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Posted: December 7th, 2022

Betty Neuman’s system model

Betty Neuman’s system model
• Assessment • Nursing diagnosis • Outcome identification and planning • Implementation • Evaluation Assessment
Mr. Am is the patient’s first name.
2. 66 years old
3. Gender-male • 4. Marital Status-married
5. Source of referral- referred from ———- medical college, ———-
Client-perceived stressors • (information gathered from the patient and his wife) • Major stressors or areas of health concern
• The patient was experiencing severe abdominal pain, nausea, vomiting, yellowish discoloration of the eye, palm, and urine, decreased appetite, and significant weight loss (8kg with in 4 months)
• One week ago, the patient was diagnosed with periampullary carcinoma.
• On March 27, 2008, the patient underwent Whipple’s procedure- pancreatoduodenectomy.
• He is psychologically disturbed about his disease condition, anticipating it as a potentially fatal condition. The patient is depressed and does not interact.
• The patient is troubled by the thought that he has become a burden to his children due to his numerous serious illnesses, which have forced them to stay with him in the hospital.
• The patient has pitting edema over the ankle region that worsens in the evening and is not relieved by elevating the affected extremities.
• He developed bph a few months ago (in January 2008) and underwent turp surgery on January 17. He still has some difficulty starting the flow of urine.
• The patient has had diabetes for 28 years and has been on H.insulin injections for the last four years (4u-0-0). It is exacerbating his health-related anxiety.
Patterns of living
• Patient is a retired school teacher • He cares for his wife and other family members • He lives with his son and his family • He is active in church • He attends community group meetings, such as local politics • He has a supportive spouse and family • He follows a mixed diet • He does not smoke or drink • He spends his leisure time reading the newspaper, watching television, and spending time with family members and relatives
Have you encountered a similar issue?
• Fatigue is comparable to that of previous hospitalization (following bph surgery) • Pain severity is comparable to that of previous surgery, i.e. Turp.
• Was disturbed psychologically during the previous surgery, i.e. Turp.
What helped him then was psychological support from family members, which helped him overcome the crisis situation.
Future expectations • Concerns about a healthy and quick recovery
• Anticipation of changes in lifestyle and eating habits • Anticipation of the demands of a modified lifestyle • Anticipation of future follow-up needs
What is he doing to assist himself?
• Talking to his friends and relatives • Reading religious materials, such as the bible • Instilling positive thoughts, such as planning activities to resume after discharge, spending time with grandchildren, going to church, returning to social interactions, and so on • Avoiding negative thoughts, such as diverting attention away from the pain or difficulties, attempting to eliminate disturbing thoughts about the disease and surgery, and so on
What are others expected to do?
• Family members visiting the patient and spending time with him will greatly relieve his stress.
• Act in a friendly and accepting manner toward him.
• Family members will assist him in meeting his own personal needs to the greatest extent possible.
• Involve the patient in making decisions about his own care, treatment, and follow-up, for example.
Stressors as seen by the caregiver
Significant stressors
• Constant tiredness
• Significant weight loss (8 kg in 4 months) • History of bph and its treatment
• Persistence of urinary symptoms (difficulty starting a stream of urine) and lower extremity edema
• Chronic hypertensive disease for the past 28 years
• Suicidal ideas and negative thoughts
• Current circumstances that differ from the usual pattern of living
• Acute pain (the patient had pain before the surgery due to the underlying pathology, and pain is still present at the surgical site after the surgery) • Nausea and vomiting that was present before the surgery and is still present after the surgery
• Anticipatory anxiety about the disease’s recovery and prognosis • Negative thoughts about becoming a burden to his children • Anticipatory anxiety about the restrictions after the surgery and the lifestyle changes that must be followed
Clients’ previous experience with similar situations
• The patient stated that the severity of his pain, nausea, fatigue, and other symptoms were similar to those experienced during his previous surgery. Checked with family members to confirm what they saw.
• Psychologically disturbed prior to surgery as well. (taken from the patient and double-checked with relatives)
• The client perceived the current disease condition to be far more severe than the previous condition. He believes it is a serious form of cancer with a poor prognosis. As a result, the patient is psychologically depressed.
Future expectations
• The client is capable of handling the situation, but will require assistance and encouragement to do so.
• He intends to return home and resume the activities he was engaged in prior to his hospitalization.
• He also considered future follow-up, such as chemotherapy continuation.
What can the client do to help himself?
• The patient is adjusting to the situation by using his own coping strategies.
• He devotes time to reading religious books and conversing with others.
• He is attempting to clarify his own doubts in order to remove doubts and instill hope.
• He establishes his main goal, which is a healthy and quick recovery.
• Expectations of family, friends, and caregivers by the client
• He considers health-care providers to be a source of information.
• He tries to think of them as important family members who can help him overcome stress. • He seeks both psychological and physical support from caregivers, friends, and family members.
Impression evaluation/summary-
• There are no obvious discrepancies between the patients’ and caregivers’ perceptions.
Intrapersonal variables
1. Physical examination and research
• Height: 162 cm; Weight: 42 kg; Tpr: 37o C, 74 b/m, 14 breaths per minute; Bp: 130/78 mm Hg
• Eye- vision is normal, and the appearance of the eye on examination is normal. The conjunctiva appears pale. Students reacting to light.
• Normal appearance of the ears. There is no wax deposition. Pinna appears normal, and hearing ability is also normal.
• Respiratory system-normal respiratory rate, no abnormal sounds on auscultation The rate of respiration is 16 breaths per minute.
• Cardiovascular system- the heart rate is 76 beats per minute. 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 \s• 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 \s• Anxious about his condition \s• Depressive mood
• Patient is a retired teacher and he is christian by religion.
• Studied up to ba
• Married and has 4 children(2sons and 2 daughters) \s• Congenial home environment and good relationship with wife and children \s• 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 \s• 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 \s• He was very active after the retirement and once he go back also he will resume the activities
4. Spiritual belief system \s• Patient is christian by religion \s• 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.
Interpersonal factors
• Has supportive family and friends \s• Good social interaction with others \s• Good social support system is present \s• Active in the agricultural works at home after the retirement \s• Active in the religious activities.
• Good interpersonal relationship with wife and the children \s• Good social adjustment present
Extrapersonal factors
• 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.
Summary
• 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.
Clinical features
• Pain abdomen since 4 days \s• Discoloration of urine \s• Complaints of vomiting \s• Fatigue \s• Reduced appetite \s• On and off fever \s• Yellowish discoloration of eye, palms and nails \s• Complaints of weight loss \s• Edema over the left leg
Investigations Values
Hemoglobin(13-19g/dl)
6.9 \sHct (40-50%)
21.9 \sWbc (4000-11000 cells/cumm)
12200 \sNeutrophil (40-75%)
77.2 \sLymphocyte (25-45%)
10.5 \sMonocyte (2-10%)
4.5 \sEosinophil (0-10%)
2.6 \sBasophil (0-2%)
.
2 \sPlatelet (150000-400000 cells/cumm)
345000 \sEsr (0-10mm/hr)
86 \sRbs (60-150 mg/dl)
148 \sPus c/s _ \sUsg
Usg shows mild diffuse cell growth at the ampulla of vater which suggests peri ampullary carcinoma of grade I with out metastasis and gross spread.
Urea (8-35mg/dl)
28 \sCreatinine (0.6-1.6 mg/dl)
1.8 \sSodium (130-143 meq/l)
136 \sPotassium (3.5-5 meq/l)
4 \sPt (patient)(11.4-15.6 sec) (11.4-15.6 sec)
12.3 \sAptt- patient (24- 32.4 sec) (24- 32.4 sec)
26.4 \sBlood group A+
Hiv
Negative \sHcv
Negative \sHbsag
Negative \sUrine protein (negative) (negative)
Negative \sUrine wbc (0-5 cells/hpf)
Nil \sRbc (nil ) (nil )
Nil

Initial treatment

Post operative period (immediate post op) (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:
• Inj tramazac iv sos
• Iv fluids – dns
Treatment at this hospital…
Pre operative period
• Tab clovipas 75 mg 0-1-0 \s• Tab monotrate 1-0-1 \s• Tab metalor xl 1-0-0 \s• Inj h insulin s/c 6-0-6u \s• Inj tramazac 50 mg iv q8h \s• Inj emset 4 mg q8h \s• Tab pantodac 40 mg 1-0-0 \s• Cap beneficiale 0-1-0 \s• Syp aristozyme 1-1-1
• k bind I sachet tid
Surgical management
• Patient underwent whipple’s procedure (pancreato duodenectomy) • Inj pethedine 1mg sos
• Inj phenargan sos \s• Inj pantodac 40 mg iv od \s• Inj clexane 0.3 ml s/c od \s• Inj vorth p 40 mg im q12h \s• Inj calcium gluconate 10 ml over 10 min \s• Iv fluids – dns
Late post op period after 3 days of surgery) \s• Inj h insulin s/c 6-0-6u \s• Tab pantodac 40 mg 1-0-0 \s• Cap beneficiale 0-1-0 \s• Tab clovipas 75 mg 0-1-0 \s• Tab monotrate 1-0-1 \s• Tab metalor xl 1-0-0
Other instructions
• incentive spirometry \s• steam inhalation \s• eearly ambulation \s• diabetic diet

Nursing process
I. Nursing diagnosis \s• 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.

Nursing actions
Primary prevention
Secondary prevention
Tertiary prevention
• Assess severity of pain by using a pain scale
• Check the surgical site for any signs of infection or complications \s• Support the areas with extra pillow to allow the normal alignment and to prevent strain \s• Handle the area gently. Avoid unnecessary handling as this will affect the healing process
• Lean the area around the incision and do surgical dressing at the site of incision to prevent any form of infections
• Provide non-pharmacological measures for pain relief such as diversional activity which diverts the patients mind.
• Administer the pain medications as per the prescription by the pain clinics to relieve the severity of pain.
• Keep the patients body clean in order to avoid infection • Teach the patient about the relaxation techniques and make him to do it
• Encourage the patient to divert his mind from pain and to engage in pleasurable activities like taking with others
• Do not allow the patient to do strenuous activities. And explain to the patient why those activities are contraindicated.
• Involve the patient in making decisions about his own care and provide a positive psychological support
• Provide the primary preventive care when ever necessary.
• Educate the client about the importance of cleanliness and encourage him to maintain good personal hygiene.
• Involve the family members in the care of patient \s• Encourage relatives to be with the client in order provide a psychological well being to patient .
• Educate the family members about the pain management measures.
• Provide the primary and secondary preventive measures to the client whenever necessary.

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.
Nursing actions
Primary prevention
Secondary prevention
Tertiary prevention
• Adequately oxygenate the client \s• Instruct the client to avoid the activities which causes extreme fatigue
• Provide the necessary articles near the patients bed side.
• Assist the patient in early ambulation \s• Monitor client’s response to the activities in order to reduce discomforts.
• Provide nutritious diet to the client.
• Avoid psychological distress to the client. Tell the family members to be with him.
• Schedule rest periods because it helps to alleviate fatigue
• Instruct the client to avoid the activities which causes extreme fatigue.
• Advice the client to perform exercises to strengthen the extremities& promote activities \s• Tell the client to avoid the activities such as straining at stool etc \s• Teach the client about the importance of early ambulation and assist the patient in early ambulation \s• Teach the mobility exercises appropriate for the patient to improve the circulation • Encourage the client to do the mobility exercises \s• Tell the family members to provide nutritious diet in a frequent intervals
• Teach the patient and the family about the importance of psychological well being in recovery.
• Provide the primary and secondary level care if necessary.
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.
Nursing diagnosis-iii
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.
Nursing actions
Primary prevention
Secondary prevention
Tertiary prevention
• Provide active and passive exercises to all the extremities to improve the muscle tone and strength.
• Make the patient to perform the breathing exercises which will strengthen the respiratory muscle.
• Massage the upper and lower extremities which help to improve the circulation.
• Provide articles near to the patient and encourage doing activities within limits which promote a feeling of well being.
• Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity.
• Teach the mobility exercises appropriate for the patient to improve the circulation and to prevent contractures
• Mobilize the patient and encourage him to do so whenever possible
• Motivate the client to involve in his own care activities \s• Provide primary preventive measures whenever necessary • Educate and reeducate the client and family about the patients care and recovery
• Support the patient, and family towards the attainment of the goals \s• Coordinate the care activities with the family members and other disciplines like physiotherapy.
• Teach the importance of psychological well being which influence indirectly the physical recovery
• Provide primary preventive measures whenever necessary
Conclusion
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.

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