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Application of Roy's adaptation model

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Application of Roy's Adaptation Model (RAM)


Last updated on January 26, 2012

I NT RO DUC T I O N September 9, 2013>Roy's Adaptation Model (RAM) w as developed by Sr.Callista Roy. RAM is one of the w idely applied nursing models in nursing practice, education and research. Nursing is the science and practice that expands adaptive abilities and enhances person and environment transformation Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying w ith dignity This is done by assessing behavior and factors that influence adaptive abilities and by intervening to expand those abilities and to enhance environmental interactions. Mr.NR w ho w as suffering w ith diabetes mellitus for past 10 years. He developed a diabetic foot ulcer and had to undergo amputation. He w as admitted in __ Hospital. Mr. NR w as selected for application of RAM in providing nursing care. NURS I NG P RO C ES S According to RAM, nursing process is a problem solving approach for gathering data, identifying the capacities and needs of the human adaptive system, selecting and implementing approaches for nursing care, and evaluation the outcome of care provided. Assessm ent of Behavior the first step of the nursing process w hich involves gathering data about the behavior of the person as an adaptive system in each of the adaptive modes. Assessm ent of Stim uli the second step of the nursing process w hich involves the identification of internal and external stimuli that are influencing the persons adaptive behaviors. Stimuli are classified as: 1. Focal- those most immediately confronting the person, 2. Contextual-all other stimuli present that are affecting the situation and 3. Residual- those stimuli w hose effect on the situation are unclear. Nursing Diagnosis step three of the nursing process w hich involves the formulation of statements that interpret data about the adaptation status of the person, including the behavior and most relevant stimuli

HONco d e s t an d ar d for tr us tw or thy h e alt h in f o r m at io n ve r if y h e r e


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Articles published on this site are handouts/class notes prepared by the editors based on the references cited. Contents provided in these articles are meant for general information only, and are not suggested as replacement to standard references. Any inaccurate information, if found, may be communicated to the editor. The editor and the publisher assume no responsibility for errors, omissions, or damages caused by the use of these files or programs or from the use of the information contained herein. Contact us at: cu r r e n t n u r s in g @ g m ail.co m Advertisement by Google

Goal Setting the forth step of the nursing process w hich involves the establishment of clear statements of the behavioral outcomes for nursing care. Intervention the fifth step of the nursing process w hich involves the determination of how best to assist the person in attaining the established goals Evaluation the sixth and final step of the nursing process w hich involves judging the effectiveness of the nursing intervention in relation to the behavior after the nursing intervention in comparison w ith the goal established.

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comparison w ith the goal established. DEM O G RA P HI C DA T A

Application of Roy's adaptation model

Name Age Sex IP number Education Occupation Marital status Religion Informants Date of admission

Mr. NR 53 years Male ----Degree Bank clerk Married Hindu Patient and Wife 21/01/08

F I RS T L EV EL A S S ES S M ENT PHYSIOLOGIC-PHYSICAL MODE Oxygenation Stable process of ventilation and stable process of gas exchange. RR= 18Bpm. Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left 5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or crepitus. NVBS. S1& S2 heard. No abnormal heart sounds. Delayed capillary refill+. JVP0. Apex beat felt- normal rhythm, depth and rate. Dorsalis pedis pulsation of affected limp is not palpable. All other pulsations are normal in rate, depth, tension w ith regular rhythm.
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Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line. S1& S2 heard. No abnormal heart sounds. BP- Normotensive. . Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis. Nutrition He is on diabetic diet (1500kcal). Non vegetarian. Recently his Weight reduced markedly (10 kg/ 6 month). He has stable digestive process. He has complaints of anorexia and not taking adequate food. No abdominal distension. Soft on palpation. No tenderness. No visible peristaltic movements. Bow el sounds heard. Percussion revealed dullness over hepatic area. Oral mucosa is normal. No difficulty to sw allow food Elim ination: No signs of infections, no pain during micturation or defecation. Normal bladder pattern. Using urinal for micturation. Stool is hard and he complaints of constipation. Activity and rest: Taking adequate rest. Sleep pattern disturbed at night due unfamiliar surrounding. Not follow ing any peculiar relaxation measure. Like movies and reading. No regular pattern of exercise.

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Application of Roy's adaptation model


Walking from home to office during morning and evening. Now , activity reduced due to amputated w ound. Mobility impaired. Walking w ith crutches. Pain from joints present. No paralysis. ROM is limited in the left leg due to w ound. No contractures present. No sw elling over the joints. Patient need assistance for doing the activities. Protection:

Left low er fore foot is amputated. Black discoloration present over the area. No redness, discharge or other signs of infection. Nomothermic. Wound healing better now . Walking w ith the use of left leg is not possible. Using crutches. Pain form knee and hip joint present w hile w alking. Dorsalis pedis pulsation, not present over the left leg. Right leg is normal in length and size. Several papules present over the foot. All peripheral pulses are present w ith normal rate, rhythm and depth over right leg. Senses: No pain sensation from the w ound site. Relatively, reduced touch and pain sensation in the low er periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses are normal. Fluids and electrolytes: Drinks approximately 2000ml of w ater. Stable intake out put ratio. Serum electrolyte values are w ith in normal limit. No signs of acidosis or alkalosis. Blood glucose elevated. Neurological function: He is conscious and oriented. He is anxious about the disease condition. Like to go home as early as possible. Show ing signs of stress. Touch and pain sensation decreased in low er extremity. Thinking and memory is intact. Endocrine function He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands. SELF CONCEPT MODE Physical self: He is anxious about changes in body image, but accepting treatment and coping w ith the situation. He deprived of sexual activity after amputation. Belongs to a Nuclear family. 5 members. Stays along w ith w ife and three children. Good relationship w ith the neighbours. Good interaction w ith the friends. Moderately active in local social activities Personal self: Self esteem disturbed because of financial burden and hospitalization. He believes in

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Self esteem disturbed because of financial burden and hospitalization. He believes in god and w orshiping Hindu culture. ROLE PERFORMANCE MODE: He w as the earning member in the family. His role shift is not compensated. His son doesn'tt have any w ork. His role clarity is not achieved. INTERDEPENDENCE MODE: He has good relationship w ith the neighbors. Good interaction w ith the friends relatives. But he believes, no one is capable of helping him at this moment. He says all are under financial constrains. He w as moderately active in local social activities SECOND LEVEL ASSESSMENT FOCAL STIMULUS Non-healing w ound after amputation of great and second toe of left leg- 4 w eek. A w ound first found on the junction betw een first and second toe-4 month back. The w ound w as non-healing and gradually increased in size w ith pus collected over the area. He first consulted in a local (---) hospital. From there, they referred to ---- medical college; w here he w as admitted for 1 month and 4 days. During hospital stay great and second toe amputated. But surgical w ound turned to non- healing w ith pus and black colour. So the physician suggested for below knee amputation. That made them to come to ---Hospital, ---. He underw ent a plastic surgery 3 w eek before. CONTEXTUAL STIMULI: Know n case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years, but sw itched to insulin and using it for 8 years now . Not w earing foot w ear in house and premises. RESIDUAL STIMULI: He had TB attack 10 year back, and took complete course of treatment. Previously, he admitted in ---Hospital for leg pain about 4 year back. . Mothers brother had DM. Mother had history of PTB. He is a graduate in humanities, no special know ledge on health matters. CONCLUSION Mr.NR w ho w as suffering w ith diabetes mellitus for past 10 years. Diabetic foot ulcer and recent amputation made his life more stressful. Nursing care of this patient based on Roy's adaptation model provided had a dramatic change in his condition. Wound started healing and he planned to discharge on 25th april. He studied how to use crutches and mobilized at least tw ice in a day. Patients anxiety reduced to a great extends by proper explanation and reassurance. He gained good know ledge on various aspect of diabetic foot ulcer for the future self care activities. NURSING CARE PLAN

Application of Roy's adaptation model

ASSESS. OF ASSESSMENT BEHAVIOUR OF STIMULI

NURSING DIAGNOSIS

GOAL

INTERVENTION EVALUATION

Ineffective protection and sense in physicalphysiological mode (No pain sensation f rom the wound site.)

Focal stimuli: Non-healing wound af ter amputation of great and second toe of lef t leg- 4 week

1. Impaired skin integrity related to f ragility of the skin secondary to v ascular insuf f iciency

Long-term objectiv e: 1. amputated area will be completely healed by 20/5/08 2.Skin will remain intact with no ongoing ulcerations. Short-Term Objectiv e: i. Size of wound decreases to 1x1 cm within 24/4/08. ii. No signs of inf ection ov er the wound within 1-wk iii. Normal WBC v alues within 1-wk iv . Presence of healthy granular tissues in the wound site within 1-wk

Maintain the wound area clean as contamination af f ects the healing process. - Follow sterile technique while prov iding cares to prev ent inf ection and delay in healing. Perf orm wound dressing with Betadine which promote healing and growth of new tissue. - Do not mov e the af f ected area f requently as it af f ects the granulation tissue f ormation. Monitor f or signs and sy mptoms of inf ection or delay in healing.

Short term goal: Met: size of wound decreased to less than 1x1 cms. WBC v alues became normal on 24/4/08 Long term goal: Partially Met: skin partially intact with no ulcerations. Continue plan Reassess goal and interv entions Unmet: not achiev ed complete healing of amputated area. Continue plan Reassess goal and interv entions

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Application of Roy's adaptation model


delay in healing. Administer the antibiotics and v itamin C supplementation which will promote the healing process.

Impaired activity in physicalphysiological mode

Focal stimuli: During hospital stay great and second toe amputated. But surgical wound turned to nonhealing with pus and black colour.

2. Impaired phy sical mobility related to amputation of the lef t f oref oot and presence of unhealed wound

Long Objectiv e:

term Assess the lev el of restriction of Patient will attain mov ement maximum possible Prov ide phy sical mobility activ e and with in 6 months. passiv e Short term exercises to all objectiv e: the extremities to improv e the muscle tone and i. Correct use of strength. crutches with in Make the 22/4/08 patient to ii. walking with perf orm the minimum supportROM exercises 22/4/08 to lower iii. He will be self extremities will motiv ated in which strengthen the activ ities- 20/4/08. muscle. - Massage the upper and lower extremities which help to improv e the circulation. Prov ide articles near to the patient and encourage perf orming activ ities within limits which promote a f eeling of well being. Prov ide positiv e reinf orcement f or ev en a small improv ement to increase the f requency of the desired activ ity . - Measures f or pain relief should be taken bef ore the activ ities are initiated as pain can hinder with the activ ity .

Short term goal: Met: used crutches correctly on 22/4/08. he is self motiv ated in doing minor excesses Partially Met: walking with minimum support. Long term goal: Unmet: not attained maximum possible phy sical mobility Continue plan Reassess goal and interv entions

Alteration in Physical self in Selfconcept mode

Contextual stimuli: Known case DM f or past 10 y ears and on (He is anxious treatment with about insulin f or 8 changes in y ears. body image) Residual Change in stimuli: no Role special performance knowledge in mode. (He health matters was the earning member in the f amily . His role shif t is not compensate)

3. Anxiety related to hospital admission and unknown Outcome of the disease and f inancial constrains.

Long term Objectiv e: The client will remain f ree f rom anxiety Short term objectiv e: i. demonstrating appropriate range ef f ectiv e coping in the treatment ii. Being able to rest and iii. Asking f ewer questions

Allow and encourage the client and f amily to ask questions. Bring up common concerns. Allow the client and f amily to v erbalize anxiety . Stress that f requent assessment are routine and do not necessarily imply a deteriorating condition. Repeat inf ormation as necessary because of the reduced attention span of the client and f amily Prov ide comf ortable quiet env ironment f or the client and f amily

Short term goal: Met: demonstrated appropriate range ef f ectiv e coping with treatment He is able to rest quietly . Long term goal: Unmet: client not completely remained f ree f rom anxiety due to f inancial constrainsContinue plan Reassess goal and interv entions

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Contextual 4. def icient Long term Explain the Short term goal: stimuli: knowledge Objectiv e: treatment Met: Verbalization Known case DM regarding the Patient will acquire measures to the and

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Application of Roy's adaptation model


Known case DM f or past 10 y ears and on treatment with insulin f or 8 y ears. Residual stimuli: no special knowledge in health matters regarding the f oot care, wound care, diabetic diet, and need of f ollow up care. Patient will acquire adequate knowledge regarding the t f oot care, wound care, diabetic diet, and need of f ollow up care and practice in their day to day lif e. Short term objectiv e: i. Verbalization and demonstration of f oot care. ii. Strictly f ollowing diabetic diet plan iii. Demonstration of wound care. measures to the patient and their benef its in a simple understandable language. Explain about the home care. Include the points like care of wounds, nutrition, activ ity etc. and demonstration of f oot care. Strictly f ollowing diabetic diet plan Unmet: Demonstration of wound care.

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Long term goal: Unmet: not completely acquired and the Clear the doubts practiced required of the patient as knowledge. the patient may present with Continue plan some matters Reassess goal of importance. and interv entions Repeat the inf ormation whenev er necessary to reinf orce learning.

REFERENCE 1. Marriner TA, Raile AM. Nursing theorists and their w ork. 5th ed. St Louis: Mosby; 2005 2. George BJ, Nursing Theories- The Base for Nursing Practice.3rd ed. Chapter 8. Lobo ML. Behavioral System Model. St Louis: Mosby; 2005 3. Alligood MR Nursing Theory Utilization and Application 5th ed. St Louis: Mosby; 2005 4. Black JM, Haw ks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006. 5. Brunner LS, Suddharth DS. Text book of Medical Surgical Nursing. 6th ed. London: Mosby; 2002 6. Boon NA, Colledge NR, Walker BR, Hunter JAA. Davidsons principle and practices of medicine. 20th ed. London: Churchill Livingstone Elsevier; 2006.

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