Orem's Theoretical Framework for Care

Transcription

1 FACULTY OF HEALTH School of Nursing and Midwifery Learning Disability Nursing Orem's Theoretical Framework for Care Resource Pack Fiona Rich Senior Lecturer

2 INTRODUCTION Credentials OREM'S THEORETICAL FRAMEWORK FOR CARE Dorothea Orem is highly respected in nursing circles. Her work is based on considerable experience since the 1930's, both in practice and education. Orem's model was first developed in 1958, but has been refined and modified in 1971, 1980 and Orem's model focuses on the concept of self-care and on the individual's state of health. Self care is defined as a process whereby a lay person functions on his/her own behalf in health promotion, prevention of illness and in disease detection and treatment. There is an emphasis on activities that maintain life, health and well-being. Orem also values personal responsibility for health and recognises that prevention and health education can be key aspects of nursing intervention PARAMETERS OF NURSING 1. Nature of the person The person has a desire to be self-caring which is innate in everyone The person is an agent of self-care the person is an integrated unit with a combination of biological, cultural and social components certain persons (infants; children; the aged; the ill and disabled persons) require complete care or assistance with self-care activities People are developmental beings with tasks to accomplish at each developmental stage. People are described as exchanging energy with the environment "in the form of deliberate action to meet self-care demands" 2. Nature of the environment Man and Environment form an integrated system The environment is linked to the person's functioning The environment consists of 2 components: Internal - the person's physical, psychological and social nature External - elements external to man such as biological and human factors The environment can be controlled by the person by "creating climates favourable or unfavourable to human functioning" through responding to or ignoring stimuli The environment is essentially the time and space in which the self-care system operates

3 3. The nature of health and illness A wellness state is when a person is able to meet all his universal self care needs When a person is ill, he is unable to meet all of these self-care needs due to "a deviation of normal structure or function" Illness is the result of an unbalanced state leaving the person unable to meet his selfcare demands. A self-care deficit is then said to exist The self-care deficit is the reason why nursing is needed, in order to regain the steady, wellness state Self-care needs are classified in two categories: universal self care needs health deviation needs The stage of development is also considered 4. The nature of the nurse The nurse may play one of three roles during intervention: wholly compensatory nursing action - The person performs no active role in his care partially compensatory nursing action - the nurse and person share the care educative/developmental nursing action - the nurse supports and assists the person with care; the nurses role may only be consultative The nurses role is to guide, teach, assist and support the person, and to promote selfcare 5. The nature of nursing Nursing is the giving of direct assistance to a person when he is unable to meet his own self-care needs and exists to meet the individual's inability to "maintain for himself self care" Nursing is the application of scientific knowledge and technology to assist people to return to the self care system The goal of nursing is to assist the patient to re-attain or stabilise his state of health The process of nursing is the means by which the goal is achieved

4 SELF-CARE REQUISITES Universal life processes common to all - e.g. air, food and water Developmental requisites - e.g. maintenance of good health to support life process and developmental stages Health deviation - to be free of conditions of illness, injury or disease UNIVERSAL SELF-CARE DEMANDS Sufficient intake of air, water and food Satisfactory eliminative functions Activity balanced with rest Time spent alone balanced with time spent with others Prevention of danger to self Being normal within social groups (within limitations of potential) ADDITIONAL SELF-CARE DEMANDS Developmental - e.g. leaving school; starting work; pregnancy; childbirth; menopause Health deviation - e.g. as a result of ill health or disability Life changes - e.g. oppressive living conditions; abrupt change of residence; failure to establish a healthy individuality THE NEED FOR NURSING INTERVENTION [See diagram on following page] In a healthy individual, the self care abilities equal the universal self-care demands. In an individual subject to disease or injury, the reserve self-care abilities come into force to fight additional self-care demands Where there is a need for nursing intervention, the self care demands outweigh the self-care abilities The nurse provides care during the illness until the person is able to assume responsibility for the fulfilment of their own needs.

5 A Healthy Individual Self care abilities equal universal self care demands = Self Care Abilities Self Care Demands An Individual subject to disease/injury Healthy Individual Reserve self-care abilities come in to force to fight additional self-care demands = Self Care Abilities + Reserve Abilities Self Care + Additional Demands Need for Nursing Intervention Self care demands outweigh self care abilities Self Care Abilities + Reserve Abilities Self Care + Additional Demands

6 After nursing Intervention The nurse provides care during illness until the client is able to assume responsibility for the fulfilment of their own needs Read the following case study and examine the assessment and care plan documents below Case Study Helena Kristowski Helena is 35 years old and lives with her elderly parents in a small two-bedroomed bungalow in a small seaside town. She is a short, rather plumpish woman. At birth, Helena appeared normal, but it was soon evident that she was developing very slowly. She was assessed as having severe learning disabilities when she was three years old. Helena s disability shows itself in the many areas of social skill which she has not yet mastered. Whilst she does not speak clearly, mumbling a few words to herself rather than to other people, she does understand everything that is said to her. Helena is capable of eating with a spoon, but requires a lot of prompting to start, and is very messy with her food. She is doubly incontinent if she is not taken to the toilet at regular intervals during the day and wets her bed every night. She cannot dress herself, but if she is encouraged she will help in pulling some of her clothes on. Helena s parents have great difficulty in persuading her to have a bath, or even to wash, and she struggles when they try to wash her hair. She also has periodic temper tantrums when she scratches and bites her parents. As a result her mother is afraid of being left alone with her. Ever since Helena was a little girl, her parents have been overprotective towards her. They have tended to do everything for her, rather than making her learn to do things for herself. Mr Kristowski retired from work three years ago and now spends more time helping with Helena. Her two older brothers have both left home and married, but occasionally come home for a visit. During these visits, Helena takes no interest in them, even though they try to help. Up until four years ago, Helena used to go out with her parents for rides in the family car, but suddenly refused to leave the house at all. Since then, she has spent all her time either sitting or lying down on a sofa, making no attempt to do any thing except look at herself in a small vanity mirror which she carries round with her constantly.

7 The family has the support of a social worker who has been involved with them for many years, and understands the whole situation. At present there is no community learning disability nurse, although it is hoped that one will be appointed in the near future. Both Mr and Mrs Kristowski have told the social worker on several occasions that they find the constant care of Helena a great strain, and that they would like a short holiday. The social worker has agreed with this and on several occasions has made all the necessary arrangements, but each time the parents have changed their minds at the last moment and kept Helena at home. Finally, a year ago, Helena spent a two week period in a respite care unit. Mr and Mrs Kristowski found the break worthwhile and the short term relief has since been repeated twice. The reports from the unit following these short periods of care, have indicated that with prompting and encouragement Helena can perform many simple tasks, but is very reluctant to do so. These tasks include washing herself, cleaning her teeth, going to the toilet, dusting and even going for a walk in the local area. She also seems to enjoy going for trips in the unit s car. This progress occurs within the two week period of admission, but is invariably lost by the time of her next admission. Assessing Helena s Needs If you were assessing Helena s needs in line with Orem s model of nursing, you would need to examine her self care abilities and deficits for both the universal demands and the additional demands. Helena s assessment and care plan might look something like the following:

8 OREM'S SELF CARE MODEL OF NURSING ASSESSMENT OF UNIVERSAL SELF-CARE DEMANDS NAME Helena Kristowski UNIVERSAL DEMANDS SELF CARE ABILITIES SELF CARE DEFICITS Sufficient intake of air, water and nutrition Helena will not feed herself without prompting Satisfactory eliminative Helena will not go to the toilet of functions her own volition Activity balanced with rest Helena has no occupation; will not dress herself; will not go outside or exercise in any way Time spent alone balanced with time spent with others Takes no interest in brothers when they visit; will not leave the house to spend time with others Prevention of danger to self Not exposed to danger; over and others Being normal within social groups and limitations of potential protected by parents Helen has frequent tempertantrums; does not mix socially, does not speak clearly OREM'S SELF CARE MODEL OF NURSING

9 ASSESSMENT OF ADDITIONAL SELF-CARE DEMANDS NAME Helena Kristowski ADDITIONAL DEMANDS SELF CARE ABILITIES SELF CARE DEFICITS Developmental self care requisites Not encouraged to meet the demands expected at this age group - e.g. selfdiscipline, hygiene, employment Health Deviation self- Learning disability makes care requisites Life Changes self-care progress slow Has failed to establish a healthy individuality OREM'S SELF CARE MODEL OF NURSING NURSING CARE PLAN

10 NAME PROBLEM GOAL NURSING ACTION TYPE OF ACTION Lack of motivation For Helena to initiate 3 Offer Helen a choice of activities and Partially compensatory activities every day encourage her to carry them out Will not eat by herself For Helena to eat independently without prompts Use suitable reward system when Helena has carried out an activity Offer Helena the choice of nutritional meals Prompt Helena to eat by herself, praising her when she does Partially compensatory Partially compensatory Withdraw prompts but continue to praise Withdraw praise gradually during meal Praise at the end of meal only Supportive/educative Supportive/educative Supportive/educative

11 Read the following case study and complete the assessment and care plan for this person using the documents below. Case Study Carole Evans Carole is 24 years old and has been in care since she was 13. She was admitted into care because her family felt that they could not cope with her problems any longer. These problems were mainly physical disabilities, incontinence and temper tantrums. Her parents felt that Carole s behaviour was having an adverse effect on her younger brother and sister. For a short while Carole s parents maintained regular contact with her and indicated that they would like to take Carole home for occasional weekends. However, Mr Evans became ill and had to give up his job. Due to the reduced income, the family was forced to move from the home they were buying, into a Council flat. Because of the crowded conditions, it was impossible for Carole to go home. Over the next few years the family contact dwindled, until now it is confined to a card at Christmas time. Even when the carers at the home have written to Carole s mother with items of news, there has been no reply. Carole suffered brain damage at birth, which resulted in severe learning disabilities and spastic paralysis of both legs. She also experiences tonic-clonic type seizures for which she is given anticonvulsant medication. Currently, Carole has one or two seizures each month. The paralysis of her legs means that Carole is unable to walk unaided. She can use a walking frame, but frequently falls, causing herself injury. As a result, most of the time Carole gets about in a wheelchair which she propels very successfully. Carole will soon have an electric wheelchair, which will make her even more mobile than she is at present. Carole s speech is very limited, with only about six recognisable, appropriate words such as Carole, food, drink. She can however understand everything that is said to her and make herself understood by using signs. Carole is currently developing her Makaton signing which she appears to be learning quickly. Carole can wash herself, but is unable to bathe on her own. She needs help with dressing and will indicate her clothing preferences. Carole is starting to become fashion conscious and takes pride in being smart. She will indicate what clothing and hairstyles she would like by pointing at staff or at magazine pictures. She likes to wear make-up to enhance her appearance. Carole could eat her meals using a knife and fork at one time, but now only uses a spoon. She is capable of taking herself to the toilet unaided but sometimes she does not go or indicate that she needs to go, and is therefore occasionally doubly incontinent, which causes some distress. At present Carole lives in a home with five other people, all with physical disabilities of a similar age. She is occupied during part of each day with various activities or watches

12 television and looks at magazines. She enjoys all social events such as dances and concerts and looks forward to them. Whilst enjoying the company of the other residents, Carole has no special friendships and prefers staff attention. At one time she preferred only male staff, reacting angrily towards female staff, but is now equally happy with staff of either sex. One problem that staff still find is that Carole is very demanding of attention and will have a temper tantrum when this cannot be given. Apart from these occasions, she has a very happy and pleasant personality and is liked by all.

13 OREM'S SELF CARE MODEL OF NURSING ASSESSMENT OF UNIVERSAL SELF-CARE DEMANDS NAME UNIVERSAL DEMANDS SELF CARE ABILITIES SELF CARE DEFICITS Sufficient intake of air, water and nutrition Satisfactory eliminative functions Activity balanced with rest Time spent alone balanced with time spent with others Prevention of danger to self and others Being normal within social groups and limitations of potential OREM'S SELF CARE MODEL OF NURSING ASSESSMENT OF ADDITIONAL SELF-CARE DEMANDS

14 NAME ADDITIONAL DEMANDS SELF CARE ABILITIES SELF CARE DEFICITS Developmental self care requisites Health Deviation selfcare requisites Life Changes

15 MEETING THE NEEDS OF PEOPLE WITH LEARNING DISABILITIES How do you feel the model caters for the following needs and rights of clients? Needs e.g.: Psychological Social Physical Spiritual Rights e.g.: Choice Privacy Respect Dignity Self-expression Individuality Participation in Nursing Methods and Consultation

16 Identify 5 positive aspects of the model for people with learning disabilities use these to generate discussion on the discussion forum Identify 5 limitations of the model use these to generate discussion on the discussion forum