APPLICATION OF OREM'S SELF-CARE DEFICIT THEORY IN NURSING PRACTICE INTRODUCTION

The history of professional nursing begins with Florence nightingale. Later in last century nursing began with a strong emphasis on practice. Following that came the curriculum era which addressed the questions about what the nursing students should study in order to achieve the required standard of nursing. As more and more nurses began to pursue higher degrees in nursing, there emerged the research era. Later graduate education and masters education was given much importance. The development of the theory era was a natural outgrowth of the research era. With an increased number of researches it became obvious that the research without theory produced isolated information; however research and theory produced the nursing sciences. Within the contemporary phase there is an emphasis on theory use and theory based nursing practice and lead to the continued development of the theories.

OBJECTIVES to assess the patient condition by the various methods explained by the nursing theory to identify the needs of the patient to demonstrate an effective communication and interaction with the patient. to select a theory for the application according to the need of the patient to apply the theory to solve the identified problems of the patient to evaluate the extent to which the process was fruitful. Areas

Patient details Name Age Sex Education Occupation Marital status Religion Diagnosis Theory applied

Mrs. X 56 years Female No formal education House hold Married Hindu Rheumatoid arthritis Orems theory of self care

deficit.

OREMS THEORY OF SELF CARE DEFICIT The self care deficit theory proposed by Orem is a combination of three theories, i.e. theory of self care, theory of self care deficit and the theory of nursing systems. In the theory of self care, she explains self care as the activities carried out by the individual to maintain their own health. The self care agency is the acquired ability to perform the self care and this will be affected by the basic conditioning factors such as age, gender, health care system, family system etc. Therapeutic self-care demand is the totality of the self care measures required. The self care is carried out to fulfill the self-care requisites. There are mainly 3 types of self care requisites such as universal, developmental and health deviation self care requisites. Whenever there is an inadequacy of any of these self care requisite, the person will be in need of self care or will have a deficit in self care. The deficit is identified by the nurse through the thorough assessment of the patient. Once the need is identified, the nurse has to select required nursing systems to provide care: wholly compensatory, partly compensatory or supportive and educative system. The care will be provided according to the degree of deficit the patient is presenting with. Once the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get an idea about whether the mutually planned goals are met or not. Thus the theory could be successfully applied into the nursing practice. For Mrs. X. She came to the hospital with complaints of pain over all the joints, stiffness which is more in the morning and reduces by the activities. She has these complaints since 5 years and has taken treatment from local hospital. The symptoms were not reducing and came to --MC, Hospital for further management. Patient was able to do the ADL by herself but the way she performed and the posture she used was making her prone to develop the complications of the disease. She also was malnourished and was not having awareness about the deficiencies and effects. DATA COLLECTION ACCORDING TO OREMS THEORY OF SELF CARE DEFICIT 1. BASIC CONDITIONING FACTORS Age Gender Health state 56 year Female Disability due to health condition, therapeutic self care demand

Development state Sociocultural orientation Health care system Family system Patterns of living Environment resources

Ego integrity vs despair No formal education, Indian, Hindu Institutional health care Married, husband working At home with partner Rural area, items for ADL not in easy reach, no special precautions to prevent injuries Husband, daughter, sisters son

2. UNIVERSAL SELF-CARE REQUISITES: Air Water Breaths without difficulty, no pallor cyanosis Fluid intake is sufficient. Edema present over ankles. Turgor normal for the age Hb 9.6gm%, BMI = 14.Food intake is not adequate or the diet is not nutritious. Voids and eliminates bowel without difficulty. Frequent rest is required due to pain. Pain not completely relieved, Activity level ha s come down. Deformity of the joint secondary to the disease process and use of the joints.

Food Elimination Activity/ rest

Social interaction Communicates well with neighbors and calls the daughter by phone Need for medical care is communicated to the daughter. Prevention of hazards Promotion of normalcy Need instruction on care of joints and prevention of falls. Need instruction on improvement of nutritional status. Prefer to walk bare foot. Has good relation with daughter

3. DEVELOPMENTAL SELF-CARE REQUISITES:

Maintenance of developmental environment Prevention/management of the conditions threatening the normal development

Able to feed self , Difficult to perform the dressing, toileting etc Feels that the problems are due to her own behaviours and discusses the problems with husband and daughter.

4. HEALTH DEVIATION SELF CARE REQUISITES Adherence to medical regimen Reports the problems to the physician when in the hospital. Cooperates with the medication, Not much aware about the use and side effects of medicines

Awareness of potential Not aware about the actual disease process. problem associated with Not compliant with the diet and prevention of hazards. Not aware the regimen about the side effects of the medications Modification of self Has adapted to limitation in mobility. image to incorporates changes in health status The adoption of new ways for activities leads to deformities and progression of the disease. Adjustment of lifestyle to accommodate changes in the health status and medical regimen. Adjusted with the deformities. Pain tolerance not achieved

5. MEDICAL PROBLEM AND PLAN: Physicians perspective of the condition: Diagnosed with rheumatoid arthritis and is on the following medications: T. Valus SR OD T. Pan 40 mg OD T. Tramazac 50 mg OD T. Recofix Forte BD T. Shelcal BD Syp. Heamup 2tsp TID Medical Diagnosis: Rheumatoid arthritis Medical Treatment: Medication and physical therapy.

AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF SELF-CARE DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING DIAGNOSIS. 1. Air 2. Water 3. Food 4. Elimination 5. Activity/ Rest 6. Solitude/ Interaction 7. Prevention of hazards 8. Promotion of normalcy 9. Maintain a developmental environment. 10. Prevent or manage the developmental threats 11. Maintenance of health status 12. Awareness and management of the disease process. 13. Adherence to the medical regimen 14. Awareness of potential problem. 15. modify self image 16. Adjust life style to accommodate health status changes and MR Nursing care plan according to Orems theory of self care deficit Nursing diagnosis Outcome and plan Implementation ( diagnostic (Prescriptive operations) (control operations) operations ) Based on self care deficits Evaluation (regulatory operations )

a. Outcome Nurse- patient actions to 1. Effectiveness of the b. Nursing goal and - Promote patient as nurse patient action to objectives self care agent -Promote patient as self care agent c. Design of nursing - Meet self care system needs - Meet self care needs d. Appropriate - Decrease the self method of helping care deficit. - Decrease the self care deficit. 2. Effectiveness of the selected nursing system to meet the needs.

Thus in the patient Mrs. X the areas that need assistance were 1. Air 2. Water 3. Food

4. Elimination 5. Activity/ Rest(2) 6. Solitude/ Interaction 7. Prevention of hazards(2) 8. Promotion of normalcy 9. Maintain a developmental environment. 10. Prevent or manage the developmental threats 11. Maintenance of health status 12. Awareness and management of the disease process. 13. Adherence to the medical regimen 14. Awareness of potential problem. 15. modify self image 16. Adjust life style to accommodate health status changes and medical regimen APPLYING THE OREMS THEORY OF SELF-CARE DEFICIT, A NURSING CARE PLAN FOR MRS. X COULD BE PREPARED AS FOLLOWS Therapeutic self care demand: deficient area: food Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Inability to maintain the ideal nutrition related to inadequate intake and knowledge deficit OUTCOMES AND PLAN a. Outcome: improved nutrition Maintenance of a balanced diet with adequate iron supplementation. b. Nursing Goals and objectives Goal: to achieve optimal levels of nutrition. Objectives: Mrs. X will: - state the importance of maintaining a balanced diet. - List the food items rich in iron , that are available in the locality. c. Design of the nursing system: supportive educative d. Method of helping: guidance support Teaching

Providing developmental environment IMPLEMENTATION Mutually planned and identified the objectives and the patient were made to understand about the required changes in the behaviour to have the requisites met. EVALUATION Mrs. X understood the importance of maintaining an optimum nutrition. She told that she will select the iron rich diet for her food. She listed the foods that are rich in iron and that are locally available. The self care deficit in terms of food will be decreased with the initiation of the nutritional intake. The supportive educative system was useful for Mrs. X -------------------------------------------------------------------------Therapeutic self care demand: deficient area: Activity Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Self-care deficit: dressing, toileting related to restricted joint movement, secondary to the inflammatory process in the joints. OUTCOMES AND PLAN a. Outcome: - improved self-care - maintain the ability to perform the toileting and dressing with modification as required. b. Nursing Goals and objectives Goal: to achieve optimal levels of ability for self care. Objectives: Mrs. X will: -perform the dressing activities within limitations -utilize the alternative measures available for improving the toileting -perform the other activities of daily living with minimal assistance. c. Design of the nursing system: Partly compensatory d. Method of helping: Guidance: Assess the various hindering factors for self care and how to tackle them. Support: Provide all the articles needed for self care, near to the patient and ask the family members also to give the articles near to her.

Provide passive exercises and make to perform active exercises so as to promote the mobility of the joint. Make the patient use commodes or stools to perform toileting and insist on avoidance of squatting position Provide assistance whenever needed for the self care activities Provide encouragement and positive reinforcement for minor improvement in the activity level. Initiate the pain relieving measures always before the patient go for any of the activities of daily living Make the patient to use loose fitting clothes which will be easy to wear and remove. Teaching: Teach the family members the limitation in the activity level the patient has and the cooperation required Promoting a developmental environment: Teach the family and help them to practice how to help the patient according to her needs IMPLEMENTATION Mutually planned and identified the objectives and the patient was made to understand about the required changes in the behaviour to have the requisites met. EVALUATION Patient was performing some of the activities and she practiced toileting using a commode in the hospital. She verbalized an improved comfort and self care ability. She performed the dressing activities with minimal assistance Patient verbalized that she will perform the activities as instructed to get her ADL done. The partly compensatory system was useful for Mrs. X ---------------------------------------------------------------------Therapeutic self care demand: deficient area: Pain control Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Ineffective pain control related to lack of utilization of pain relief measures OUTCOMES AND PLAN a. Outcome: - improved pain self control - achieve and maintain a reduction in the pain. b. Nursing Goals and objectives Goal: to achieve reduction in the pain. Objectives: Mrs. X will: describe the total plan of pharmacological and non pharmacological pain relief demonstrate a reduction in the pain behaviours

verbalize a reduction in the pain scale score from 7 4 c. Design of the nursing system: supportive educative d. method of helping: Guidance: Explore the past experience of pain and methods used to manage them. Ask the client to report the intensity, location, severity, associated and aggravating factors. Support: Provide rest to the joints and avoid excessive manipulations provide hot and cold application to have better mobility. Encourage exercises to the joints by immersing in the warm water. Administer T. Ultracet and Tab Diclofecac as prescribed. Provide diversion and psychological support to the patient Teaching: Teach the non pharmacological method to the patient once the pain is a little reduced. Providing the developmental environment: Discuss with the patient the necessity to maintain a pain diary with all information regarding episodes of pain and refer to that periodically Enquire from the health team, the need for opioid analgesics or other analgesics and get a prescription for the patient. IMPLEMENTATION ----------------------------------------------------------------------------EVALUATION Patient still has pain over the joints and she agreed that she will use the measures for pain relief that is told to her. The pain scale score was 6 after the measures were provided to the patient. She demonstrated slight reduction in the pain behaviours. The supportive educative system was useful for Mrs. X -------------------------------------------------------------Therapeutic self care demand: deficient area: prevention of hazards. Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Potential for fall and fractures related to rheumatoid arthritis. OUTCOMES AND PLAN a. Outcome:

Absence of falls and injury to the patient b. Nursing Goals and objectives Goal: prevent the falls and injury and to maintain a good body mechanics. objectives: Mrs. X will: -remain free from injury as evidenced by: -absence of signs and symptoms of fall or injury - explaining the methods to prevent the injury. c. Design of the nursing system: supportive educative d. method of helping: Support Never leave the client alone in the unit Assess the patients gait, activities and the mental status for any confusion or disorientation Encourage the patient to use supportive devices as required. Provide a safe environment in the hospital by avoiding sharp objects or wooden objects on the way and slippery floor. Involve the family members in providing and maintaining a safe environment in the home Involve the family members to provide support to the patient whenever necessary Plan a balanced diet for the patient with a mutual interaction IMPLEMENTATION -----------------------------------------------------------------EVALUATION Patient remained free from injury as evidenced by absence of signs and symptoms. Patient explained the various measures that they will take to prevent the injury. The supportive educative system was useful for Mrs. X -----------------------------------------------------------------Therapeutic self care demand: deficient area: prevention of hazards. Adequacy of self care agency: Inadequate NURSING DIAGNOSIS: Potential for impaired skin integrity related to edema secondary to renal cysts. OUTCOMES AND PLAN: a. Outcome: Maintenance of normal skin integrity.

b. nursing Goals and objectives Goal: Maintain the skin integrity and take measures to prevent skin impairment. Objectives: Mrs. X will: maintain a normal skin integrity list the measures to prevent the loss of skin integrity identify the measures to relieve edema. c. Design of the nursing system: supportive educative d. method of helping: Support: Assess the skin regularly for any excoriation or loss of integrity or colour changes. Keep the skin clean always Avoid stress or pressure over the area of edema by providing extra cushions or padding Monitor the lab values as well as the patient for any signs and symptoms of renal failure. Encourage the patient to use slippers while walking and that should not be tight fitting. Assess the edema for its degree, pitting or non pitting and continue the assessment daily. Provide a leg end elevated position or elevation of the leg on a pillow if no cardiac abnormalities are identified. Explain the patient the need for taking care of the edematous parts Explain the patient to report the symptoms like decreased urine output, palpitations, increased edema etc. to the health team IMPLEMENTATION ------------------------------------------------------------------EVALUATION Patient remained free from impaired skin integrity She listed the measures to prevent the loss of skin integrity She identified the measures to relieve edema. The supportive educative system was useful for Mrs. x ----------------------------------------------------------------Therapeutic self care demand: deficient area: awareness of the disease process and management Adequacy of self care agency: Inadequate NURSING DIAGNOSIS Potential for complications related to rheumatoid arthritis secondary to knowledge deficit. OUTCOMES AND PLAN a. Outcome: Absence of complications and improved awareness about the disease process.

b. nursing Goals and objectives Goal: Improve the knowledge of the patient about the disease process and the complications. Objectives: Mrs. X will: -verbalize the various complication and their preventions -verbalize the changes occurring with the disease process and the treatment available -describe the actions and side effects of the medications which she is using c. Design of the nursing system: supportive educative d. Methods of helping: 1. Guidance 2. Teaching 3. Promoting a developmental environment IMPLEMENTATION ------------------------------------------------------------EVALUATION Patient got adequate information regarding the disease She verbalized what she understood about the disease and its management. Patient has cleared her doubts regarding the medication actions and the side effect The supportive educative system was useful for Mrs. X EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY The theory of self-care deficit when applied could identify the self care requisites of Mrs. X from various aspects. This was helpful to provide care in a comprehensive manner. Patient was very cooperative. the application of this theory revealed how well the supportive and educative and partly compensatory system could be used for solving the problems in a patient with rheumatoid arthritis. REFERENCES 1. Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications; 2002. 2. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002 3. George JB .Nursing Theories: The Base for Professional Nursing Practice .5th ed. New Jersey :Prentice Hall;2002.