lasting a long time
Etiology (Related/Risk Factors) the probable cause of the health
problem; may include clients behavior, environmental factors or the
interaction of the two; NANDA uses the term related to to describe the
etiology or likely cause of the nursing diagnosis
o Example
Activity intolerance related to decreased cardiac output
Ineffective breast-feeding related to inexperience and lack of
knowledge
Altered bowel elimination; constipation related to insufficient
fluid intake
Medical Diagnosis made by a physician and refers to a condition that only a
physician can treat; refers to a pathophysiologic responses that are fairly
uniform from one client to another
Nursing Diagnosis describes the clients physical, sociocultural, psychologic
and spiritual responses to an illness or potential health problems; very among
individual
o Examples
Altered nutrition: less than body requirements related to lack of
appetite and nausea secondary to disease process
Basic Two-Part Diagnostic Statement
o Situational Low Self-Esteem related to rejection by husband
Basic Three-Part Diagnostic Statement
o Situational Low Self-Esteem related to rejection by husband as
manifested by hypersensitivity to criticism states I dont know if I can
manage by myself and rejects positive feedback
o Altered Thermoregulation related to the infection process as
manifested by warm to touch, temperature of 39.5 C

Planning involves decision making and problem solving

Planning process includes
o Setting priorities
o Clients health values and beliefs
o Clients priorities
o Urgency of health problems
o Medical treatment plan
Planning should be SMART (specific, measurable, attainable, realistic and
time-bound)
 o E.g. After 4 hours of continuous nursing intervention, patients
temperature will decrease from 38.9C to 37.5C

Implementation/Intervention
The nurse implements the interventions identified in the plan of care
Types of Nursing Actions
o Independent nursing actions an activity that the nurse initiates as a
result of the nurses own knowledge and skills
o Dependent nursing actions activities carried out on the order of the
physician, under the physicians supervision or according to specified
routines
o Collaborative nursing actions activities performed either jointly with
another member of the health care team or as a result of a joint
decision by the nurse and another health care team member
Evaluation
6 Components
o Identifying the expected outcomes that the nurse will use to measure
client goal achievement
o Collecting data related to the expected outcomes
o Comparing the data with the expected outcomes and judging whether
the goals have been achieved
o Relating nursing actions to client outcomes
o Drawing conclusions about problem status
Evaluation statement consist of 2 parts (a conclusion and a supporting data)

Purposes of the Physical Examination

Obtain baseline data
Supplement, confirm or refute data from the history
Help establish nursing diagnoses and plans of care
Evaluate physiologic outcomes and progress
Make clinical judgment

Positions
Dorsal recumbent head and neck, axillae, anterior thorax, lungs, breast,
extremities, peripheral pulses
Supine (horizontal recumbent)
Sitting
Lithotomy
Sims
Prone

Methods Used in Physical Examination

Inspection
o Deliberate, purposeful, and systematic visual examination
o Moisture, color, texture
Palpation
 o Texture, temperature, vibration, position, size, consistency, mobility of
organs or masses, distention, pulsation, presence of pain upon
pressure
o Light and deep, flatness, dullness, resonance, hyperresonance,
tympany
o Light palpation
o Deep palpation
Percussion striking body surface to elicit sounds or vibration
o Direct striking body directly
o Indirect striking of an object held against the body
Auscultation listening to sounds produced within the body
o Direct use of unaided ear
o Indirect use of stethoscope
o Pitch, intensitiy, duration, quality

Stepping in Examination Procedures

Planning
Obtaining appropriate equipment
Preparing the client
Implementation of the procedures
Evaluation of findings

Borborhythmic sound
Normal Bowel sounds 5-30

Vital Signs
Monitor functions of the body
Should be a thoughtful, scientific assessment

When to Assess Vital Signs

On admission
Change in clients health status
Client reports symptoms such as chest pain, feeling hot or faint
Pre and post-surgery/invasive procedure

Factors affecting body temperature

Age
Exercise
Hormones
Stress
Environment

Factors Affecting Pulse

Age
Gender
 Exercise
Fever
Medications
Hypovolemia
Stress
Position changes
Pathology
Age Pulse Respirations
average (and average
ranges) (and ranges)
Newborn 130 (80-180) 35 (30-80)
1 year 120 (80-140) 30 (20-40)
5-8 years 100 (75-120) 20 (15-25)
10 years 70 (50-90) 19 (15-25)
Teen 75 (50-90) 18 (15-20)
Adult 80 (60-100) 16 (12-20)
Older adult 70 (60-100) 16 (15-20)
Factors Affecting Respirations
Exercise
Stress
Environmental temperature
Medications

Factors Affecting Blood Pressure

Age
Exercise
Stress
Race
Gender
Medications
Obesity
Disease process

Category Systolic BP Diastolic BP

mmHg mmHg
Normal <120 <80
Prehypertension 120-139 80-89
Hypertension, stage 1 140-159 90-99
Hypertension, stage 2 >160 >100

Oxygenation

Function of the Respiratory System

The function of the respiratory system is gas exchange
 Oxygen from inspired air diffuses from alveoli in the lung into the blood in the
pulmonary capillaries

Gas Exchange
Occurs after the alveoli are ventilated
Pressure differences on each side of the respiratory membranes affect
diffusion

Oxygen Transport
Transported from the lungs to the tissues
97% of oxygen combines with hemoglobin in red blood cells and carried to
tissues

Carbon Dioxide Transport

Must be transported from the tissues to the lungs
Continually produced in the process of cell metabolism
65% is carried inside the red blood cells as bicarbonate
30% combines with hemoglobin as carbhemoglobin
5% transported in solution in plasma and as carbonic acid

Common Manifestations of Impaired Respiratory Function

Hypoxia
Altered breathing patterns
Obstructed or partially obstructed airway

Altered Breathing Patterns

Tachypnea (rapid rate)
Bradypnea (abnormally slow rate)
Apnea (cessation of breathing)
Kussmauls breathing (deep and labored)
Cheyne-Stokes respirations (periodic)
Biots respirations (ataxic breathing)

Alterations in ease of Breathing

Orthopnea (DOB on lying flat position)
Dyspnea

Nursing Measures to Promote Respiratory Function

Ensure a patent airway
Positioning
Encouraging deep breathing, coughing
Ensuring adequate hydration