Saint Louis University School of Nursing Graduate School Program

In Partial Fulfillment Of the Course Masters of Science in Nursing

In Partial Fulfillment Of the Course Requirement In Behavioral Perspectives in Heatlh

A Case Analysis Using Health Models and Nursing theories

Submitted to: Ms. Teresa Basatan, MSN Professor

Submitted by: Charmaine Acosta Baniqued MSN student

September 25, 2012

Case Analysis
Charmaine Baniqued

Table of Contents
i. ii. iv. v. BACKGROUND .................................................................................................................................. 3 DISCUSSION/ ANALYSIS ................................................................................................................ 6 EVALUATION................................................................................................................................... 17 REFERENCES ................................................................................................................................. 18

APPENDICES CONSENT DOCUMENTATION

Case Analysis
Charmaine Baniqued

i.

BACKGROUND Worldwide, between 80,000 and 100,000 kids start smoking every

day. Approximately one quarter of children alive in the Western Pacific Region* will die from smoking.

The World Health Organization (WHO) has compiled worldwide smoking statistics for the year 2002. The smoking facts and stats presented are sobering.

GLOBAL SMOKING STATISTICS About a third of the male adult global population smokes. Smoking related-diseases kill one in 10 adults globally, or cause four million deaths. By 2030, if current trends continue, smoking will kill one in six people. Every eight seconds, someone dies from tobacco use. Smoking is on the rise in the developing world, tobacco consumption is rising by 3.4% per year. About 15 billion cigarettes are sold daily - or 10 million every minute. Among WHO Regions, the Western Pacific Region - which covers East Asia and the Pacific - has the highest smoking rate, with nearly two-thirds of men smoking.

Youth Among young teens (aged 13 to 15), about one in five smokes worldwide. Between 80,000 and 100,000 children worldwide start smoking every day roughly half of whom live in Asia. Evidence shows that around 50% of those who start smoking in adolescent years go on to smoke for 15 to 20 years. Peer-reviewed studies show teenagers are heavily influenced by tobacco advertising. About a quarter of youth alive in the Western Pacific Region will die from smoking.

*The 37 countries and areas comprising the WHO Western Pacific Region include Philippines.

Case Analysis
Charmaine Baniqued

With the concrete presented statistics above, its definitely alarming for me to turn a blind eye with the rising incidence of smoking especially to those who are still studying basically who are already employing a maladaptive coping towards stress. Another reason for choosing him as my patient was that, if he is not into his smoking and drinking, he seems so kind, respectful and responsible towards other people. What gives him that hard man effect is that when he does the inhaling and exhaling of smoke! So, I wanted to explore what is beyond his smoking and alcohol drinking.

My case is that of Mr. RT who is a 22 year old male with a history of smoking way back since 3rd year high school apparently all because of curiosity to try it. It is not known from his family because accordingly, he will be reprimanded for the behavior. He is the last child in the family having 3 siblings, 2 females and a male. No other family smoke aside from his father whom he also claimed is into gambling.

When he reached college and being away from his family, he already started smoking regularly with the freedom provided. He claimed that it makes him calm when tense especially with regards to his problems (school and relationships). He also claimed that he is into reinforced drinking every time he has money (allowance) because of the urge to spend the money at hand. Accordingly because of his allowance is not sufficient and is not given on time which makes a problem for him.

With school, he verbalized problems like lacking motivation to study, and that he garnered couples of failing grades already and because of this, the more he smokes because of frustrations and the feeling of losing control to what is happening. Furthermore, he felt pressured because all of his siblings are already finished college.

Adding insult to an injury, his past 2-year relationship with his ex-girlfriend has no closure. He verbalized that at the time of the interview, he really has a lot of things making his thought messed-up. One is that, his ex was the one who became unfaithful to their relationship resulting to their breaking apart and after some months later now she claims that he is the father of the child she has gave birth.

Case Analysis
Charmaine Baniqued

With all of these troubles he is into, he claimed that he is not open to any member of his family to have at least one whom he can vent out his feelings, emotions and problems. He also tends to keep these from his college friends. So, to compensate, he struggles to appear happy by having a happy-happy moments with them. That is, by having more frequent smoking episodes and drinking sprees.

Mr. RT chooses not to be in detail of these things but at the time of the interview, he seems bothered. Anyway, he claimed to be aware of smoking hazards that it imposed to his health, but he also claimed that, smoking is the only way that calms his nerves and thats the time he could think clearly then about things that troubles him. Accordingly, he tried to stop smoking but he cant just do it especially if he is faced with problems/troubles again like that of his ex kept demanding from him, the school grades are failing and the like.

All of these factors as he claimed had aggravated his smoking and alcohol indulgence.

Case Analysis
Charmaine Baniqued

ii.

DISCUSSION/ ANALYSIS Basing from the case, the appropriate model for giving interventions for this

particular client is the Cognitive Behavioral Model- Lapse-Relapse Process. Clearly because of the imbalanced lifestyle, and yes, I cannot deny the fact of the severity of his problems he is going through, but instead of directing through these problems, he is coping in a maladaptive way which is smoking and drinking but more into his smoking and not seeking any social support. He decided somehow to start smoking cessation but have been unsuccessful for many times, and these past attempts gave him the feeling that he cannot do the behavioral change desired and so the further involvement in the vices. There is the existence of maladaptive behavior, together with the desire for it. If one is not equipped/ guided through the knowledge of effective coping mechanisms, one would easily give in. Especially so, because Mr. RT uses rationalization or denial that makes that maladaptive behavior correct or the effects that could serve him right. In our life where stress is everywhere and it could be basically anything owing to our individual differences. Stress is the one that provokes him to indulge to this maladaptive behavior so stress management is very important to address this problem and selfefficacy plays a pivotal role in doing this change. It is also appropriate to integrate Health Promotion Model by Pender, the Health Belief Model and Theory of Reasoned Action together with nursing theories of Betty Neuman which is the Health Care Systems Model and of Imogene King which is the Goal Attainment theory along with that of Tannahills Model of Health Promotion.

Case Analysis
Charmaine Baniqued

Penders Model
Perceived benefits from smoking: Makes him calm Helps him to think well

Prior related behavior: >Ineffective coping mechanism Smoking Drinking

Perceived self-efficiency in stopping smoking: Cannot stop smoking He believes to be addicted to it Belief that it is in their bloodline

No commitment/ plan t stop smoking/ drinking

SMOKING/ DRINKING Interpersonal influences: Father also smokes Peers in school and his cousins also smoke and drink ROH

Personal factors: Male College student Ineffective Stress management

Situational influences: Nothing could relieve his stress except for smoking/ drinking (situational) Presence of problems (failing grades, failure relationship)

Increasing lifestyle balance: Encouraged him to develop

positive addictions like playing metal puzzles and Sudoku when he is under stress to make himself busy since he said that he loves playing those. Suggested that if he needed a break, maybe, he could go for a strolling with his peers Reinforced him to study and not to be lazy about it by keeping in mind those people whom are the reasons why he is studying and keep his goals and continue striving for his dreams by doing his part as a student

A HEALTH PROMOTING BEHAVIOR

Stimulus control technique: Taught him of avoiding or removing of items/ situations that is associated with his smoking (Not stocking or buying cigarettes, not going to events that would smoking)

Case Analysis

4 Self-monitoring and

Revise Charmaine Relapse road maps and Baniqued behavior assessment: decision cycle is explained to him. When he experienced matrix: We identify together the We usual situations which difficulty of saying NO identified poses inevitable risks for to a temptation of together him to smoke: he said smoking, try not to the drinking with his peers smoke to relax him. positive and when some mishaps Suggested act.: listen to & occurred like if he has music, watch television, negative failing grades, quizzes/ effects of exams, and when his ex have a time for self smoking keeps confronting him) alone to meditate and to him think what was really is (Pros & the problem Cons) Exposure to Gives in Desire for difficult Due to to the indulgence; situations Problems Rationalizes unresolved urges so much where coping not Existence of that this problems; and more if is needed addressed; Substance maladaptive maladaptive feeling of cravings there is/are (failing lack of abuse coping: behavior is inadequacy and its problems grades, coping Smoking, (smoking/ the only way (decreased 1 positive encountered unsuccessful mechanism alcohol alcohol and that helps self efficacy effects it / stress: relationships, and not seeking drinking) him relax is offers: school no one to problem social and think experienced) smoking, problems, verbalize solving support clearly alcohol relationship upon): capabilities drinking issues maladaptive Eliminating myths coping and placebo effects: The beneficial Avoidance As a form of urge mgt: psychological strategies: Taught him of distractions Efficacy enhancing Coping skills Educated him effects of smoking Saying no to method like watching strategies: training: on warning to him: cannot high risk movies and informed him Suggested Counseled him to signals of defecate without situations about urge surfing opening up his think of a relapse. (Giving smoking, cannot Told to keep to his siblings if possible solution as an example think clearly & the in mind that he cannot direct was what he that is attainable calming effect he could it to their CBT-RP experienced at a shortest Taught him on control parents. previously) immediate and himself time. Stress mgt: long term effects Reminded him (praying, of smoking and that this is a form confront We also brought up to the present the experiences and how he has been of skill acquisition, problems, focus he looks at up himself after giving into his past relapses scared of to learn so keep avoiding on emotions, that smoking may it and practice use problem also cause CA in resolving solving 3 genitourinary problems directly. technique) system.

Lapse mgt: Setting contract to limit smoking again Taught him how to cope up with a lapse by not having a negative self concept. He was also given credit by telling it immediately to the nurse. We had evaluated readily what had triggered the lapse. (failed grades) Abstinence violation effect: does not have the power to stop the smoking because of constant stress in life & the effect of being a failure every time he tried to stop, he just cant do it effectively

Cognitive restructuring Told him that it is not himself that is inefficient rather his coping mech. 8 Go back to stress & skills training

TRA+HBM

Attitude beliefs: Evaluation: Its a good Charmaine Baniqued decision to stop smoking

Case Analysis

Attitude: Trying to stop smoking

Perceived self-efficiency: After interventions done in the CBM-RP, perceived self efficiency improves I can do this time as verbalized by Mr. RT

Plan or compliance to stop/ control smoking & drinking

Cues to action to stop smoking: Counseled upon by the nurse of the long and short term effects of smoking Feeling of a weakened body Apparently, he reported theres blood in his urine and he associate this possibly by smoking Advocacy program of city

Susceptibility to the disease: Family history of cancer in maternal side Male is commonly more affected by lung cancer Statistics say that the leading cancer is lung cancer for males.

Severity Aware about smokers body diseases and afraid of it somehow He is also afraid of having liver diseases associated with reinforced drinking

Perceived benefits of stopping: Health promotion Smoking-related diseases prevention Motivation to comply: He value much of his girlfriends want and expectations

Normative beliefs: His siblings expect him to stop smoking His current girlfriend wants him to stop smoking

Case Analysis
Charmaine Baniqued
Primary prevention: Advised to reduce possibility of encounter with stressors by avoidance strategy towards the ex Counseled on adaptive and coping mechanisms use Response pattern: (personal factors) Feeling of loss Feeling of pain Being hopeless at the moment Smoking and drinking behaviors

Basic structure: factors: Innate survival factors Genetics (male) Response pattern (maladaptive coping) Strength/ weaknesses Ego

Prevention of progression to the need of secondary and tertiary prevention

Basic Energy Resources

Environment

HEALTH CARE SYSTEMS MODEL

Interventions: Strengthen physiologic response towards stress by advising adequate food intake, balance between rest and play On psychological: Stress management techniques Developmental: the need to be responsible by studying as his part Sociocultural: Socializing with peers yet doing the right things (avoid vices); identify balancing factors: seeking help from friends/cousins Spiritual: Advising to go to church, saying prayers Goal: Control/ stop smoking and drinking. Learns increasing balance in lifestyle, makes use of effective coping mechanisms and stress management and problem solving techniques Anticipated outcome: able to control/stop smoking and drinking as a coping mechanism for stress

Feelings of guilt Feelings of inadequacy

Reconstitution: Could begin at any degree/ level of reaction Support for successful reconstitution

Stressors: Failing grades due to lack of motivation to study Failed relationships When stressed: not seeking social support

A 10

Case Analysis
Charmaine Baniqued
TRANSACTION Mr. RT and the nurse communicates about goal-setting and agreement

GOAL SETTING

AGREEMENT

GOAL
5
Mr. RT has lack of knowledge regarding stress management and adaptive coping mechanisms Goal Setting: To develop effective coping mechanism/ problem solving and stress management techniques Agreement: To stop/control smoking and drinking Goal Attainment Scale: Health promoting behavior

4
COMMUNICATION Body

COMMUNICATION Space Time

Growth & Devt

Learning

GOAL ATTAINMENT THEORY

Mr. RT is aware of his maladaptive coping response

Learning: Takes place when there is effective communication Mr. RT gained knowledge of his maladaptive behavior and proper techniques to handle it.

Mr. RT

GOAL IS ATTAINED

A 11

Case Analysis
Charmaine Baniqued

Educate on health promoting behaviors Reinforce on the use of proper stress management and use of adaptive coping mechanisms and problem solving strategies

By supporting psychological, physiological and sociological strengthening of the client trough ways of under health education, my client is also spared from secondary/ tertiary prevention is also spared.

In support of the govt for the smoking hazards, Baguio city government implemented law on no smoking at public places

TANNAHILLS INTERLAPPING SPHERES

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Case Analysis
Charmaine Baniqued

iii.

PLANS/ INTERVENTIONS Upon the first meet up, the client was cooperative and opens himself to the nurse

readily. This may indicate that he is actually willing to make a behavioral change, geared toward health promoting behaviors and to learn on how to manage these undesirable health habits that he is currently having. To be further aware of my clients needs and for appropriate models to be employed for initiating change, I validated with him my findings on his case and the client validated that understanding upon his case is correct and he participated well with the planning of interventions for the succeeding weeks. Here, we could integrate the transaction process and learning concept of King from her model. Prior to that, the model by Pender was used to explain the current behavior of the client on how things lead to the behavior. It is therefore useful for Mr. RT to adapt the interventions from the model of CBTRelapse Model because this is the key for achieving the goals from the different models and theories that could be integrated in this study. To start with: to increase lifestyle balance, I encouraged him to develop positive addictions like playing metal puzzles and Sudoku when he is under stress to make himself busy since he said that he loves playing those. I also suggested that if he needed a break, maybe, he could go for a strolling with his peers. I also reinforced him to study and not to be lazy about it by keeping in mind those people whom are the reasons why he is studying and keep his goals and continue striving for his dreams by doing his part as a student **The client said that he would be trying these things and that he will inform me of his possible signs/symptoms that he could experience related to the desired goal. For stimulus control technique, I taught him of avoiding or removing of items/ situations that is associated with his smoking (Not stocking or buying cigarettes and alcohol, not going to events that could entail the need for him to smoke and drink). And as a form of urge management, I taught him of distractions like watching movies and

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Case Analysis
Charmaine Baniqued

informed him about urge surfing for him not to think immediately that he cannot do it if he experienced urge. **True enough, Mr. RT at the 1st 3days of managing his urges experienced difficulty and thought of giving up the process and almost gave in to his cravings. The difficulty experienced is brought about by the need to adjust without the cigarette or drinking. So, with the experience of urge surfing, I introduced him immediately to revised decision matrix. We identified together the positive and negative effects of smoking and drinking to him. Like if he has been drunk, this would definitely impair his functioning instead of him studying his lessons. I also educate him on warning signals of relapse. (Giving as an example was what he experienced previously). Relapse road maps were also initiated. (We identify together the usual situations which poses inevitable risks for him to smoke: he said drinking with his peers and when some mishaps occurred like if he has failing grades, quizzes/ exams, and when his ex keeps confronting him). We also brought up to the present experiences and how he looks at up himself after giving into his past relapses. This is done for analyzing his past relapse fantasies. **Mr. RT further looks himself as a big failure when he was reminded about his past relapses and does not want to experience losing control of his self again. This gave him however a positive effect: He said to himself then and to the nurse that he should do this by this time! So to reinforced him that when he experienced difficulty of saying NO to a temptation of smoking (like when he is presented with the stimuli he just said earlier), might as well try not to smoke to relax him, rather. I suggested for him to listen to music, watch television, have a time for himself alone to meditate and think what was really is the problem and think of a possible solution that is attainable at a shortest time that is a form of enhancing the feeling of self-efficacy. I reminded him that this is a form of skill acquisition, (how to resist temptations apparently and have that behavioral change). And if it is a skill, one needs to practice it over and over again. So, for him, he just needs to practice not holding on to smoking also when there is an opportunity that he was faced with a stressor. Practice avoiding it and practice resolving problems directly. I

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Case Analysis
Charmaine Baniqued

also suggested opening up his problems to his siblings if he cannot direct it to their parents but he refused saying that all of them are not really opening up to one another. **Mr. RT realized that, of course, there is no easy way to acquire skills. So, he needs to work upon it by not giving to the urges and cravings. **He also said that, there is one cousin who is really close to him, at that he is the one he will try to open up upon when problems crashes him. To further enhance the coping mechanisms and self efficacy, concepts from Health Care Systems Model are lifted particularly; the strengthening or supporting the intervention from the primary prevention so that it would not lead further that necessitates secondary or tertiary prevention or penetrating all of his defenses and worst: entropy. We then moved in to eliminating myths from him, typically the beneficial psychological effects of smoking to him. Like he said, he cannot defecate without smoking, he is apparently constipated and that he cannot think clearly if there is an existing uneasiness within him. He also learned about the immediate and the long term effects of smoking and he has been scared of to learn that smoking may cause any cancer in the body. Like in the genitourinary system particularly, because lately, he claimed that he has blood in his urine without any other cause. Moreover, he also claimed that recently, he has again another ineffective relationship with his new girlfriend because of his ex and his smoking and drinking habits. According to him, his girlfriend matters to him ant that she is the one that matters most aside from his siblings in stopping his smoking and drinking when feeling troubled. With the preceding paragraph above, this is in relation to Health Belief Model and Theory of Reasoned Action conceptual framework. The subjective norms and attitude beliefs also influence him to further contribute for the proposed goals. In conjunction with the Goal Attainment, wherein the perspective of the nurse of what is deficit leads to the formulation of appropriate goals, learning is a key concept for the client to move towards achieving his potentials. That is where health education is also needed to be emphasized. Moreover, in Kings theory, health is the focus, which is the

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Case Analysis
Charmaine Baniqued

counterpart of disease prevention in Tannahills Model and it is also in this model that legislations in influencing the health is taken into consideration since Mr. T also verbalized that the regulation on smoking of the city government has also a bearing on minimizing his smoking in public places since then. After for some time of not seeing him, I had been to Mr. RT to see how he was coping with his progress to the proposed behavioral change. **He said that for many times, he had been tempted to start smoking again especially if he sees people who are smoking and also when he was upset about his school requirements but insisted to keep up with the planned interventions and what has taught to him for effective coping. After the midterm examinations, Mr. RT experienced the initial lapse of substance use because apparently he has almost sure failing subject again just after taking the exams. He said that he suddenly thought of about her ate who sends him to school. He seemed distraught with the outcomes of his grades and the lapse he experienced. **Lapse management has been initiated then with Mr. RT by setting contract to limit smoking and drinking again, and taught him how to cope up with a lapse by not having a negative self concept. He was also given credit by telling it immediately to the nurse. We had evaluated readily what had triggered the lapse. I immediately assessed him for abstinence violation effect. He might be feeling some decreased self-efficacy to continue with the behavioral change. We did cognitive restructuring by not letting him feel he is a failure. **He said the next time he would be confronted again with such immense problem, he would try to go and seek the availability of the nurse and his available social support which is the dearest cousin to him ASAP.

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Case Analysis
Charmaine Baniqued

iv.

EVALUATION

Ineffective stress management and coping mechanism; impaired problem solving skills: smoking and drinking The goal/s with Mr. RT are fully met basing it to the Lapse-Relapse Process Model and Goal attainment theory. Change is in line with the time frame provided in Goal attainment scale. Also, the other models/ theories that helped in enhancing the efficacy and coping mechanisms in achieving the health promoting behavior also succeeded in enhancing the desired behavior change. It has been almost 4 months since we set the goals. It is not because Mr. RT experienced relapse made my goal for him partially met. Because, infusing him with an insight is the primary goal, and he had been receptive to those. Behavior change is not achieved over night but it is achieved over time. The client identified the presence of a problem, the client identified the triggering factors that let him do to smoke, helped the client verbalize feelings and thoughts regarding the coping mechanism used, the client eradicated the smoking as a coping mechanism and he also addresses problem directly by having a confrontation with his ex and he initiated the closure accordingly (however, the client is still under observation and monitoring, the last time he smoked was September 9, 2012 and as of this moment, he still not smoke), The client developed and maintained a healthy coping mechanism. According to him, he plays guitar, sings and he even clean the house when he feels stress now.

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Case Analysis
Charmaine Baniqued

v.

REFERENCES

George, Julia (2002). Nursing Theories: The Base for Professional Nrsing Practice 5th ed. Singapore. Pearson publishing Global lifestyle self control strategies handout from Mam Basatan in Behavioral Perspectives in Health Marlatt, Allan G. (1984) Society for the Study of Addiction to Alcohol and other Drugs. Relapse Prevention: Introduction and Overview of the Model. Bntish joumalof Addiction79(1984), 261-273 Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press. World Health Organization - Smoking Statistics http://recoveryroadmap.com/Members/RP-Pages/RP8-TheoryPractice.html http://books.google.com.ph/books?id=Fx9oqIbIQ_QC&pg=PA4&lpg=PA4&dq=La pseRelapse+Process&source=bl&ots=tllzVeBNej&sig=QGDNBmx4qEaFgrLBIJjg GJulaQI&hl=en#v=onepage&q=Lapse-Relapse%20Process&f=false Downie RS, Fyfe C & Tannahill A (1990). Oxford: Oxford University Press, Tannahill A.( 1985) What is health promotion? Health Education Journal Health Protection Agency. What the Health Protection Agency Does. 2010 (last updated 12 April). Last viewed 22 June 2011.

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Case Analysis
Charmaine Baniqued

APPENDIX 2 DATE July 2012 7, ACTIVITIES DONE Asking for informed consent and divulging intentions/ purpose Building rapport Interview/ eliciting initial database July 2012 14, Validating data for correct understanding of the case situation Formulation of planning and interventions with the client for the next weeks July 2012 21, Interventions on increasing lifestyle balance How to avoid high risk situations Urge management July 2012 24, Identified the positive and negative effects of smoking to him Discussed on warning signals of relapse. (giving as an example was what he experienced previously) Identifying usual situations which poses SIGNATURE

inevitable risks for him to smoke We reflected at his past experiences and how he looks at up himself after giving into his past relapses Constant reinforcements of interventions

previously taught

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Case Analysis
Charmaine Baniqued

Problem solving techniques discussion Stress management options Discussion on effective coping mechanisms Discussion on the beneficial psychological

effects of smoking to him and about the immediate and the long term effects of smoking August 12, 2012 Visit to Mr. RT He related his experiences about being tempted to smoke/ drink Sept. 2012 9, Mr. RT experienced the initial lapse of substance use. Lapse management by setting contract to limit smoking again, and taught him how to cope up with a lapse by not having a negative self concept. He was also given credit by telling it immediately to the nurse. We had evaluated readily what had triggered the lapse. I immediately assessed him for abstinence violation effect. We did cognitive restructuring.

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