Outcome identification and planning
1. Name- Mr. AM
2. Age- 66 years
4. Marital status-married
5. Referral source- Referred from ------- Medical College, -------
STRESSORS AS PERCEIVED BY CLIENT
(Information collected from the patient and his wife)
Major stress area, or areas of health concern
Patient was suffering from severe abdominal pain, nausea, vomiting, yellowish discolorations of eye, palm, and urine, reduced appetite and gross weight loss(8kg with in 4 months)
Patient is been diagnosed to have Periampullary carcinoma one week back.
Patient underwent operative procedure i.e. WHIPPLE’S PROCEDURE- Pancreato duodenectomy on 27/3/08.
Psychologically disturbed about his disease condition- anticipating it as a life threatening condition. Patient is in depressive mood and does not interacting.
Patient is disturbed by the thoughts that he became a burden to his children with so many serious illnesses which made them to stay with him at hospital.
Patient has pitting type of edema over the ankle region, and it is more during the evening and will not be relieved by elevation of the affected extremities.
He had developed BPH few months back (2008 January) and underwent surgery TURP on January 17. Still he has mild difficulty in initiating the stream of urine.
Patient is a known case of Diabetes since last 28 years and for the last 4 years he is on Inj. H.Insulin (4U-0-0). It is adding up his distress regarding his health.
Life style patterns
patient is a retired school teacher
cares for wife and other family members
living with his son and his family
active in church
participates in community group meeting i.e. local politics
has a supportive spouse and family
taking mixed diet
no habits of smoking or drinking
spends leisure time by reading news paper, watching TV, spending time with family members and relatives
Have you experienced a similar problem?
The fatigue is similar to that of previous hospitalization (after the surgery of the BPH)
Severity of pain was some what similar in the previous time of surgery i.e. TURP.
Was psychologically disturbed during the previous surgery i.e. TURP.
What helped then- family members psychological support helped him to over come the crisis situation
Anticipation of the future
Concerns about the healthy and speedy recovery.
Anticipation of changes in the lifestyle and food habits
Anticipating about the demands of modified life style
Anticipating the needs of future follow up
What doing to help himself?
Talking to his friends and relatives
Reading the religious materials i.e. reading the Bible
Instillation of positive thoughts i.e. planning about the activities to be resume after discharge, spending time with grand children, going to the church, return back to the social interactions etc
Avoiding the negative thoughts i.e. diverts the attentions from the pain or difficulties, try to eliminate the disturbing thoughts about the disease and surgery etc
Trying to accept the reality etc..
What is expected of others?
Family members visiting the patient and spending some time with him will help to a great extent to relieve his tension.
Convey a warm and accepting behaviour towards him.
Family members will help him to meet his own personal needs as much as possible.
Involve the patient also in taking decisions about his own care, treatment, follow up etc
STRESSORS AS PERCEIVED BY THE CARE GIVER.
Major stress areas
Massive weight loss i.e.( 8 kg of body weight with in 4 months)
History of BPH and its surgery
Persistence of urinary symptoms (difficulty in initiating the stream of urine) and edema of the lower extremities
Persistent disease- chronic hypertensive since last 28 years
Depressive ideations and negative thoughts
Present circumstances differing from the usual pattern of living
acute pain ( before the surgery patient had pain because of the underlying pathology and after the surgery pain is present at the surgical site)
nausea and vomiting which was present before the surgery and is still persisting after the surgery also
anticipatory anxiety concerns the recovery and prognosis of the disease
negative thoughts that he has become a burden to his children
Anticipatory anxiety concerning the restrictions after the surgery and the life style modifications which are to be followed.
Clients past experience with the similar situations
Patient verbalized that the severity of pain, nausea, fatigue etc was similar to that of patient’s previous surgery. Counter checked with the family members that what they observed.
Psychologically disturbed previously also before the surgery. (collected from the patient and counter checked with the relatives)
Client perceived that the present disease condition is much more severe than the previous condition. He thinks it is a serious form of cancer and the recovery is very poor. So patient is psychologically depressed.
Client is capable of handling the situation- will need support and encouragement to do so.
He has the plans to go back home and to resume the activities which he was doing prior to the hospitalization.
He also planned in his mind about the future follow up ie continuation of chemotherapy
What client can do to help himself?
Patient is using his own coping strategies to adjust to the situations.
He is spending time to read religious books and also spends time in talking with others
He is trying to clarify his own doubts in an attempt to eliminate doubts and to instill hope.
He sets his major goal i.e. a healthy and speedy recovery.
Client's expectations of family, friends and caregivers
he sees the health care providers as a source pf information.
He tries to consider them as a significant members who can help to over come the stress
He seeks both psychological and physical support from the care givers, friends and family members
He sees the family members as helping hands and feels relaxed when they are with him.
Evaluation/ summary of impressions-
There is no apparent discrepancies identified between patients perception and the care givers perceptions.
1. Physical examination and investigations
Height- 162 cm
Weight – 42 kg
TPR- 37o C, 74 b/m, 14 breaths per min
BP- 130/78 mm of Hg
Eye- vision is normal, on examination the appearance of eye is normal. Conjunctiva is pale in appearance. Pupils reacting to the light.
Ear- appearance of ears normal. No wax deposition. Pinna is normal in appearance and hearing ability is also normal.
Respiratory system- respiratory rate is normal, no abnormal sounds on auscultation. Respiratory rate is 16 breaths per min.
Cardiovascular system- heart rate is 76 per min. on auscultation no abnormalities detected. Edema is present over the left ankle which is non pitting in nature.
GIT- patient has the complaints of reduced appetite, nausea; vomiting etc. food intake is very less. Mouth- on examination is normal. Bowel sounds are reduced. Abdomen could not be palpated because of the presence of the surgical incision. Bowel habits are not regular after the hospitalization
Extremities- range of motion of the extremities are normal. Edema is present over the left ankle which is non pitting in nature. Because of weakness and fatigue he is not able to walk with out support
Integumentary system- extremities are mild yellowish in color. No cyanosis. Capillary refill is normal.
Genitor urinary system- patient has difficulty in initiating the urine stream. No complaints of painful micturation or difficulty in passing urine.
Self acre activities- perform some of his activities, for getting up from the bed he needs some other person’s support. To walk also he needs a support. He do his personal care activities with the support from the others
Immunizations- it is been told that he has taken the immunizations at the specific periods itself and he also had taken hepatitis immunization around 8 years back
Sleep –. He told that sleep is reduced because of the pain and other difficulties. Sleep is reduced after the hospitalization because of the noisy environment.
Diet and nutrition- patient is taking mixed diet, but the food intake is less when compared to previous food intake because of the nausea and vomiting. Usually he takes food three times a day.
Habits- patient does not have the habit of drinking or smoking.
Other complaints- patient has the complaints of pain fatigue, loss of appetite, dizziness, difficulty in urination, etc...
2. Psycho- socio cultural
Anxious about his condition
Patient is a retired teacher and he is Christian by religion.
Studied up to BA
Married and has 4 children(2sons and 2 daughters)
Congenial home environment and good relationship with wife and children
Is active in the social activities at his native place and also actively involves in the religious activities too.
Good and congenial relationship with the neighbors
Has some good and close friend at his place and he actively interact with them. They also very supportive to him
Good social support system is present from the family as well as from the neighborhood
3. Developmental factors
Patient confidently says that he had been worked for 32 years as a teacher and he was a very good teacher for students and was a good coworker for the friends.
He told that he could manage the official and house hold activities very well
He was very active after the retirement and once he go back also he will resume the activities
4. Spiritual belief system
Patient is Christian by religion
He believes in got and used to go to church and also an active member in the religious activities.
He has a personal Bible and he used to read it min of 2 times a day and also whenever he is worried or tensed he used to pray or read Bible.
He has a good social support system present which helps him to keep his mind active.
has supportive family and friends
good social interaction with others
good social support system is present
active in the agricultural works at home after the retirement
active in the religious activities.
Good interpersonal relationship with wife and the children
Good social adjustment present
All the health care facilities are present at his place
All communication facilities, travel and transport facilities etc are present at his own place.
His house at a village which is not much far from the city and the facilities are available at the place.
Financially they are stable and are able to meet the treatment expenses.
Physiological- thin body built pallor of extremities, yellowish discoloration of the mucus membrane and sclera of eye. Nausea, vomiting, reduced appetite, reduced urinary out put. Diagnosed to have periampullary carcinoma.
Psycho socio cultural factors- patient is anxious abut his condition. Depressive mood. Not interacting much with others. Good support system is present.
Developmental –no developmental abnormalities. Appropriate to the age.
Spiritual- patient’s belief system has a positive contribution to his recovery and adjustment.
pain abdomen since 4 days
Discoloration of urine
Complaints of vomiting
on and off fever
Yellowish discoloration of eye, palms and nails
Complaints of weight loss
Edema over the left leg
Post operative period (immediate post op)
Patient got admitted to ---- Medical college for 3 days and the symptoms not relieved. So they asked for discharge and came to ---this hospital. There he was treated with:
Treatment at this hospital...Pre operative period
Late post op period after 3 days of surgery)
I. NURSING DIAGNOSIS
- Acute pain related to the presence of surgical wound on abdomen secondary to periampullary carcinoma
Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and verbalization.
|Primary Prevention||secondary Prevention||Tertiary Prevention|
Evaluation – patient verbalized that the pain got reduced and the pain scale score also was zero. His facial expression also reveals that he got relief from pain.
II. NURSING DIAGNOSIS
Activity intolerance related to fatigue secondary to pain at the surgery site, and dietary restrictions
Outcome/ goals: Client will develop appropriate levels of activity free from excess fatigue, as evidenced by normal vital signs & verbalized understanding of the benefits of gradual increase in activity & exercise.
|Primary prevention||Secondary prevention||Tertiary prevention|
Evaluation – patient verbalized that his activity level improved. He is able to do some of his activities with assistance. Fatigue relieved and patient looks much more active and interactive.
Impaired physical mobility related to presence of dressing, pain at the site of surgical incision
Outcomes/goals: Patient will have improved physical mobility as evidenced by walking with minimum support and doing the activities in limit.
|Primary prevention||Secondary prevention||Tertiary prevention|
The Neuman’s system model when applied in nursing practice helped in identifying the interpersonal, intrapersonal and extra personal stressors of Mr. AM from various aspects. This was helpful to provide care in a comprehensive manner. The application of this theory revealed how well the primary, secondary and tertiary prevention interventions could be used for solving the problems in the client.
Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications; 2002.
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby, Philadelphia, 2002
George JB .Nursing Theories: The Base for Professional Nursing Practice,5th ed. New Jersey :Prentice Hall;2002.
A patient/client was evaluated according to the Neuman model. Intrapersonal stressors (physiological, psychological, socio-cultural, and spiritual), interpersonal stressors (being away from family and children) and extra-personal stressors (aggression and psychological pressure from the spouse) were found. Based on the examination, 12 nursing diagnoses based on the taxonomy of the North American Nursing Diagnosis Association International, and nursing care based on three levels of prevention that are important in the view of Neuman, are presented. The results were used in the classification of nursing interventions and the classification and nursing outcomes respectively.
The results suggest the desirability of care and patient/client satisfaction in the evaluation of nursing care based on the Neuman model. The model can be used as a framework to help nurses care for patients/clients. Thus, the application of this model and other models is recommended in the nursing care of patients/clients.