Endotracheal tube Intubation..nursesoutlook

INTRODUCTION-:

Very often, the nurses working in the causality services may have to help the doctors in endotracheal intubation in order to save the life of the patient.

Endotracheal intubation are artificial airways inserted to relieve mechanical airway obstruction, provide a route for mechanical ventilation, permit easy access for secretion removal, and protect the airway from gross aspiration in clients with impaired cough or gag reflexs.

Endotracheal intubation is a procedure performed by a physician or specially trained health personnel.

Endotracheal tube intubation 

DEFINITION-:

Endotracheal tube Intubation is assisting in passing of a hollows tube into trachea through nose or mouth using aseptic techniques to facilitate artificial ventilation and resuscitation. It passes through the vocal cords and its distal tip sits just above the Carina.



PURPOSES-:

• To treat acute respiratory failure, persistent hypoxemia, persistent rise in PCO2.


• To maintain patient airway


• To ensure adequate oxygenation in fracture cervical vertebrae, spinal cord injury.


• To provide ventilatory assistance when indicated.


• To remove secretions


• To administer anaesthetics ( in the operation theater).

OBJECTIVES-:

• To insert an endotracheal tube into trachea to provide a patient airway for ventilatory support or to manage secretions.

INDICATION-:

• CNS depression


• Neuromuscular disease


• Chest wall injury


• Upper airway obstruction

Anticipated upper airway obstruction ( edema, soft tissue swelling due to head and

Neck trauma) postoperative head and neck surgeries.

• Aspiration prophylaxis


• Fracture of cervical, vertebral and spinal cord injury.

ENDOTRACHEAL TUBE-:

A wide variety of endotracheal tube in use for orotracheal or naso- tracheal intubation. They are available with cuffs and without cuffs. Orotracheal tubes are larger than the naso- tracheal tubes. As in the case of tracheostomy tubes, the endotracheal tube have no inner tubes which can be removed for cleaning. The size of each tube is marked in mm on the outer side of each tube.

Approximate size of the endotracheal tubes for different age groups are as follows-:

• New born infants               -  5mm   to  4mm


• 0 to 1 years                           -    4mm to 4.5mm


• Children up to 10 years   - 5mm to 7mm


• Children                              -    7mm to 8mm


• Adults                                   - 8mm to 9.5 mm

PREPARATION OF THE ARTICLES/ARTICLES NEEDED FOR ET INTUBATION-:

• Endotracheal tube of different sizes with an adaptor to connect to the ventilator or ambu


• Syringes to inflate the


• Laryngoscope to visualize the larynx and to depress the tongue during the insertion.


• Flexible copper style-to be used as a guide during the insertion and to give the tube greater rigidity.


• Extra syringes and needles for medication.


• Lubricant to lubricate the tube.


• Ambu bag to ventilate the lungs.


• Oral airway to keep in the mouth of the patient after the patient biting on to and occluding an endotracheal tube.


• Gauze wipes, to clean the secretions.


• Gloves to maintain asepsis.

Adhesive plaster-to fix the endotracheal tube in place.

• Magill,s intubating forceps to direct endotracheal tube into the trachea.


• Oxygen supply


• Suction apparatus.


• Anaesthetics ( if required)

PROCEDURE-:

• Explain procedure to the patient if conscious and get consent from patient and relatives.


• Place patient in supine position with head extended by keeping sand bag or towel roll under neck.


• Check for loose teeth/dentures, if so remove with magill’s forceps.


• Seal mouth and nose with mask and ambo bag and initiate bagging with oxygen.


• Provide laryngoscope to doctor.


• Suction oral cavity


• Provide lubricated endotracheal tube with stiletto in situ.


• Press crico- thyroid cartilage with thumb and index finger against esophagus.

Assist while endotrachealtube is introduced into trachea and remove stiletto. The tube when inserted should have the 22cm marking at the incisor teeth and tube should be fixed

At the midline to prevent pressure ulcer at the angle of the mouth.

• Verify placement of tube by auscultation, listening or feeling for airflow through tube and observe for bilateral chest movements.


• Connect ambo bag with oxygen attached to endotracheal tube and continue.


• Inflate cuff of the endotracheal tube with 10ml of air.


• Insert an oral airway and apply endotracheal suctioning if necessary.


• Fix endotracheal tube in position by using adhesive tape.


• Connect to ventilator if needed.

Post procedural care

• Place patient in lateral position


• Arrange for chest X- ray to be taken in order to check placement of ET tube.


• Apply endotracheal suctioning if secretions present.


• Watch for chest movement, ET tube kinking, obstruction with secretions and blood, leakage of tube cuff, change in position of the tube and over inflammation of cuff.

Document type and size of tube used, chest movements, vital signs and patient’s tolerance To procedure.

• Check ABG periodically.

After care of the patient:

• Never leave the patient alone


• Watch and maintain an open airway


• Remove secretions by effective suctioning


• Prevent displacement of the tube.


• Watch for complications such as laryngeal oedema, tracheal stenosis, haemorrhage  etc..


• Provide for the humidification of the air by boiling a kettle of water in the patient’s unit


• Prevent infection introduction into the lungs.


• Prevent contamination of the inhaled air.


• Maintain adequate nutrition of the patient by naso- gastric feeding or by giving intravenous fluids. They should never be fed on oral feeds as long as the tube is in the mouth.


• Maintain the oral hygiene of the signs.


• Carefully watch and record the vital signs.


• Apply suction if there is much secretions.


• Give oxygen if the patient is cyanosed.

Keep an emergency tracheotomy tray with tracheotomy tubes of correct size at the bedside of the patient for emergency use.



ADVANTAGES OF THE ENDOTRACHEAL TUBE INTUBATION-:

• The intubation can be done rapidly and an incision on the throat can be avoided. It is less time consuming and the results are predictable.


• Good for the short term intubation.


• Easy to insert


• Shorter length


• Minimal gastric distension.


• DISADVANTAGES OF THE ENDOTRACHEAL TUBE INTUBATION-:

• Suctioning through the endotracheal tube is less effective and it is more traumatic because it can cause extensive and permanent damage to the larynx and the vocal cord.


• In case of severe burns and laryngeal edema, the endotracheal tubeis less practical.

Nursing care plan for patient with chest trauma

CHEST TRAUMA OR CHEST INJURY

Chest trauma or chest injury is defined as any injury to the walls of chest including the heart

NURSING DIAGNOSIS

nursing care plan for patient with chest trauma

INEFFECTIVE BREATHING PATTERN RELATED TO DECREASED LUNG EXPANSION

Goal and expected outcome – Effective breathing pattern ,regular respiration and no dyspnea.

Interventions –

• Monitor the patient closely for increasing respiratory distress as indicated by tachycardia ,dyspnea, cyanosis and anxiety


• Inspect the trachea for deviation that may caused by mediastinal shift.


• Check arterial blood gas result for hypoxemia -;low blood oxygen and ,hypercapnoea;-high blood carbon dioxide


• After the chest tube has been inserted ,protect the tube and monitor it’s function


• Position the patient for comfort in a fowlers or semifowlers position.


• Avoid the side lying position until the affected lung has re expanded ,because this position could foster mediastinal shift


• Administer oxygen as ordered


• Support and encourage the patient to do deep breathing and coughing exercise

FEAR RELATED TO BREATHING DIFFICULTY

Goal and Expected Outcome – Decreased fear, patient statement that fear is reduced

Intervention ;

• Speak the patient calmly and explain what is happening


• Tell the patient that chest tube will allow the lung to reexpand and relieve dyspnea


• Tell the patient how to prevent dislodging the tube


• Give the patient the opportunity to ask questions and express the fear

DECREASED CARDIAC  OUTPUT  RELATED TO MEDIASTINAL SHIFT

Goal and Expected Outcome – Adequate cardiac output ,pulse and B P consistent with patient

Intervention ;

• Monitor the patient pulse and B .P and pulse


• If cardiac output decreases because of mediastinal shift ,the B P falls and pulse rate increases


• Immediately notify the physician of signs of this potentially life threatening stage

ACUTE PAIN RELATED TO TRAUMA ,ALTERED PRESSURE IN THE CHEST CAVITY ,CHEST TUBE

Goal and Expected Outcome ; - Pain relief ,patient statement that pain is reduced and relieved

Intervention ;

• Be alert for the signs of pain and document the characterestics of pain


• Administer analgesics as ordered


• In addition to drug therapy use positioning ,massage and other measures


• Notify the physician if pain is not relieved.

RISK FOR INFECTION RELATED TO TRAUMATIC INJURY AND CHEST TUBE INSERTION

Goal and Expected Outcome– Absence of infection and maintain normal body temperature

• Monitor the patient for signs and symptoms of infection ,fever ,increased pulse ,respiration ,foul smell drainage from the tube insertion site and elevated W.B.C.


• Use sterile technique for invasive procedure and dressing change and administer prescribed antimicrobials


• Monitor fluid intake and hydration status and promote fluid intake of 2- 3 L /day


• Instruct the patient to keep the chest insertion site clean ,dry and to notify the signs of infection

Nursing Diagnosis of HIV...nursesoutlook

Nursing Diagnosis of HIV

1. Risk for infection related to HIV infection and subsequent immunodeficiency
2. Imbalanced nutrition less than body requirements related to diarrhoea secondary to opportunistic infection
3. Risk for deficit fluid volume related to diarrhoea secondary cryptosporidiosis
4. Anxiety related to fear of losing independence , job, and income
5. Risk for impaired skin integrity related to frequent diarrhoea

Risk for infection related to HIV infection and subsequent immunodeficiency

Intervention

• Monitor for signs and symptoms of infection (fever, chills, dyspnea, fatigue, oral lesion, dysuria). Frequent and or prolonged infections contribute to the wasting syndrome that occurs with HIV infection.


• Monitor laboratory data (WBC, CD4 count) and viral load. For monitor the progress of treatment

• Teach patient to report sigh and symptoms of infection. To assist with early detection of infection.


• Screen all visitors for communicable disease. To protect the immunocompromised patient from source of new infection.


• Culture wound drainage, mouth lesions, sputum, blood, or urine, as needed. To identify the pathogenic organism so that appropriate treatment methods can be initiated.


• Administer prescribed antimicrobial medication on time. To maintain blood levels of antimicrobial agents for maximum effectiveness.


• To teach patient way to reduce exposure to infection, such as practicing good hand washing techniques, cleaning household surfaces with disinfectant solution, maintaining personal hygiene. To decrease exposure to new infections and prevent exposing others to HIV infection.


• Ensure aseptic handing of all intravenous lines and invasive procedures, such as catheterization or injection. To decrease exposure to new, hospital-acquired infections.

Nursing Diagnosis

Imbalanced nutrition less than body requirements related to diarrhoea secondary to opportunistic infection.

Intervention

• Monitor intake and output. To determine if fluid output is excessive when compared with fluid intake so that fluid deficits can be avoided or treated early.


• Monitor hydration status. To determine adequacy of fluid intake and to initiate fluid replacement early if needed.


• Obtain daily weights and monitor trends. Weight is a clinical indicator of adequate nutrition and fluid balance. Weightless indicates the needs for nutritional supplements or total parental nutrition.


• Monitor laboratory data (blood urea nitrogen, haemoglobin). Provides objective data regarding nutritional status so that corrective action can be initiated early.


• Encourage six small meal, excluding dairy products and raw fruits and vegetable. Small meals prevent gastric distension and nausea.


• Administer intravenous fluids as prescribed. To prevent fluid volume deficit, hypovolemia, and cellular dehydration.


• Teach the patient to increase intake or high-calorie, protein-rich, carbohydrate foods. To provide calories, aid healing, and prevent wasting.

Nursing Diagnosis

Risk for deficit fluid volume related to diarrhoea secondary cryptosporidiosis

Intervention

• Monitor skin turgor and mucus membranes. Poor skin turgor and sticky mucous membranes are indication of fluid deficit.


• Monitor weight daily. Weight is a good indicator of hydration status, rapid change in the weight are usually due to changes in fluid volume.


• Monitor the vital signs. To detect changes associated with fluid deficit. Tachycardia, hypo tension, and low grade fever are associated with fluid volume deficit.


• Monitor the intake output. to determine if imbalance between intake and output exist and to determine fluid deficiency effect on renal function.


• Administer prescribed intravenous fluids. To replace fluid losses.


• Administer prescribed anti diarrhoeal  To correct the cause of the fluid loss.

Nursing Diagnosis

Activity intolerance related to decreased oxygen  transport and reduced energy reserves secondary to opportunistic infection.

Intervention

• Assess severity of fatigue and patient’s understanding of the physiology cause. To establish a baseline for later comparison and to determine effectiveness of treatment.


• Encourage patient to prioritize daily activities and let go of unessential task. Fatigue compromise one’s ability to participate in daily activity.


• Encourage patient to obtain at least 8 hours of uninterrupted sleep at night. Effective night time sleep pattern may decrease daytime fatigue.


• Encourage intake of well-balanced diet. to adequate nutrients to meet energy needs.

Nursing Diagnosis

Anxiety related to fear of losing independence , job, and income.

Intervention

• Explain all care and procedure. Decrease anxiety that often occurs when unfamiliar procedure s are scheduled.


• Encourage verbalization of fears and concern. Venting of feelings often allows the patient to put fears into perspective and may decreases in a rational manner.


• Discourage decision making until outcomes are known. Decisions based on inadequate information may cause grater stress in the future.


• Explore past effective coping strategies that were successful. Patterns of past successful coping are indicators of present resources and stenghts.

Nursing Diagnosis

Risk for impaired skin integrity related to frequent diarrhoea

Intervention

• Monitor skin for signs of breakdown. To detect skin deterioration so that treatment can be implemented as early as possible.


• Inspect skin turgor and mucous membranes daily. Dry mucous membranes and poor skin turgor indicate fluid deficit, which predisposes the patients to skin breakdown.


• Keep rectal area clan and dry. Prevents secondary infections and spread of existing micro-organisms.


• Apply topical protective cream to reddened areas as prescribed . to protect skin from wetness and acidic stool and prevent breakdown while increasing comfort.

HIV-RISK FACTORS AND TRANSMISSION ..nursesoutlook

DEFINITON

Acquired immunodeficiency syndrome (AIDS) is a disease of human immune system caused by Human Immunodeficiency Virus (HIV), characterized by progressively reduces the effectiveness of the immune system and leaves susceptible to opportunistic infection and other disease

HIV-RISK FACTORS AND TRANSMISSION

It is a fragile virus that can be transmitted only under specific condition. It transmitted from human to human through infected blood, semen, vaginal secretions, and breast milk. If this infected fluids are introduced to an uninfected person’s body the potential for transmission occur. The HIV infected individual can transmit HIV to others starting a few days after initial infection. After that the ability to transmit HIV is lifelong. Transmission of HIV is subject to the same requirements as other microorganisms. Duration and frequency of contact, quantity of inoculants, virulence of organism, and most immune defense capability all affect whether infection will actually occur after exposure.

HIV is not spread casually: it cannot be transmitted through hugging, kissing, shaking hands, sharing eating utensils, or attending school with and HIV infected person. It is not transmitted through saliva, tears, or sweat. In addition, there is no evidence that the virus can be transmitted by insects. The health care worker has a low occupational risk of acquiring.

Sexual transmission

Sexual contact with an HIV infected partner is the most common method of transmission. Sexual activity provides an opportunity for contact with semen, vaginal secretions, and blood. Although the homosexual initially accounted for most cases of HIV in the United States, heterosexual transmission is becoming more prevalent, and is now the most common method of infection in women. The most important variable is whether HIV is present in one of the sexual partner and not whether the couple is homosexual or heterosexual. The intercourse can be in the form of anal, oral or vaginal. The most risk from of sexual intercourse is unprotected anal intercourse. Although many people associated anal intercourse exclusively with homosexual men, many heterosexuals’ couples also use this form of sexual expression. Anal intercourse frequently results in trauma to the rectal mucosa; rectal trauma increases the likelihood of HIV infection because tearing of the mucous membrane provides a portal of entry for the virus. Sexual intercourse with one partner who is HIV infected creates a risk. Where as sexual intercourse with multiple uninfected partners results in no risk. Sexual activities that involved blood, such as during menstruation or as a result of trauma to tissue, also increase the risk of transmission.



Contact with blood and blood product

HIV  is transmitted by exposure  to contaminated blood through the accidental or intentional sharing of injection equipment. Sharing equipment to inject drugs is a major means of transmission for both sexes in many large metropolitan areas, and used equipment becoming more common in smaller cities and rural areas. It is important to remember that equipment used to inject drug such as insulin, vitamin B₁₂ and clotting factors, as well as narcotic drugs such as steroids are also contaminated after use. Used equipment is potentially contaminated with HIV and should not be shared.

Transfusion of infected blood and blood products has caused AIDS. Routine screening of blood donors was implemented to identify individual at risk and to test the blood for the presence of HIV antibodies, thereby improving the safety of the blood supply. HIV infection now unlikely but still not be positive for HIV antibodies on testing.

HIV has been transmitted to heath care workers, after exposure to HIV-infected fluids through percutaneous injury and into open wounds on the skin and mucus membrane. The greatest  risk of occupational transmission of HIV occur through puncture wounds. Those the syrnge which used for Perinatel transmission The intramuscular and subcutaneous injection which is less risk than the blood filled needle.Transmission from an HIV infected mother to an infant can occur during pregnancy, at the time of delivery, after the birth through the breast feeding.

ETIOLOGY

The origin of HIV is unknown. Evidence appears to supports the hypothesis of an African origin. Since an AIDS like illness in central Africa has been known to exist since the early of 1960s. it further hypothesized that the most likely source of human infection was from nonhuman primates.

The causative agent of HIV infection and AIDS is the human immunodeficiency virus, a retrovirus that belongs to the lentivirus subfamily. Several human retroviruses have been identified. Two of them are HIV-1 and HIV-2 associated with T4 –helper cell depletion and subsequent loss of cellular immunity.HIV-1 is predominant cause of HIV infection in both developing and developed countries, according for more than 80% of AIDS cases worldwide.



HIV-2 seems to be limited in geographic distribution and is most prevalent in West Africa. Although there has been scientific and clinical progress and development of new treatments and comprehensive models of care, HIV disease remains an incurable disease

RISK FACTORS

Sexual practice

• Unprotected sex


• Multiple sexual partners


• Anal or oral sexual activity


• Improper condom use or condom breakage


• Open sore, lesions, or irritation in the genital area

Contaminated blood

Contaminated needle

Occupational exposure

• All health care workers- acute care, long term care, and home care.

• Dental workers


• Perinatal exposure ( during pregnancy, birth, or breast feeding)

Levine conservation model...Nursesoutlook

levine conservation model

 INTRODUCTION

• Born in Chicago, raised with a sister and a brother with whom she shared a close loving relationship


• Also very fond of her father who was often ill and frequently hospitalized with GI problem. This was the reason of choosing nursing as a career.


• Also called as renaissance women-highly principled, remarkable and committed to patient’s quality of care.


• Died in 1996

ACHIEVEMENT

• Diploma in nursing:-Cook county SON, Chicago, 1944


• BSN:-University of Chicago,1949


• MSN:-Wayne state University, Detroit, 1962


• Publication:-An Introduction to Clinical Nursing, 1969,1973 & 1989


• Received honorary doctorate from Loyola University in 1992


• Clinical experience in OT technique and oncology nursing


• Director of nursing at Drexel home in Chicago


• Clinical instructor at Bryan memorial hospital in Lincoln, Nebraska


• Administrative supervisor at university of Chicago

CONSERVATIONAL MODEL

 Goal

• To promote adaptation and maintain wholeness using the principles of conservation.


• Model guides the nurse to focus on the influences and responses at the organismic level.


• Nurse accomplishes the goal of model through the conservation of energy, structure and personal and social integrity.

Two Important Concepts

Adaptation: An ongoing process of change in which patient maintains his integrity within the realities of environment and achieved through the "frugal, economic, contained and controlled use of environmental resources by individual in his or her best interest"



Wholeness

• Exist when the interaction or constant adaptations to the environment permits the assurance of integrity


• Promoted by use of conservation principle

Conservation: Is the product of adaptation and primary focus on "Keeping together "of the life systems or the wholeness of the individual

 Major concepts of conservation model

Person: A holistic being who constantly strives to preserve wholeness and integrity and a unique   individual in unity and integrity, feeling, believing, thinking and whole system of system

 Environment: Completes the wholeness of person. The individual has both an internal and external environment.

Internal environment

• Homeostasis: A state of energy sparing that also provide the necessary baselines for a multitude of synchronized physiological and psychological factors


• Homeorrhesis: A stabilized flow rather than a static state, emphasis the fluidity of change within a space-time continuum.

External Environment

• Perceptual: Aspect of the world that individual are able to intercept.


• Operational: Elements that may physically affects individuals but not perceived by them: radiation, micro-organism and pollution


• Conceptual: Part of person's environment including cultural patterns characterized by spiritual existence, ideas, values, beliefs and tradition.

 Health: Is a wholeness and successful adaptation. It is not merely healing of an afflicted part, it is return to daily activities, selfhood and the ability of the individual to pursue once more his or her own interest without constraints .

Disease: It is unregulated and undisciplined change and must be stopped or death will ensue

 Nursing:"Is a profession as well as an academic discipline, always practiced and studied in concert with all of the disciplines that together from the health sciences"

• The human interaction relying on communication ,rooted in the organic dependency of the individual human being in his relationships with other human beings


• Nursing involves engaging in "human interactions"

Person and environment: Levine’s conservation model discussed that the way in which it become congruent over time

1. Adaptation: The specific adaptive responses make conservation possible occur on many levels; molecular, physiologic, emotional, psychologic, and social. These responses are based on three factors:

 Historicity: Adaptations are grounded in history and await the challenges to which they   respond

 Specificity: Individual responses and their adaptive pattern varies on the base of specific genetic structure

Redundancy: Safe and fail options available to the individual to ensure continued adaptation

Organismic response: A change in behavior of an individual during an attempt to adapt to the environment and helps individual to protect and maintain their integrity. They are four types:

Flight or fight: An instantaneous response to real or imagined threat, most primitive response

 Inflammatory: Response intended to provide for structural integrity and the promotion of healing

Stress: Response developed over time and influenced by each stressful experience encountered by person

Perceptual: Involves gathering information from the environment and converting it in to a meaning experience

Four Conservational Principle:

These principles focus on conserving an individual's wholeness. Her framework includes:

Conservation of energy: Refers to balancing energy input and output to avoid excessive fatigue. It includes adequate rest, nutrition and exercise.

Example: Availability of adequate rest, Maintenance of adequate nutrition

Conservation of structural integrity: Refers to maintaining or restoring the structure of body preventing physical breakdown and promoting healing.

Example: Assist patient in ROM exercise, Maintenance of patient’s personal hygiene

Conservation of personal integrity: Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination.

Example: Recognize and protect patient’s space needs

4. Conservation of social integrity: An individual is recognized as someone who resides with in a family, a community,a religious group, an ethnic group, a political system and a nation.

Example: Position patient in bed to foster social interaction with other patients, Promote patient’s use of news paper, magazines, radio. TV and Provide support and assistance to family.

 Nursing Process

• Assessment


• Trophicognosis


• Hypothesis


• Interventions


• Evaluation

• Collection of provocative facts through observation and interview of challenges to the internal and external environment using four conservation principles


• Nurses observes patient for organismic responses to illness, reads medical reports. talks to patient and family


• Assesses factors which challenges the individual

• Nursing diagnosis-gives provocative facts meaning


• A nursing care judgment arrived at through the use of the scientific process


• Judgment is made about patient’s needs for assistance

• Planning


• Nurse proposes hypothesis about the problems and the solutions which becomes the plan of care


• Goal is to maintain wholeness and promoting adaptation

• Testing the hypothesis


• Interventions are designed based on the conservation principles


• Mutually acceptable


• Goal is to maintain wholeness and promoting adaptation

• Observation of organismic response to interventions


• It is assesses whether hypothesis is supported or not supported


• If not supported, plan is revised, new hypothesis is proposed

Applications

1. Nursing research


2. Nursing education

• Principles of conservation have been used for data collection in various researches


• Conservational model was used by Hanson et al.in their study of incidence and prevalence of pressure ulcers in hospice patient

• Conservational model was used as guidelines for curriculum development


• It was used to develop nursing undergraduate program at Allentown college of St.Francis de sales, Pennsylvania.

3. Nursing administration

• Taylor described an assessment guide for data collection of neurological patients which forms basis for development of comprehensive nursing care plan and thus evaluate nursing care


• McCall developed an assessment tool for data collection on the basis of four conversational principles to identify nursing care needs of epileptic patients

4. Nursing practice

• Conservational model has been used for nursing practice in different settings


• Bayley discussed the care of a severely burned teenagers on the basis of four conservational principles and discussed patient’s perceptual, operational and conceptual environment

FLORENCE NIGHTINGALE'S THEORY

FLORENCE NIGHTINGALE'S THEORY

INTRODUCTION OF THE THEORIST:

Florence Nightingale was born on May 12, 1820, in Florence, Italy.  From an early age, she felt she had a calling to be a nurse. She "trained" to be a nurse at a hospital in Kaiserworth, Germany, and returned to London.  She led nurses during the Crimean War at Scutari, Turkey; gathered extensive statistics about the health of the soldiers she and her nurses served; and began a life-long effort to improve health by improving the environment. She was a statistician, using bar and pie charts, highlighting key points. International Nurses Day, May 12 is observed in respect to her contribution to Nursing. She died - 13 August 1910.

Florence Nightingale considered the founder of educated and scientific nursing and widely known as "The Lady with the Lamp", wrote the first nursing notes that became the basis of nursing practice and research. The notes, entitled Notes on Nursing: What it is, what is not (1860), listed some of her theories that have served as foundations of nursing practice in various settings. Nightingale is considered the first nursing theorist. One of her theories was the Environmental Theory, which incorporated the restoration of the usual health status of the nurse's clients into the delivery of health care—it is still practised today.

PURPOSE:

• To facilitate & encourage the process of healing by manipulating the environment.


• The environment is critical to health, & the nurse’s role in caring for the sick is to provide a clean, quiet, peaceful environment to promote healing.

ASSUMPTIONS OF NIGHTINGALE'S THEORY:

• Nursing is separate from medicine


• Nurse should be trained


• The environment is important to the health of the patient


• The disease process is not important to nursing


• Nursing should support the environment to assist the patient in healing


• Research should be utilized through observation and empirics to define the nursing discipline.


• Nursing is both an empirical science and an art.


• Nursing’s concern is with the person in the environment.


• The person is interacting with the environment


• Sick and well are governed by the same laws of health.


• The nurse should be observant and confidential.

 

5 MAJOR COMPONENTS OF A HEALTHFUL ENVIRONMENTAL

1. CLEAN AIR


2. PURE WATER


3. EFFICIENT DRAINAGE


4. CLEANLINESS


5. LIGHT

 

NIGHTINGALE’S CANONS: MAJOR CONCEPTS

1. Ventilation and warming


2. Light, noise


3. Cleanliness of rooms/walls


4. Health of houses


5. Bed and bedding


6. Personal cleanliness


7. Variety


8. Chattering hopes and advices


9. Taking food.  What food?


10. Petty management/observation

ORIGIN OF NIGHTINGALE’S ENVIRONMENTAL CONCEPTS:

• Nightingale believed that the environment could be altered to improve conditions so that the natural laws would allow healing to occur.


• This grew from empirical observation that poor or difficult environments led to poor health and disease.


• In her Crimean experience, filth, inadequate nutrition, dirty water, and inappropriate sewage disposal led to a situation in which more British soldiers died in the hospital than of battlefield wounds.


• Florence nightingale conceptualized disease as a reparative process.


• Nurses role as manipulating the environment.


• Persons are in relation with the environment


• Stresses the healing properties of the physical environment (fresh air, light, warmth,diet,noise and cleanliness)


• Nursing puts patients in the “best conditions” for nature to act upon them


• Health is “the positive of which the pathology is the negative”


• “Nature alone cures”

 

THREE TYPES OF ENVIRONMENTS

• Physical


• Psychological


• Social

PHYSICAL ENVIRONMENT

• Consists of physical elements where the patient is being treated


• Affects all other aspects of the environment


• Cleanliness of environment relates directly to disease prevention and patient mortality


• Aspects of the physical environment influence the social and psychological environments of the person

PSYCHOLOGICAL ENVIRONMENT

• Can be affected by a negative physical environment which then causes STRESS


• Requires various activities to keep the mind active (i.e, manual work, appealing food, a pleasing environment)


• Involves communication with the person, about the person, and about other people.


• Communication should be therapeutic, soothing, & unhurried!

SOCIAL ENVIRONMENT

• Involves collecting data about illness and disease prevention


• Includes components of the physical environment - clean air, clean water, proper drainage


• Consists of a person’s home or hospital room, as well as the total community that affects the patient’s specific environment.

NURSING PARADIGM:

Nightingale's documents contain her philosophical assumptions and beliefs regarding all elements found in the metaparadigm of nursing.  These can be formed into a conceptual model that has great utility in the practice setting and offers a framework for research conceptualization. (Selanders LC, 2010).

Nursing

• Nursing is different from medicine and the goal of nursing is to place the patient in the best possible condition for nature to act.


• Nursing is the "activities that promote health (as outlined in canons) which occur in any caregiving situation.  They can be done by anyone."

 

Person

• People are multidimensional, composed of biological, psychological, social and spiritual components.

Health

• Health is “not only to be well, but to be able to use well every power we have”.


• Disease is considered as dys-ease or the absence of comfort.

Environment

• "Poor or difficult environments led to poor health and disease".


• "Environment could be altered to improve conditions so that the natural laws would allow healing to occur.

NIGHTINGALE'S THEORY AND NURSING PRACTICE:

Application of Nightingale's theory in practice:

• "Patients are to be put in the best condition for nature to act on them, it is the responsibility of nurses to reduce noise, to relieve patients’ anxieties, and to help them sleep."


• As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.

CRITICISMS

• She emphasized subservience to doctors.


• She focused more on physical factors than on psychological needs of patient.

CONCLUSION:

Florence nightingale’s legacy of caring & activism it implies is carried on in nursing today. Nightingale for inspiration, for she remains a role model for excellence on the transformation of values of caring into an activism that could potentially transform our current health care system into a more humanistic & just one. Florence Nightingale provided a professional model for nursing organization. She was the first to use a theoretical foundation to nursing Her thoughts have influenced nursing significantly

HUMAN-TO-HUMAN RELATIONSHIP MODEL

HUMAN-TO-HUMAN RELATIONSHIP MODEL

 

The theory of Joyce Travelbee indeed has a very great contribution not only to those who are in the Psychiatric Nursing field but in the whole nursing practice. Not only should we be able to assist them towards wellness but also to be able to find meaning in the situation or experiences they had been through whether it may be good or bad. This theory does not only focus on the patient but as well as with the nurse practitioner, both having a unique personality.

Autobiography of the Theorist:
Joyce Travelbee, born in 1926, was a psychiatric nurse, educator and writer. In 1956, she completed her Bachelor of Science degree in Nursing Education at Louisiana State University and her Master of Science Degree in Nursing from Yale University in 1959. She started a doctoral program in Florida in 1973. Unfortunately, she was not able to finish the program because she died later that year. She passed away at the prime age of 47 after a brief sickness.

In 1952, Travelbee started to be an instructor focusing in Psychiatric Nursing at DePaul Hospital Affiliate School, New Orleans, while working on her baccalaureate degree. Besides that, she also taught Psychiatric Nursing at Charity Hospital School of Nursing in Louisiana State University, New York University and University of Mississippi. In 1970, she was named Project Director at Hotel Dieu School of Nursing in New Orleans. Travelbee was the director of Graduate Education at Louisiana State University School of Nursing until her death.
In 1963, Travelbee started to publish various articles in nursing journals. Her first book entitled Interpersonal Aspects of Nursing was published in 1966 and 1971. In 1969, she had her second book published entitled: Intervention in Psychiatrics Nursing: Process in One-to-One Relationship.

Basic Concepts

• Suffering


• "An experience that varies in intensity, duration and depth ... a feeling of unease, ranging from mild, transient mental, physical or mental discomfort to extreme pain and extreme tortured ..."
  
  
  
  • Meaning
  
  
  • Meaning is the reason as oneself attributes
  
  
  
  


• Nursing


• Hope
  
  
  
  • It is strongly associated with dependence on other people.
  
  
  • It is future oriented.
  
  
  • It is linked to elections from several alternatives or escape routes out of its situation.
  
  
  • The desire to possess any object or condition, to complete a task or have an experience.
  
  
  • Confidence that others will be there for one when you need them.
  
  
  • The hoping person is in possession of courage to be able to acknowledge its shortcomings and fears and go forward towards its goal.
  
  
  
  


• Communications


• Using himself therapeutic


• Targeted intellectual approach
  
  
  
  • Nurse must have a systematic intellectual approach to the patient's situation.
  
  
  
  

• Is to help man to find meaning in the experience of illness and suffering.


• Has a responsibility to help individuals and their families to find meaning.


• The nurses' spiritual and ethical choices, and perceptions of illness and suffering, are crucial to helping to find meaning.

• Nurse's job is to help the patient to maintain hope and avoid hopelessness.


• Hope is a faith that can and will be change that would bring something better with it.


• Hope's core lays in a fundamental trust the outside world, and a belief that others will help someone when you need it.


• Six important factors characteristics of hope are:

• "a strict necessity for good nursing care"

• “One is able to use itself therapeutic."


• Self-awareness and self-understanding, understanding of human behavior, the ability to predict one's own and others' behavior are important in this process.

Description of the Theory:


Human-to-Human Relationship Model
Travelbee’s formulation of her theory was greatly influenced by her experiences in nursing education and practice in Catholic charity institutions. She concluded that the nursing care rendered to patients in these institutions lacked compassion. She thought that nursing care needed a “humanistic revolution”- a return to focus on the caring functions towards the ill person.
Travelbee’s mentor, Ida Jean Orlando, is one of her influences in her theory.

Orlando’s model has similarities to the model that Travelbee proposes. The similarities between the two models are shown in Travelbee’s statement: “the nurse and patient interrelate with each other and by her description of the purpose of Nursing.” She stated that the purpose of nursing is to “assist an individual, family or community to prevent or cope with the experience of illness or suffering, and if necessary, to find meaning in these experiences.”

In her human-to-human relationship model, the nurse and the patient undergoes the following series of interactional phases:

1. Original Encounter
   this is described as the first impression by the nurse of the sick person and vice-versa. The nurse and patient see each other in stereotyped or traditional roles.
   2. Emerging Identities
   this phase is described by the nurse and patient perceiving each other as unique individuals. At this time, the link of relationship begins to form.


2. Empathy
   Travelbee proposed that two qualities that enhance the empathy process are similarities of experience and the desire to understand another person. This phase is described as the ability to share in the person’s experience. The result of the emphatic process is the ability to expect the behavior of the individual whom he or she empathized.
   4. Sympathy
   Sympathy happens when the nurse wants to lessen the cause of the patient’s suffering. It goes beyond empathy. “When one sympathizes, one is involved but not incapacitated by the involvement.” The nurse should use a disciplined intellectual approach together with therapeutic use of self to make helpful nursing actions.
   5. Rapport
   Rapport is described as nursing interventions that lessens the patient’s suffering. The nurse and the sick person are relating as human being to human being. The sick person shows trust and confidence in the nurse. “A nurse is able to establish rapport because she possesses the necessary knowledge and skills required to assist ill persons, and because she is able to perceive, respond to, and appreciate the uniqueness of the ill human being.”
   Note that the above stated interactional phases are in consecutive order and developmentally achieved by the nurse and the patient as their relationship with one another goes deeper and more therapeutic.

Nurse  

Patient

 Environment

 

ASSUMPTIONS UNDERLYING THE ONE-TO-ONE RELATIONSHIP:
1. Establishing, maintaining and terminating a one-to-one relationship are activities which fall within the  province of nursing practice.
2. A relationship is established only when each participant perceives the other as a unique human being.

3. Only qualified psychiatric nurses are prepared to supervise nurses in the practice of psychiatric nursing.


4. The major learning experience provided in the psychiatric nursing course in to provide students with the opportunity to establish maintain and terminate one-to-one relationships.
   5. Nurses need to know how to use library facilities and how to search the literature for needed information.


5. The knowledge, understanding and abilities needed to plan, structure, give and evaluate care during the one-to-one relationship are necessary prerequisites for developing competency in group work.

 

THE GOALS OF THE NURSE:

1. 1. The nurse helps the ill person cope with present problems.
   The nurse helps the ill person to conceptualize his problem.
   3. The nurse assists the ill person to perceive his participation in an experience.


2. The nurse assists the ill person to face emerging problems realistically.


3. The nurse assists the ill person to envisage alternatives.
   6. The nurse assists the ill person to test new patterns of behavior.
   7. The nurse assists the ill person to communicate


4. The nurse assists the ill person to socialize


5. The nurse assists the ill person to find meaning in illness.

Metaparadigm in Nursing
1. Person

Person is defined as a human being. Both the nurse and patient are human beings. A human being is a unique, irreplaceable individual who is in the continuous process of becoming, evolving and changing.
2. Health
Travelbee stated that health is measured by subjective and objective health. “A person’s subjective health status is an individually defined state of well-being in accord with self0appraisal of physical-emotional-spiritual status.” Objective health is “an absence of discernible disease, disability, or defect as measured by physical examination, laboratory tests, assessment by a spiritual director or psychological counselor.”
3. Environment
Environment was not clearly defined in Travelbee’s theory. She defined human conditions and life experiences encountered by all men as sufferings, hope, pain and illness. These conditions are associated to the environment.
4. Nursing
As defined by Travelbee, Nursing is “an interpersonal process whereby the professional nurse practitioner assists an individual, family or community to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences.”
She explained that nursing is an interpersonal process because it is an experience that occurs between the nurse and an individual or group of individuals.

Acceptance by the Nursing Community

1. Nursing Practice
The hospice is one good example in which Travelbee’s theory is applied. The hospice nurse attempts to build rapport or a working relationship with the patient, as well as with his significant others. She stated that understanding illness and suffering enables the patient not only to accept the sickness, but also to use it as self-actualizing life experience.
A sick person’s insight of worthlessness in his or her sickness leads to non-acceptance of his condition and the great possibility to lose hope.
A hospice nurse believes that the dying person must find meaning in his or her death before he or she can ever begin to accept the actuality of death, just as his or her loved one must find meaning in death before they can complete the grieving process.
2. Nursing Education
Travelbee’s concepts served as better assistance for nurses who help individuals understand the meaning of illness and suffering. Travelbee’s second book, Intervention in Psychiatric Nursing: Process in the One-to-One Relationship, has been used in different nursing programs. According to Travelbee’s model, courses in philosophy and religion would also be helpful in preparing nursing students to fulfill the purpose of nursing sufficiently.
3. Nursing Research
Numerous researches in research studies have cited some aspects of the one-to-one relationship projected by Travelbee. One study by O’Connor, Wicker and Germino, which is nearly related to some of Travelbee’s ideas, discovers how individuals who were recently diagnosed with cancer described their personal search for meaning. The results of this study make known that the search for meaning seems to be both a spiritual and psychosocial process. The researchers acknowledged nursing interventions that would support this process. No other theory of Travelbee that would create further development is available.

Conclusion

• Travelbee's theory has significantly influenced nursing and health care.


• Travelbee's ideas have greatly influenced the hospice movement in the west.

Human becoming theory

human becoming theory

Rosemarie Rizzo Parse theory

INTRODUCTION ABOUT THE THEORIST

Rosemarie Rizzo Parse is an articulate, courageous, and vibrant leader with a strong vision and a deliberate determination to advance the discipline of nursing. She is well-known internationally for her human becoming school of thought a nursing perspective that focuses on quality of life and human dignity from the perspective of patients, families, and communities. Dr. Parse is an inspirational mentor who has helped many seasoned and budding nurse scholars to pursue their dreams.

Education and Positions

Educated at Duquesne University, Pittsburgh

MSN and Ph.D. from University of Pittsburgh

Published her theory of nursing, Man-Living-Health in 1981

Name changed to Theory of Human Becoming in 1992

Editor and Founder, Nursing Science Quarterly

Has published eight books and hundreds of articles about Human Becoming Theory

Professor and Niehoff Chair at Loyola University, Chicago

 

HER ACHIEVEMENTS

Two Lifetime Achievement Awards (one from the Midwest Nursing Research Society and one from the Asian American Pacific Islander Nurses’ Association), the Rosemarie Rizzo Parse Scholarship was endowed in her name at the Henderson State University School of Nursing, her books were twice named to the “best picks” list of theory books by Sigma Theta Tau International Honor Society in Nursing, and the Society of Rogerian Scholars honored her with the Martha E. Rogers Golden Slinky Award. In 2008 she was the recipient of the New York Times Nurse Educator of the Year Award.

INTRODUCTION ABOUT THEORY

The Parse theory of human becoming guides nurses in their practice to focus on quality of life as it is described and lived (Karen & Melnechenko, 1995).

The human becoming theory of nursing presents an alternative to both the conventional bio-medical approach and the bio-psycho-social-spiritual (but still normative) approach of most other theories of nursing.(ICPS)

The human becoming theory posits quality of life from each person's own perspective as the goal of nursing practice. (ICPS)

Rosemarie Rizzo Parse first published the theory in 1981 as the "Man-living-health" theory (ICPS)

The name was officially changed to "the human becoming theory" in 1992 to remove the term "man," after the change in the dictionary definition of the word from its former meaning of "humankind."

ASSUMPTIONS

About man

• The human is coexisting while co-constituting rhythmical patterns with the universe.


• The human is open, freely choosing meaning in situation, bearing responsibility for decisions.


• The human is unitary, continuously co-constituting patterns of relating.


• The human is transcending multi-dimensionally with the possible.

About Becoming

• Becoming is unitary human-living-health.


• Becoming is a rhythmically co-constituting human-universe process.


• Becoming is the human’s patterns of relating value priorities.


• Becoming is an inter-subjective process of transcending with the possible


• Becoming is unitary human’s emerging

Three Major Assumptions of human becoming theory

• Meaning
  
  
  
  • Human Becoming is freely choosing personal meaning in situations in the inter-subjective process of living value priorities.
  
  
  • Man’s reality is given meaning through lived experiences
  
  
  • Man and environment co-create
  
  
  
  


• Rhythmicity
  
  
  
  • Human Becoming is co-creating rhythmical patterns of relating in mutual process with the universe.
  
  
  • Man and environment co-create ( imaging, valuing, languaging) in rhythmical patterns
  
  
  
  


• Transcendence
  
  
  
  • Human Becoming is co-transcending multi-dimensionally with emerging possibilities
  
  
  • Refers to reaching out and beyond the limits that a person sets
  
  
  • One constantly transforms
  
  
  
  

NURSING PARADIGMS AND PARSE'S THEORY 

• Person

• Open being who is more than and different from the sum of the parts




• Environment
  
  
  
  • Everything in the person and his experiences
  
  
  • Inseparable, complimentary to and evolving with
  
  
  
  


• Health
  
  
  
  • Open process of being and becoming. Involves synthesis of values
  
  
  
  


• Nursing
  
  
  
  • A human science and art that uses an abstract body of knowledge to serve people
  
  
  
  

SYMBOL OF HUMAN BECOMING THEORY

• Black and white = opposite paradox significant to ontology of human becoming and green is hope


• Center joined =co created mutual human universe process at the ontological level & nurse-person process


• Green and black swirls intertwining = human-universe co creation as an ongoing process of becoming

STRENGTH AND WEAKNESSES

Strengths

• Differentiates nursing from other disciplines


• Practice - Provides guidelines of care and useful administration


• Useful in Education


• Provides research methodologies


• Provides framework to guide inquiry of other theories (grief, hope, laughter, etc.)

Weaknesses

• Research considered to be in a “closed circle”


• Rarely quantifiable results - Difficult to compare to other research studies, no control group, standardized questions, etc.


• Does not utilized the nursing process/diagnoses


• Negates the idea that each person engages in a unique lived experience


• Not accessible to the novice nurse


• Not applicable to acute, emergent care

APPLICATION OF THE THEORY

Nursing Practice

• A transformative approach to all levels of nursing


• Differs from the traditional nursing process, particularly in that it does not seek to “fix” problems


• Ability to see patients perspective allows nurse to “be with” patient and guide them toward desired health outcomes


• Nurse-person relationship co-creates changing health patterns

Research

• Enhances understanding of human lived experience, health, quality of life and quality of nursing practice


• Expands the theory of human becoming


• Builds new nursing knowledge about universal lived experiences which may ultimately contribute to health and quality of life

CRITIQUE

• Congruence with personal values
  
  
  
  • Nurse must subscribe to this world view to truly use it
  
  
  
  


• Congruence with other professional values
  
  
  
  • Complements and competes with other health care professionals’ values
  
  
  • Exoteric foundations
  
  
  • Esoteric utility
  
  
  
  


• Congruence with social values
  
  
  
  • Fulfills society’s expectations of nursing role
  
  
  
  


• Social Significance
  
  
  
  • Makes a substantial difference in the lives of clients and nurses
  
  
  
  

BETTY NEUMAN’S THEORY

BETTY NEUMAN’S THEORY

INTRODUCTION:

The Neuman Systems Model was originally developed in 1970 at the University of California, Los Angeles, by Betty Neumann, Ph.D., RN. It is based upon Neumann’s own personal philosophy, teaching, and experience. The goal of Neumann System model was to provide a holistic overview of the physiological, psychological, sociocultural, developmental and spiritual aspects of human beings.

One of the primary problem with the application of general systems theory to phenomena of interest to nursing is that “what” of assessment, intervention and evaluation is not identified. Neuman(1989)addressed this shortcoming by clearly identifying how the model relates to the nursing process rather than using the less meaningful general systems language of “input”, “throughputs”, and “feedback loops”. Neuman states that the model is “open to creative implementation. Although creative interpretations and implementation of the model are valued, structural changes that could alter its original meaning and purpose are not sanctioned”.

THE CONCEPTUAL MODEL: “

The Neumann systems model provides a comprehensive, flexible, holistic and system based perspective for nursing. This conceptual model for nursing focuses attention on the response of client system to actual or potential environmental stressors and the use of primary, secondary and tertiary nursing prevention interventions for retention attainment and maintenance of optimal client system wellness.”

The model was organized by the nursing meta paradigm concepts: person, environment, health and nursing. The aim of model is the development of a person in a state of wellness having the capacity to function optimally by adaptation with environmental stimuli causing illness back to state of wellness.

 

• Person: The concept of person in the Neuman model is called client-client system model .The person is a layered multidimensional being. Each layer consists of five person variables or subsystems:


• Physiological(refers of the physicochemical structure and function of the body).


• Psychological(refers to mental processes and emotions).


• Socio-cultural(refers to relationships; and social/cultural expectations and activities).


• Developmental(refers to those processes related to development over the lifespan).


• Spiritual(refers to the influence of spiritual beliefs).

The layers, usually represented by concentric circle, consist of the central core, lines of resistance, lines of normal defence, and lines of flexible defence. The basic core structure is comprised of survival mechanisms including: organ function, temperature control, genetic structure, response patterns, ego. Lines of resistance and two lines of defence 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 defence 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).

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 homoeostatic, 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 homoeostasis, occurs when the amount of energy that is available exceeds that being used by the system. A haemostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance.

Lines of Resistance: The lines of resistance protect the basic structure and become activated when environmental stress ors invade the normal line of defence. Example: activation of the immune response after invasion of micro-organisms. 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.

Line of Normal  Defence: The normal line of defence represents system stability over time. It is considered to be the usual level of stability in the system. The normal line of defence 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.

Lines of Flexible Defence: 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 defence fails to provide adequate protection to the normal line of defence, the lines of resistance become activated. The flexible line of defence acts as a cushion and is described as accordion-like as it expands away from or contracts closer to the normal line of defence. The flexible line of defence is dynamic and can be changed/altered in a relatively short period of time.

• Environment: Neumann model consist of the following topology: internal, external or created. Internal and External environment include the intrapersonal, interpersonal and extrapersonal stress ors 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.


• The created environment unconsciously developed by the client to protect from intrapersonal, interpersonal, extrapersonal stressors and maintain system stability.

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


• Extrapersonal - 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.

• Health: Health is 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.

 

• Nursing: Neuman states that nursing is a “unique” profession concerned with the interrelationship of all “variables affecting a client’s possible are an actual response to stressors”. Neuman defines that nursing can help “individuals, families and groups to retain, attain and maintain a maximum level of wellness”. The primary aim is stability of the client system, through nursing interventions to reduce stressors and when a stressor reaction occurs, the secondary aim is the treatment of symptoms. The tertiary aim to help the client to reconstitute and maintain the current level of wellness.   The nursing process within the Neuman model consists of three components: Nursing Diagnosis, Goals and Outcomes.

1. Nursing Diagnosis– A large component of the nursing diagnosis phase of Neuman nursing process involves nurse assessment of all factors influencing the client .The perception of client and nurse may vary widely and thereby influence appropriate interventions, active client participation is essential to validate the meaning of a client’s experience with the nurse.


2. Nursing Goals – This decision results from collaborative negotiation with the patient, and take account of patient's and nurse's perceptions of variance from wellness


3. Nursing Outcomes – Actual outcomes are the result of the effectiveness of selected interventions and are evaluated in relation to mutually set goals.

The nurse’s role in relation to assessment and intervention varies depending upon the type of intervention (primary, secondary or tertiary)that is needed.

• 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.


• o   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.


• o   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.

APPLICATION:

Research: Neuman’s System Model is being used in Nursing research that guides enhancement of nursing care.

Nursing Education:

• Effective in conceptual transition among all levels of nursing education.


• Basis for continuing education after graduation facilitating professional growth.


• Validate nursing roles and activities and its applicability beyond nursing practice.

Nursing Practice: Holistic approach in the care of the patients.

 CONCLUSION:

Neuman has presented a comprehensive and systematic approach for organizing nursing phenomena that is based on tested scientific findings from multiple disciplines. It is a valuable model for understanding relationships between clients and their environments.

ERIK ERIKSON’S PSYCHOSOCIAL THEORY

ERIK ERIKSON’S PSYCHOSOCIAL THEORY

INTRODUCTION:

Erikson studied the influence of social process on the personality. He describe eight stages of life cycle during which individual struggle with “developmental crisis”. Specific tasks associated with each stage must be completed for resolution of the crisis and for emotional growth to occur.

LIFE HISTORY OF ERIK ERIKSSON:

• 15 June, 1905- Erik hamburger Erikson was born in Karlsruhe, Germany.


• 1993- Erikson immigrated to U.S. Conducted research at university of California in the influence of culture on the child development.


• 1950- As a result of his above studies and including his anthropological work, he published a book “childhood and society”. In these book he presented a psychosocial theory of development that describes crucial steps in person’s relationship with the social world, based on the interplay between biology and society.


• 1994- He died

ERIK ERIKSON’S PSYCHOSOCIAL THEORY

ERIKSON’S STAGES OF PERSONALITY DEVELOPMENT:

Erikson’s conception of the eight stages of ego development across the life cycle is the centrepiece of his life’s work. The eight stages represent points along a continuum of development in which physical, cognitive, instinctual and sexual changes combine to trigger an internal crisis. Whose resolution or growth and development of specific virtues.

STAGE 1: TRUST VERSUS MISTRUST (BIRTH TO 18 MONTH)

MAJOR DEVELOPMENT TASK: To develop a basic trust in mothering figure and learn to generalize it to others.

ACHIEVEMENT OF THE TASK: Results in self confidence, optimism, faith in the gratification of needs and desires and need for the future. The infant learns to trust when basic needs are met consistently.

NON ACHIEVEMENT RESULT: Results in emotional dissatisfaction with self and others, suspiciousness, and difficulty with interpersonal relationships. The task remain unresolved when primary caregivers fail to respond to the infant’s distress signals promptly and consistently.

STAGE 2 AUTONOMY VERSUS SHAME DOBT (18 TO 3 YRS):

MAJOR DEVELOPMENT TASK: To gain some self control and independence within the environment.

ACHIVEMENT OF THE TASK: Result in a sense of self control and the ability to delay gratification and a feeling of self confidence in one’s ability to perform. Autonomy is achieve when parents encourage and provide a opportunity for independent activity.

NON-ACHIVEMENT: result in a lack of self confidence and a lack of pride in the ability to perform a sense of being control by others and a rage against self. The task remains unresolved when primary care givers restrict independent behaviour both physically and verbally set the child up for failure with unrealistic expectation.

STAGE 3  INITIATIVE VERSUS GUILT (3-6 YEARS)

MAJOR DEVELOPMENT TASK: To develop a sense of purpose and the ability to initiate and direct own activities.

ACHIEVEMENTS: Task results in the ability to exercise restraint and self control of inappropriate social behavior. Assertiveness and dependability increase  and the child enjoys learning and personal achievement. The conscience develops, thereby controlling the impulsive behaviors of the id. Initiative is achieved when creativity is encouraged and performance is recognized and positively reinforced.

NON ACHIEVEMENT: Results in feeling of inadequacy and a sense of defeat. Guilt is experienced to an excessive degree, even to the point of accepting liability in situations for which one is not responsible. The child may view himself/herself as evil and deserving of punishment. The task remains unresolved when creativity is stifled and parents continually expect a higher level of achievement has the child produces.

STAGE 4:INDUSTRY VERSUS INFERIORITY (6 TO 12 YEARS)

MAJOR DEVELOPMENT TASK: To achieve a level of self confidence by learning competing, performing successfully and receiving recognition from significant others, peers and acquaintances.

ACHIEVEMENTS OF THE TASK RESULTS: Results in a sense of satisfaction and pleasure in the interaction and involvement with others. The individual masters reliable work habits and develops attitudes of trustworthiness. He or she is conscientious, feels pride in achievement and enjoy play but desires a balance between fantasy and real world activities. Industry is achieved when encouragement is given to activities and responsibilities in school and community, as well as those within the home and recognition is given for accomplishment.

NON ACHIEVEMENT: results in difficulty in interpersonal relationships because of feelings of personal inadequacy. The individual can neither cooperates and compromise with others in group activities nor completes task successfully. He or she may become either passive and meek or overly aggressive to cover up for feeling of inadequacy. If this occurs, the individual may manipulate or violate the rights of others to satisfy his or her own needs. This task remains unresolved when parents set unrealistic expectations for the child, when discipline is harsh and tends to impair self esteem and when accomplishments are consistently met negative feedback.

STAGE 5: IDENTITY VERSUS ROLE CONFUSION (12 – 20 yrs):

MAJOR DEVELOPMENT TASK: To integrate the task mastered in the previous stages in to a secure sense of self.

ACHIEVEMENTS OF THE TASK RESULTS: in a sense of confidence emotional stability, view of self as a unique individual. Commitment related to career and relationship with members of both genders. Identity is achieved when adolescence are allowed to experience independence in decision making that influence their lives. Parents should be available to offer support when needed but should gradually relinquish control to the maturing individuals in an effort to encourage the development of an independent sense of self.

NON ACHIEVEMENT: results in a sense of self consciousness, doubt, and confusion about one’s role in life. Personal values and goals for ones lie are absent. Commitment to life are nonexistent instead are superficial and brief. A lack of self confidence is often expressed by delinquent and rebellious behaviour. Entering adulthood with its accompanying responsibilities may be an underlying fear.

STAGE 6: INTIMACY VERSUS ISOLATION (20 TO 30 YEARS)

MAJOR DEVELOPMENT TASK: to form an intense lasting relationship or a commitment to another person, a cause, an institution or creative efforts.

ACHIEVEMENTS OF THE TASK RESULTS: in the capacity for mutual love and respect for two people and the ability of an individual to pledge the total commitment to another. The intimacy goes beyond the sexual contact between the two individual. Personal sacrifices are made for each other. The intimacy achieved when an individual developed the capacity for giving oneself to another. And this is learned when one has been the recipient of his type of giving within the family unit.

NON ACHIEVEMENT:  results in withdrawal, social isolation and loneliness, the individual is unable to form lasting intimate relationships, often seeking intimacy through numerous superficial sexual contacts. No career is established; he may have the history of occupational changes. The task remains unresolved when love in the home has been deprived through the younger years. One fail to achieve the ability to give the self without having been the recipients early on from the primary caregivers.

STAGE 7:GENERATIVITY VERSUS STAGNATION(30 TO 65 YEARS)

MAJOR DEVELOPMENT TASK: to achieve the life goals established for oneself while also considering the welfare of future generations.

ACHIEVEMENTS OF THE TASK RESULTS in a sense of gratification from personal and professional achievements and from meaningful contribution to others. The individual is active in the service of the society. Generativity is achieved when the individual expresses satisfaction with his stage in life and demonstrates responsibility for leaving the world a better place in which to live.

NON ACHIEVEMENT: results in lack of concern for the welfare of others and total preoccupation with the self. He become withdrawn, isolated, highly self indulgent, with no capacity for giving of the self to others. The tasks remain unresolved when earlier developmental tasks are not fulfilled and the individual doesn’t achieve the degree of maturity. Required to achieve gratification out of personal concern for the welfare of others.

STAGE 8: EGO INTEGRITY VERSUS DESPAIR :(65 YEARS TO DEATH)

MAJOR DEVELOPMENT TASK:  review one’s life and derive meaning from both positive and negative events while achieving a positive sense of self.

ACHIEVEMENTS OF THE TASK RESULTS: in a sense of self worth and self acceptance as one’s reviews life goals accepting that some were achieved some where not. The individual derives a sense of dignity from his or her life experiences. And doesn’t fear death, rather viewing it as another phase of development .ego integrity is achieved when individuals have successfully completed the developmental tasks of the other stages and have little desire to make major changes in how their lives have progressed.

NON ACHIEVEMENT: results in a sense of self contempt and disgust with how life has progressed. The individual would like to start over and have a second chance at life. He or she feels worthless and helpless to change. Anger, depression and loneliness are evident. The focus maybe on past failures or perceived failures. Impending death is feared or denied or ideas of suicide may prevail. The task remains unresolved when earlier tasks are not fulfilled, self confidence, a concern for others and a strong sense of self identity is achieved.

ERIKSON’S CONTRIBUTION IN TREATMENT:

Among his most important contributions is his belief that establishing a state of trust between doctor and patient, which is the basic requirement for successful therapy. When psychopathology stems from basic mistrust (e.g. depression) a patient must reestablish the trust with therapist, whose task as that of the good mother may be sensitive to the patient’s need. The therapist must have a sense of self trustworthiness that may be transmitted to the patient.

RELEVANCE OF PSYCHOSOCIAL DEVELOPMENT THEORY TO NURSING PRACTICE:

 Erikson’s theory is particularly relevant to nursing practice in that it incorporates sociocultural concepts in to the development of personality. Erikson provides a systematic, stepwise approach and outline specific tasks that should be completed during each stage. This information can be used quietly readily in psychiatric health nursing. Many individuals with mental health problems are still struggling to achieve the task froe a number of developmental stages. Nurses can plan care to assist these individuals to fulfill this tasks and move on to a higher developmental level.

 

Sullivan's interpersonal theory of personality

Sullivan's interpersonal theory of personality

Introduction:

An interpersonal theorist was Harry Stack Sullivan (1892-1949). He believed that individual behaviour and personality development are the direct result of interpersonal relationships. Sullivan’s major concepts include the following:

• Anxiety: Anxiety is the feeling of emotional discomfort, toward the relief or prevention of which all behavior is aimed. Sullivan believed that anxiety is the chief disruptive force in interpersonal relations and the main factor in the development of serious difficulties in living.


• Satisfaction of needs: Satisfaction of needs is the fulfillment of all requirements associated with an individual’s psychochemical environment. Sullivan identified examples of these requirements as oxygen, food, water, warmth, rest, activity, sexual expression anything that when absent, produces discomfort in the individual.


• Interpersonal Security: Interpersonal Security is the feeling associated with the relief from anxiety. He believed individuals have an innate need for interpersonal security.


• Self Esteem: Self Esteem is a collection of experiences or security measures adopted by the individual to protect against anxiety. Sullivan identified three components of self esteem which are based on interpersonal experiences early in life:


• Good me: Good me is the part of personality that develop in the response to positive feedback from the primary caregiver


• Bad me: Bad me is the part of personality that develops in the response to negative feedback from the primary caregiver.


• Not me: Not me is the part of the personality that response to situations that produce intense anxiety in the child. Feeling of horror, awe, and dread are experienced in response to situations.

Principles of sullivan's interpersonal theory of personality

1. Interpersonal relationship and personality development: According to Sullivan’s personality development proceeds through various stages involving different patterns of interpersonal relationship. At first for example interaction are mainly with parents who begin socialization of the child. Later with adolescence and a gradual emancipation from parents peer relationships become increasingly and in young adulthood intimate relationships are established. Failure to progress satisfactory through the various stages of development paves the way for later maladaptive behavior.

In this development Sullivan was concerned with anxiety arousing aspects of development of interpersonal relationships during early development. Since the infant completely dependent on significant others for meeting all physical and psychological needs lack of love and care lead to an insecure and anxious human being. Sullivan emphasized the role of early childhood relationship in shaping the self concepts, which he saw as constructed largely out of the reflected appraisals of significant others. For example if a little boy perceives others as rejecting him as being of little or no worth he is likely to view himself in a similar light and to develop a negative self- image that almost inevitably leads to maladjustment.

The pressure of the socialization process and the continual appraisal by others leads a child to label some personal tendencies as the “good me” and others as the “bad me”. Bed me is that is associated with the anxiety. With time the individual develops a self system that serves to protect him or her from such anxiety through the use of ego defense mechanisms. If anxiety arousing tendency is too service the individual perceives it as the “not me” totally screening it out of consciousness or even attributing it to someone else. Such action leads to incongruity between the individual’s perception and the world as it really is and may there for result in maladaptive behavior. Here we can readily see a similarity between Sullivan’s views and those of both Freud and Rogers.

 2.Social exchange, roles and games: three ways of viewing our relationship with other people will helpful in understanding both satisfying and hurtful interactions.

The social exchange view largely developed by Thibault and Kelly(1959) and homans(1961) is based on the premise that we form relationships with each others for the purpose of satisfying our needs.

Each person in the relationship wants something from the other and the exchange that results is essentially a trading or bargaining one. For example when a person feels that he has entered into a bad bargain- that the rewards are not worth the costs- he may attempt to work out some compromise or simply terminate the relationship.

A second way of viewing interpersonal relationship is in terms of social roles. Society prescribes role behavior for teachers generals and others occupying given positions designed to facilitate the functioning of the group. While each individual lends a personal interpretation to the role there usually are limits to the “script” beyond which the person is not expected to go. Similarly in intimate personal relationships each person holds certain role expectations in term of obligations rights, duties and so on that the other person in the relationship is expected to meet. If one spouse fails to live up to the other’s role expectations or finds them uncomfortable or if husband and wife have different conceptions or finds them uncomfortable or if husband and wife have different conceptions of what a wife or husband should be or do serious complications in the relationship are likely to occur.

Another view of interpersonal relationships focuses on the games people play. Eric Berne has pointed out that such games are  not consciously planned but rather involve a sort of role playing of which the person are either entirely or partially unaware. For example a woman who lacks self confidence may marry a man who is very domineering and then complain that she could do all sorts of outstanding things if it weren’t for you.

Such games presumably serve two useful functions

1. As substitutes for or defenses against true intimacy for which many people are unprepared


2. As stabilizers to help maintain a relationship. Such games however are likely to prove a poor substitute for an authentic relationship though called games in the sense of being ploys they are often deadly serious.


3. Interpersonal Accommodation: It is the process where by two persons evolve patterns or communication and interaction that enable to attain common goals, meet mutual needs and build a satisfying relationship.

People communicate in many verbal and nonverbal ways the individuals in a relationship use many cues in their attempts to attempts to interpret what is really being said to them. Sullivan believed that faulty communication is far common than most people realize especially in family interactions on an emotional level.

Psychopathology:    

The interpersonal model places strong emphasis on the unsatisfactory interpersonal relationships as the primary causal factor in many forms maladaptive behavior. Such relationships may extend back to child hood as when a boy’s self concept was distorted by significant others who appraised him as being worthless or when rigid socialization measures made it difficult for a girl to accept and integrate the bad me into her concept. However it is the individual’s current interpersonal relationship and their effects on behavior that are of primary concern. Thus the focus of therapy is on the alleviation of current pathogenic relationships and on helping the individual achieve more satisfactory relationships. Such therapy is concerned with verbal and nonverbal communication and social roles process of accommodation and the general interpersonal context of behavior and as might be expected strong emphasis is placed on the use the therapy situation itself as a vehicle for new learning of interpersonal skills.

The interpersonal model is handicapped by incomplete information concerning most aspects of interpersonal relationship. As a result many of Sullivan’s concepts and those of later investigators lack of limitations, however the interpersonal model has served to focus attention on the quality of the individuals close personal relationships as a key factor in determining whether behavior will be effective or maladaptive.

In reviewing these psychosocial models of human behavior the psychoanalytic, behaviorstic ,humanistic, existential and interpersonal – we have seen that each contributes to our understanding of psychopathology but that none alone seems to be account for the complex types of maladaptive behavior exhibited by human beings. Each has a substantial amount of research evidence to support it, yet each model also depends on generalization from limited kinds of events and observation. Such as schizophrenia for example: behavior stick model focuses on faulty learning and an environmental condition that may exacerbate on maintain such maladaptive behavior while the humanistic model focuses on problem relating to values meaning and personal growth. Thus it becomes apparent that adopting one model or another has important consequences. It influences our perception of maladaptive behavior as well as the types of evidence we look for and how we are likely to interpret the data.

 

Sullivan’s Stages of Personality Development:

• Infancy: Birth to 18 Month

During the beginning stage, the major developmental task for the child is the gratification of needs. This is accomplished through activity associated with the mouth such as crying, thumb sucking.

• Childhood: 18 Month to 6Years

At ages 18 month to 6 years, the child learns that interference with fulfillment of personal wishes and desires may result in the delayed gratification. He or she learns to accept this and feel comfortable with it, recognizing that delayed gratification often results in parental approval, a more lasting type of reward. Tools of this stage include the mouth, the anus, language, experimentation, manipulation, and identification.

 

 

• Juvenile: 6 to 9 Years

The major task of juvenile stage is formation of satisfactory relationships within peer groups. This is accomplished through the use of competition, co-operation, and compromise.

• Preadolescence: 9 to 12 Years

The task at the Preadolescence stage focus on developing relationships with persons of the same sex. One’s ability to collaborate with and show love and affection for another person begins at this stage.

• Early Adolescence: 12 to 14 Years

During early adolescence, the child is struggling with developing a sense of identity that is separate and independent from the parents. The major task is the formation of satisfactory relationships with members of the opposite sex.

• Late Adolescence: 14 to 21 Years

The late adolescence period is characterized by tasks associated with the attempt to achieve interdependence with the society and the formation of a lasting, intimate relationship with a selected member of opposite sex. The genital organs are the major developmental focus of this stage.

Factors influencing the Interpersonal Communication

1. Values, Attitudes and Beliefs: Values, attitudes and beliefs can influence interpersonal communication.

1. Culture or Religion: Culture values are learned and differ from society to society.

For example: In some European countries men may great each other with hugs and kisses. This behavior was appropriate in those cultures but would communicate a different message in the United States.

Religion can influence interpersonal communication. Priests and ministers who were clerical collars publicly communicate their mission in life. The collar may influence the way in which others relates to them either positively or negatively. Other symbolic gestures such as wearing a cross around the neck or hanging a crucifix on the wall also communicate an individual’s religious beliefs.

 

• Social Status: Social status or powers have suggested that high status persons are associated with gestures communicate their higher power position.

For example: They use less eye contact have a more relaxed posture, use louder voice pitch, place hands on hips more frequently are power dresser have greater heights and maintain more distance when communicating with individuals considered to be of lower social status.

 

1. Gender: Gender influences the manner in which the individuals communicate. Each culture has gender signals that are recognized as either masculine or feminine and provide a basis for distinguishing between members of each sex.

 

1. Age: Age influences the interpersonal communication and it is more evident than during adolescence. In their struggle to separate from prenatal confines and establish their own identify adolescents generate a pattern of communication that is unique and changes from generation to generation.

For example: Word such as “dude”, cool have had special meaning for certain generation of adolescents.

1. Environment: Some individuals who feel uncomfortable and refuse to speak during a group therapy session may be open and willing to discuss problems privately on a one-to-one basis with the nurse.