Case report
A 55-year-old female patient arrives from her home accompa-nied by her relatives. She has been treated for diabetes mel-litus for eight years. She is taken to the department for the re-vision of her drug therapy applied so far, also due to the ulcer that formed on her big toe in the meantime. She also reports neuropathic symptoms.
From time to time she experience’s probe
Lems with her balance, her blood pressure is usually high (values measured between 150–160/90–100 mmHg), she mentions regular headaches. She does not take her prescribed medication regularly. Her appetite is good, but she says she does not keep to her diet strictly, her weight has increased by 5 kg in half a year, her present BMI is 28. She is constipated and takes laxatives. Her urine is normal, she talks about occassional leaking of urine (incontinence).
Table 1 According to Virginia Henderson
Problem Objective Nursing activity
Basic Needs
1. Satisfactory eating and drinking
Problem:
Higher calorie intake than required based on needs.
While she is in the department, the patient should take optimal nourishment into her body, in accordance with her needs.
• the nurse should inform the patient about the proper diet, involving a nutritionist
• during the days of orientation she should check if the patient keeps her diet
• check the patient’s body weight daily
• she should carry out blood draws as prescribed by the instructions to check nutritional state and blood sugar levels.
2. Waste excretion from the body
Problem:
The patient often has constipation, urinary incontinence also occurs.
• providing nutrition rich in fibres and fluids
• giving laxatives on the doctor’s instructions or administering enema
• providing incontinency napkins if needed
• instructing female intimate exercises (pelvic floor) involving a physiotherapist
3. Movement and taking the desired postures
Problem:
Imbalance, the existing ulcer and
neuropathia hinder/limit the patient in her movement
Achieving that the patient does safely implemented exercise in adequate quantity and intensity within three days.
• the nurse should inform the patient about the importance of exercise
• continuous motivation
• creating safe environment
• providing equipment as required
• involving a physiotherapist 4. Sleep and rest
Problem:
Factors perplexing sleep (headache, urine leaking) disturb rest at night.
Night sleep should be sufficient and relaxing for the patient while she is in the department.
• providing a peaceful environment
• solving continency problems (providing incontinency pads for the night)
• giving and documenting the use of analgesic drugs and/or antihypertensive drugs on the doctor’s instructions
5. Keeping the body clean
Problem:
Due to her body weight her movement is restricted and so is the satisfaction of her hygienic needs.
Achieving adequate hygienic state right at the beginning of her stay and keeping up this state while she is in the department.
• creating a safe environment
• assistance from the nurse in satisfying her hygienic needs (daily shower, washing her hair every 3 days, providing pedicure and manicure weekly)
• continuously keeping up the patient’s motivation
6. Avoiding the dangers in the environment
Problem:
Due to imbalance and neuropathia the patient is at risk of accidents.
Avoidance of accidents while she is in the department.
• creating a safe environment
• in the beginning (for 2 days) the nurse should play the role of a helper, then (for 2-4 days) a supporter, and finally (while she is in the department) a supervisor while the patient is moving
• mounting a nurse alarm to an accessible place
• teaching the patient how to use the aids safelya 7. Keeping contact with other people
Problem:
The patient lives alone and away from her family, so the opportunity for visits is scarce.
It carries the risk that the patient will not have the opportunity to discuss problems with her family members.
Continuous mainteneance and improvement of the quality of family relationships.
• the nurse should encourage the patient and her relatives to have confidential conversations during their visits
• the nurse should take part in these
conversations if it is needed by the patient and the family
• based on the patient’s needs, the nurse should sometimes take the role of a ”relative”
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8. Doing rewarding work
Problem:
The patient feels hopelessness due to her physical limitations.
Elimination of the feeling of uselessness within some hours.
• providing the most frequent conversations possible with the nurse
• athe nurse should encourage the patient to always discuss her feelings with her family members, raise questions, talk about possible solutions
• in case of a culminative problem the doctor should be informed and a psychologist should be involved
9. Education Problem:
The patient has incomplete knowledge on her disease, diet and treatment.
The patient should be given enough knowledge on her disease, diet and treatment within 2 days.
• the nurse should provide comprehensive infor mation corresponding with the patient’s competencies
• the nurse should initiate the involvement of the doctor and other professionals (e.g. nutritionist, physiotherapist) in the patient’s education Always existing modifying factors
1. age:
– middle-aged 2. emotional state:
– normal
3. social and cultural state:
– relatively lonesome
4. physical and intellectual abilitites – overweight
– normal mentality
– loss of a certain sense (touch) – mobility impairment
Pathological states modifying basic needs 1. injuries: due to her basic disease, a leg
ulcer formed on the patient’s left leg
b
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The conceptual framework of nursing is defined by the notions of health, humans, environment and nursing it-self. The most important definitions of these are collected hereafter.
The notion of health
• “Health is a state of perfect equilibrium” (Hippocrates)
• All functions of the body are in balance with the factors of the environment. Illness occurs when this balance is lost.
• A relative state which means something different for everyone, and it represents a continuous scale ranging from optimal health through disease to death.
• “Health is a state of complete physical, mental and so-cial well-being and not merely the absence of disease or infirmity.” The enjoyment of the highest attainable stan-dard of health is one of the fundamental rights of every human being. The health of all peoples is fundamental to the attainment of peace and security and is depen-dent upon the fullest co-operation of individuals and States. Governments have a responsibility for the health of their peoples.” (Constitution of the World Health Or-ganisation, 1946)
• A perpetually and dynamically changing state of bal-ance made up of several factors.
• Periods of different qualities follow each other in every human being’s life, which bring along changes in the biological, psychological and social dimensions, and the change is uneven.
• “A healthy person is somebody who can react to the environment effectively, health is the state which is the most frequent statistically.” (NATURALIST approach)
• The definitions of health and disease depend on how the individual or the society judges them. (NORMATIV-IST approach)
• “Health is a condition that allows people to fulfil their own needs without any specific effort.” (HEN-DERSON)
• “The state of maximum independence that allows people to do daily routine activities without assistance.”
(ROPER)
• “A level of emotional conditions at which interpersonal activities and improvement aims are.” (PEPLAU)
• “Health and disease are inevitable dimensions of a per-son’s life” (ROY)
• “A value – as defined by individuals and cultures.” (ROG-ERS)
The notion of individual/person/human
• “An individual is someone who has universal basic hu-mane needs that he can fulfil on his own when he is healthy.” (HENDERSON)
• “A living organism for which self-fulfilment is very im-portant and who pursues equilibrium but only achieves it by death. Humans are physical, psychological and bio-chemical systems.” (PEPLAU)
• “A biological, psychological and social being that is con-stantly in interaction with a permanently changing en-vironment.” (ROY)
• “A unified, dynamic whole, something more and other than the sum of the parts. An open system in constant interaction of material and energy with the environ-ment. The course of his life irreversibly proceeds to one direction. Development takes place within one spatial-temporal unit. Humans are characterised by the capac-ity for abstraction, language, thought, perception and emotion.” (ROGERS)
• “Man is an open system continuously interacting with his environment, adapting, growing, developing, pur-sues independence – independence is a dynamic state that can change any time.” (ROPER)
The notion of environment
• “Four-dimensional, space and time exist, and the indi-vidual exists within them. The changes of human life are inseparable from the changes of the environment, the individual and his environment seek a harmonic unity.”
(ROGERS)
• „Interpersonal environment, others’ microcosm is im-portant.” (PEPLAU)
The notion of nursing
• “A caring vocation with services for the well-being and health of people” (ANA)
• “Those activities of the nurse that contribute to and maintain health and recovery of a patient, that alleviate