PEMILIHAN DAN PENERAPAN TEORI MODEL KEPERAWATAN DALAM INTERVENSI

Seminar Nasional Keperawatan Fakultas Keperawatan Universitas Airlangga Surabaya, 25 Januari 2014

Oleh: Prof. Dr. Nursalam, M.Nurs (Hons)

Why do we need theory to care?

Teori merupakan dasar untuk praktik dan riset keperawatan yang efektif. Profesionalisasi keperawatan telah dan sedang dibawa melalui pengembangan dan penggunaan teori keperawatan (Ahmad, 2012). Teori keperawatan memberikan kerangka berpikir untuk mengkaji situasi dengan menyediakan struktur organisasi, analisis, dan pengambilan keputusan serta struktur komunikasi dengan perawat dan tenaga kesehatan lain.

NURSING PHYLOSOPHY
Nursing Phylosophy HUMANISM HOLISM CARE

PERSON CENTER OF NURSING

CARING AS BASIC OF NURSING

PARADIGMA KEPERAWATAN

MAN

HEALTH

ENV

NURSING

Nursalam (2006)

Patobiologi: Cont Perub Biologis (imbalance)

Fisiobiologis:
Perub Biologis (balance)
NURSING

ART

SCIENCE I. KEDOKTERAN THE HEALTH SCIENCE OF CARING

PROFESSION

I. PSIKOLOGI

HEALTH SCIENCE

NURSING SCIENCE / CARING SCIENCE

BASIC NURSING SCIENCES

BEHAVIORAL SCIENCES
SOCIAL SCIENCES

BIOMEDICAL SCIENCES
PUBLIC HEALTH SCIENCES

CLINICAL NURSING SCIENCES COMMUNITY NURSING SCIENCES

Our Philosophy
Balance (Health)
Necessity Necessity A need (Nursing) Research

Individual (Human)

Harmony (Environment)

People dont change when you tell them there is a better option. They change when they conclude they have no other option

PEMILIHAN & PENERAPAN TEORI KEPERAWATAN

There are no right or wrong theories There are better fitting theories/models that explain why a specific strategy or mechanism causes the intended change The implementation strategy(s) may be operationalized from the theoretical concepts. To apply the better fitting theory, youll need to specify several key issues.

1. Mengkaji Target
Strategi implementasi digunakan untk menjawab penyebab dari kesenjangan atau kegagalan sistem. Apa yang diharapkan dari perubahan organsisasi sbg akibat dari intervensi? Apa yg diharapkan dari organisasi / unit untuk belajar dan menerapkan dari intervensi?

a. Menetapkan Target
Who

are the targets?

Kelompok target yang berbeda mungkin memerlukan pendekatan strategi implementasi yang berbeda. Sistem Tenaga keperawatan Pasien (individu, kelompok khusus, keluarga, atau komunitas)

b. Menetapkan tujuan
Strategi

intervensi digunakan sebagai usaha untuk mengatasi penyebab dari masalah (Nursalam, 2008). Hal pertama yang dilakukan adalah menetapkan harapan perubahan yang diinginkan untuk terjadi setelah dilakukan intervensi dan apa yang pasien harapkan untuk belajar atau lakukan sebagai hasil dari intervensi tersebut.

2. Memilih teori dan memberikan rasional

a. Menganalisis impelementasi sebelumnya
Implementasi

terdahulu dapat dijadikan sebagai masukan untuk menetapkan intervensi saat ini. Mengidentifikasi faktor-faktor yang dapat ditindaklanjuti untuk ditargetkan dalam intervensi. Mengidentifikasi hambatan yang terjadi serta fasilitas yang memadai.

b. Mengkaji Beberapa Teori Mengkaji beberapa teori (keperawatan dan non keperawatan yang relevan) dan komponen utamanya yang mungkin sesuai dengan situasi yang dihadapi Mengidentifikasi faktor-faktor penentu yang mempengaruhi suatu perubahan perilaku atau pemberian intervensi dapat mempengaruhi hasil yang diinginkan

c. Kajian Literatur (Literature Review)

What do you know from the literature about this change mechanism? What if any theories have been employed for this type of change? Consider the strength of this evidence What have others interested in this mechanism/strategy previously used? How well has this mechanism/strategy produced change?

1. COMFORT THEORY (Kolcaba)

Best Practices

Health Care Needs

Nursing Interventions

Intervening Variables

Enhanced Comfort

Health Seeking Behaviors

Institutional Integrity

Best Policies Internal Behavior Peaceful Death

External Behaviors

Kolcaba (2007)

2. SELF CARE (OREM

R

Self-care
R

Conditioning factors

Conditioning factors

Self-care capabilities (self-care agency)

<
Deficit

Therapeutic self-care demand

Conditioning factors

FIG. OREM SELF CARE DEFICIT

Nursing Agency (supportive Educative)

3.CARING The Structure of Caring

Maintaining belief

Knowing

Being with

Doing for

Enabling

( )
Client wellbeing Intended outcome

Philosoohical attitudes towards persons (in general) and the designated client (in specific)

Informed understanding Message of the clinical condition conveyed to client (in general) and the situation and client (in specific)

Therapeutic actions

The structure of caring as linked to the nurses philosophical attitude, informed understandings, message conveyed, therapeutic actions, and intended outcome. (from Swanson, K. M. [1993]. Nursing as informed caring for well-being of others. Image: The Journal of Nursing Scholarship, 25 [4], 352-357.)

4. Human Interaction for Goal Attainment (King)

FEEDBACK PERCEPTION NURSE JUDGMENT ACTION

PATIENT

ACTION JUDGMENT PERCEPTION

REAC TION

INTERAC TION

TRANSACTION

FEEDBACK

5. SUNRISE (LEININGER)

Health (well being)

Of

Individuals, families, group and institutions

Diverse health systems

Diverse health systems

Nursing

Professional system

Nursing care decisions and actions cultural care preservation/ maintenance cultural care accommodation/ negotiation cultural care repatterning/ restructuring Culture congruent

Father or intimate partner a Mother Infant a

cb

6. BECOMING A MOTHER: A revised model. (From R. T. Mercer, 2008)

7. SERVEQUAL PERCEIVED SERVICE QUALITY

(Parasuraman)
Word of mouth Service Quality Dimensions: (RATER) Reliability Assurance Tangibles Empathy Responsiveness Personal needs Expected service Perceived service Past experience

Service Quality Assessment 1. Expectations exceeded ES<PS (Quality surprise) 2. Expectations met ES~PS (Satisfactory quality) 3. Expectations not met ES>PS (Unacceptable quality)

8. MODEL OF PERCEIVED UNCERTAINTY IN ILLNESS

Coping: Mobilizing Strategies Affectcontrol strategies

Danger (-) Interference Illusion

(+)

Uncertainty

Appraisal

Stimulati frame Symptom pattern Event familiarity Even congruency

(+) (+)

Adaptation

Opportunity (-)

(+)

Cognitive capacities

Structure providers Credible authority Social support Education

Coping: buffering strategies

Model of perceived uncertainty in illness. (from Mishel, M. in illnes. Image: The Journal of Nursing Scholarship, 20, 226)

H. [1988, Winter]. Uncertainty

9. Lazarus & Folkman (1984) & MBI (1996)

How do you expect to get from

CURRENT PRACTICE Where are you now? Where do you want to be? Potential Barriers to change? Possible facilitators to Change?
=HOW to get to desired outcomes, EBP

EBP

5 Steps to EBP
1. 2. 3.

4.

5.

Ask the burning clinical question Collect the most relevant and best evidence Critically appraise the evidence Integrate all evidence with ones clinical expertise, patient preferences, and values in making a practice decision or change Evaluate the practice decision or change
(Burns & Grove, 2001; Melnyk & FineoutOverholt, 2005)

Forming A Good Questions: EVIDENCE BASED - PICO

P = Patient population or disease of interest (age, gender, ethnicity, with a certain disorder hepatitis) I = Intervention or range of interventions of interest (exposure to disease, prognostic factor A, risk behavior) C = Comparison, you want to compare the intervention against (no disease, placebo or no intervention, prognostic factor B, absence of risk factor) O = Outcome of interest (accuracy of diagnosis, rate of occurrence of adverse outcome)

In (P) immobile acute care patients, what is the effect of (I) turning every 2 hours on (O) prevention of pressure ulcers compared with (C) (Burns & Grove, 2001; Melnyk & Fineoutnot turning patients every 2 hours? Overholt, 2005)

d. Memberikan Rasional pada Teori yang Dipilih

Determinan Teori/model Komponen program intervensi
Pengembangan nurseled clinic untuk mengatasi nyeri neuropati

Rasional

Rasa nyaman Theory of Comfort (Kolcaba)

Kolcaba menjelaskan kebutuhan pelayanan kesehatan sebagai suatu kebutuhan akan kenyamanan dengan menentukan desain tindakan comfort melaui nurse-led clinic diharapkan dapat meningkatkan kenyamanan pasien yang mengalami nyeri neuropati

Kemandirian Self care deficit Supportive-educative pasien theory (Orem) system: melatih teknik purse lips breathing pada pasien dengan PPOK

Kemampuan Adaptation adaptasi model (Roy)

Teori Orem menjelaskan tentang bagaimana seseorang dapat meningkatkan kemandirian seseorang dalam memenuhi kebutuhannya, dengan mengajarkan teknik purse lips breathing pasien dapat melakukan sendiri saat sesak untuk meningkatkan pernapasannya. Penggunaan Teori Roy menjelaskan polyethylene wrap pada upaya individu untuk BBLR dapat beradaptasi dengan Caring terhadap situasi atau lingkungan adaptasi pada pasien sekitar. BBLR diupayakan HIV untuk dapat beradapasi dengan suhu ruangan yang berbeda dengan ketika masih dalam kandungan.

Adaptation Model
Input Control processes Effectors Output

Stimuli Adaptation level

Coping mechanisms Regulator Cognator

Physiological function Self-concept Role function Interdependence

Adaptive and ineffective response

Feedback

Person as adaptive system. (From Roy, C. [1984]. Introduction to nursing: An adaptation model [2nd ed., p. 30]. Englewood Cliffs, NJ: Prentice Hall.)

STRESSOR

RESP. PERCEPTION (COGNATOR)

(Enviromental stimuli External)

Role Function

Sell-Concept

Interdependence

Physiological Mode
RESP. BIOLOGICAL

Caring
Behavior

-Predisposing
(Demographics)

INDIVIDU
functional status psychological state

--Enabling --Reinforcing

Severity of Deseast

Psychosocial
Interpersonal Relations
IMMUNE STATUS

Treatment Regimen

MODEL - ADAPTASI DARI ROY

(Nursalam, 2007)

PNI
Psycho Neuro Immunology
HEALTH

Lived Experience

Potential Co-Factors

Psychosocial Moderators

Psychosocial Functioning

Person Factors

Perceived Stress

Coping Pattern s

NeuroEndocrine Mediators

Immunological Mediators

Quality of Life

Pre tx: Critical Factors

Physical Health

PNI

(Thorton & Andersen, 20

COGNATOR
Internal stimuli

Intact pathways and apparatus for Perceptual/ information processing

Processes for Selective attention, coding, and memory

Perceptio n Learning
R

Imitation, reinforcement, insight

Judgeme nt Emotio n

Problem Solving & Decision Making

Psychomotor choice of response

Effector s

Response

ADAPTIF
Defenses to seek relief , affective appraisal & attachement

G
Externa l stimuli

PAKAR

REGULATOR
Internal stimuli

Neura l Chemical

Spinal cord;brainstem and autonomic reflexes

Effector s

Automati c reflex response

Intac Circulation

Intact Pathways to & from CNS

Responsiveness of endocrine glands

Hormonal output

Responsiveness of target organs or tissues

Body response

Chemical Externa l stimuli Neura l Perception Short term memory Psychomoto r choice of response Effector s

Long term memory

PENERAPAN TOERI ROY & PNI TERHADAP RESPON ADAPTASI BIOPSIKOSIOSPIRITUAL PADA PASIEN HIV AIDS
CARING (PAKAR) Biologis: IO, UP
Psikologis (coping) Sosial (interaksi) Spiritual (mengambil hikmah)

RESPONS PERSEPSI (KOGNISI)

Respons Spiritual Harapan Tabah Hikmah Respons Sosial Emosi Cemas Interaksi Respons Penerimaan diri Denial K O P I N G

Anger Bargaining Depression-Acceptance

H O S T

RESPONS BIOLOGIS
HPA-AXIS Adrenal (Cortisol )

Th-1 (CD4 )
IFN-

IL2,IFN-

Th-2 (CD4 )

D a b b a
Sel Plasma

Ab- HIV NK-cell CTL

M c E n w e e
2 0 0

Nursalam (2007)

FRAMEWORK (p.403 ADAPTATION & PNI)

Counseling for patient with Stress pre op
Learning process (cognator)

Perception (+)

Coping (+)

Cognition Emotion

Stress

H P

Hypotalamus (CRF)

A
AXIS

Pituitary (ACTH) - endorphin Adrenal Cortex (Cortisol )

Adrenal medulla (Catecolamines

Vital signs (T, P, R, PB)

A D A P T A T I O N

IMMUNE RESPONSE MODULATION (CD4; cytokin; IgG)

nursalam-MASALAH

Pencapaian Becoming a peran ibu Mother (Mercer)

Mengajarkan teknik Teori Mercer sebagai acuan untuk kangaroo mother care mencapai peran seorang ibu dapat digunakan untuk mendasari KMC dalam upaya mendekatkan ikatan antara ibu dan bayi serta melatih ibu untuk merawat bayinya dengan penuh kasih sayang Teori peplau menjelaskan tentang kemampuan dalam memahami diri sendiri dan orang lain sehingga tepat untuk mengatasi masalah keperawatan menarik melalui fase orientasi, fase identifikasi, fase resolusi, fase eksplorasi yang sesuai dengan dengan tahapan CBT yaitu tahap orientasi, tahap kerja, dan tahap terminasi

Interaksi sosial

Interpersonal Intervensi cognitive relation behavior therapy (Peplau) (CBT) pada pasien menarik diri

Holistic Care

Caring (Swanson)

Penerapan caring dalam meningktkan mutu dan keselamatan pasien

Teori ini menekankan peran caring dalam meningkatkan pelayanan berfokus pada pasien (kepuasan) dan mencegah terjadinnya adverse event (dekubitus, medication error, plebitis, pneumonia, infeksi daerah operasi, dan jatuh).

e. Identifikasi kesenjangan
Memetakan

keadaan pasien saat ini dan memetakan teori secara ideal Mengidentifikasi adanya kesenjangan yang terjadi antara keadaan pasien dengan teori. Menganalisis apa yang perlu dilakukan untuk mengatasi kesenjangan tersebut.

Cont
3.

Develop tailored implementation strategy 4. Execute tailored implmentation strategy 5. Evaluate effectiveness of implementation strategy 6. Assess fit of finding with initial theory

PEMETAAN PROSEDUR PENERAPAN

0. Needs Assessment 1. Matrices 2. Theorybased methods and practical strategies 3. Design Program 4. Adoption and Implementation Plan 5. Evaluation Plan

Pemetaan Need assessment

1. 2. 3. 4.

5.
6. 7.

kaji intervensi yg sudah ada dan terbaru kaji kemampuan sumber daya kaji hasil yg diharapkan susun kegiatan kaji pustaka tentukan kesenjangan penerapan yg ada kaji hambatan dan dukungan

Tahap 1: kerangka acuan

tuliskan tujuan fokuskan pada determinan perilaku kelompok yg akan dicapai tetapkan perubahan yg diharapkan dalam perilaku dan lingkungan susun suatu alir kerangka kerja

Tahap 2: Dasar metode teori dan strategi praktik

Tulis daftar metode intervensi yang sesuai dgn tujuan tahap 1 (Komponen teori; Strategi praktik berdasarkan teori; dan Masukan dari pakar

Tahap 3: Mendesain program

Strategi yg operasional tentang penerapan teori dan implementasi klinik (EBP) Menelaah masukan dari para pakar dan pengguna Menyusun sarana yg diperlukan

Tahap 4: Adopsi EBP dan Penerapan

Tahap 5: Evaluasi (Evaluasi proses
dan hasil)

OtherS Strategy Identify Implementation Tools to Support Implementation Strategy

T: O: O: L: S: Teaching Others tO Live with Stroke

Other Approaches to Applying Theory to Implementation Interventions

1. Consolidated Framework for Implementation Research (CFIR) (Damschroeder et al 2009) 2. PARIHS (RycroftMalone, 2004) 3. Climate for Implementation Theory (Klein and Sorra, 1996)

1. Consolidated Framework for Implementation Research (CFIR)

Refer to CFIR Constructs with Short Definitions handout Consult with knowledgeable stakeholders
Determine highpriority constructs

Adapt the list of constructs for overall context

Diagnostic evaluation of intervention, setting, individuals, and process as appropriate Use results to develop tailored implementation strategy
Damschroder et al, Imp Sci 2009

2. PARIHS framework
PARIHS: SI=f(E,C,F)
VA QUERI IMPLEMENTATION GUIDE/CIPRS Sharepoint: A basic to do list:

A. Do diagnostic analysis of Evidence and Context

See Guide Appendices and described tools [ORCA, ACT, CAI]

B. Use results to plan implementation within the Facilitation element

(RycroftMalone et al 2004)

3. Climate for Implementation Theory

Use of diagnostics
Evaluate the implementation climate Assess organizational priority

Use results to tailor implementation policies and practices Strong climate for implementation is a shared perception that innovation use is supported by the organization and peers
(Klein & Sorra, 1996. The challenge of innovation implementation. Academy of Management Review, 21(4): 10551080)

Tailoring Vs. Adapting

Locally Tailor
Utilize results from

Adapt a Program
Essential Core

context evaluation to tailor to the site Any combination of information or change strategies intended to reach a group based on group/organization characteristics

components Adaptable components Adapting a program is when you preserve necessary elements while adding new or changing modifiable elements to make the program relevant for (or fit) the context

Intervention Tailoring
Tailoring is when you specify the intervention to match
the needs of a group based on a characteristic(s) of the targeted group/organization
Examples

Tailoring written reminders for women to receive a mammogram based on race/ethnicity. The reminder featured a woman who matched the race/ethnicity of the patient. Tailoring intervention based on stage of change (smoking cessation). Tailoring implementation intervention based on organizational structure of care (General medicine service vs a stroke unit) Nutritional needs based on Sasak culture and sunrise model

(Leeman et al. Tailoring a diabetes selfcare intervention for use with older, AfricanAmerican women. Diabetes Educator, 2008;34:31017)

Adapting an Intervention
Adapting a program is when you preserve the necessary elements deemed necessary to change behaviors while adding new elements that make the program relevant to the new group. Examples:
Adapted Chronic Disease Self Management

Program for Stroke Self Management Get With The Guidelines Stroke in VA data reporting

Theoretical Issues / hambatan

Kegagalan dlm memilih teori Kegagalan dalam mengidentifikasi mekanisme perubahan secara adekuat kegagalan dlm mengidntifikasi faktor yg berhubungan dgn perubahan yg didapat dari EBP
Kurang dukungan dari pimpinan

Tidak mendapatkan kontribusi dan diskusi dgn teman

Intervensi klinik(EBP) menjadi tidak sesuai sbg

praktik berbasis bukti yg baru

Contoh: PENERAPAN TEORI ROY DLM 1. INTERVENSI

PERSON

ENVIRONMENT

METAPARADIGM OF ROYS ADAPTATION

GOAL OF NURSING

HEALTH
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PERSON
the recipient of nursing care; Roy implies that a client has an active role in the care Is a BIOPSYCHOSOCIAL BEING who constantly interacts with a changing environment Is an adaptive system who uses innate and acquired coping mechanisms to deal with STRESSORS Can be an individual, family, group, community, orARUN society 3/17/2014 PIRAVOM
Is

ENVIRONMENT

is defined by Roy as all conditions, circumstances, and influences surrounding and affecting the development and behavior of person and groups Consists of internal and external environments, which provide input in the form of stimuli Is always changing and constantly interacting with the person
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HEALTH
Was originally described by Roy as health-illness continuum, with one end of the continuum being death and the other end wellness; health and illness considered an inevitable dimension of the persons life 2. is currently defined by Roy as a process of being and becoming an integrated and whole person; 3. health is viewed as the goal of the persons behavior and the persons ability to be an adaptive organism 3/17/2014 ARUN PIRAVOM
1.

NURSING
is required when a person expends more energy on coping, leaving less energy available for achieving the goals of survival, growth, reproduction, and mastery 2. uses the four adaptive modes to increase a persons adaptation level during health and illness 3. employs activities that promote adaptive, not ineffective, responses in situations of health and illness 4. is a practice centered discipline geared toward persons and their responses to stimuli and adaptation to the environment 5. includes assessment, diagnosis, goal setting, intervention, and evaluation. 3/17/2014 ARUN PIRAVOM 1.

THE NURSING PROCESS

RAM offers guidelines to nurse in developing the nursing process. The elements : 1. First level assessment 2. Second level assessment 3. Diagnosis 4. Goal setting 5. Intervention 6. Evaluation
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Demographic data

Name Age Sex

Mr. NR 53 years Male

Education
Occupation Marital status Religion Informants
3/17/2014 Date of admission

Degree
Bank clerk Married Hindu Patient and Wife 21/01/08

ARUN PIRAVOM

Contoh: SBAR
Situation
Identifikasi data pasien dengan jelas, keluhan dan diagnosa penyakit, dst

Back Ground
Menyediakan riwayat kesehatan yang signifikan dengan singkat, termasuk tes atau perawatan yang telah dilakukan, atau perubahan pasien dari kondisi sebelumnya.

Contoh: Selamat siang saya Ns. Artok PP dinas pagi, melaporkan Tn. Y dengan Diagnosa medis internal bleeding post operasi hari ke-2. Keadaan umum lemah, kesadaran komposmentis.

Contoh: nafas spontan, RR:18x/menit, suara nafas: vesikuler, ronchi: negatif, whezzing: negatif, terdapat luka operasi sepanjang 15cm, perdarahan: negatif, pus: negatif, GCS: 456, Hb: 9 g/dl, wbc: 12.000, pusing (-), mual-muntah: negatif BAB (1x tadi pagi) BAK positif tidak di tampung, mobilisasi terbatas, dekubitus: negatif.
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Assesment
Jelaskan kondisi / DATA pasien TERKINI (saat ini) : TTV, GCS, Pain scale, Risk fall

Recomendation
Jelaskan tindakan keperawatan yang telah dilakukan, rencana perawatan untuk pasien selanjutnya, dan tindakan kolaboratif yang memungkinkan. Jika Anda menerima pasien baru, pastikan untuk mendapatkan semua informasi ini dari perawat sebelumnya.

Contoh: MK: hipertermi, ...... Tanda infeksi

Contoh: Hari ini sudah dilakukan rawat luka, injeksi cefazoline 1g, asam traneksamat 1 ampul, antrain 1 ampul. Direncanakan ambil kultur darah, menunggu tabung.
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1. FIRST LEVEL ASSESSMENT

Physiologic- Physical Mode
.Physiologic function Involves the bodys basic needs and ways of adapt .Includes a persons patterns of oxygenation, nutrition, elimination, activity, and rest; skin integrity; sense; fluids and electrolytes; and neurologic and endocrine function
PHYSIOLOGIC ADAPTATION

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.Is less abstract than the other three adaptive modes ARUN PIRAVOM

1A. PHYSIOLOGIC-PHYSICAL MODE

(1) 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 S1& S2 heard. No abnormal heart sounds. Delayed capillary refill+. 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 with regular rhythm. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line. BP- Normotensive. . Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.
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(2) 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. Bowel sounds heard. Percussion revealed dullness over hepatic area. Oral mucosa is normal. No difficulty to swallow food 3/17/2014 ARUN PIRAVOM

(3) Elimination:
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.

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(4) ACTIVITY AND REST:

Taking

adequate rest. Sleep pattern disturbed at night due unfamiliar surrounding. Not following any peculiar relaxation measure. Like movies and reading. No regular pattern of exercise. Walking from home to office during morning and evening.
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Cont..
activity reduced due to amputated wound. Mobility impaired. Walking with crutches. Pain from joints present. No paralysis. ROM is limited in the left leg due to wound. No contractures present. No swelling over the joints. Patient need assistance for doing the activities. 3/17/2014 ARUN PIRAVOM
Now,

(5) PROTECTION:
lower fore foot is amputated. Black discoloration present over the area. No redness, discharge or other signs of infection. Nomothermic. Wound healing better now. Walking with the use of left leg is not possible. Using crutches.ARUN PIRAVOM 3/17/2014
Left

Cont..
Pain

form knee and hip joint present while walking. 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 with normal rate, rhythm and depth over right leg.
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(6) SENSES:
No

pain sensation from the wound site. Relatively, reduced touch and pain sensation in the lower periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses are normal.

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(7) FLUIDS AND ELECTROLYTES

Drinks

approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte values are with in normal limit. No signs of acidosis or alkalosis. Blood glucose elevated

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(8) NEUROLOGICAL FUNCTION

He

is conscious and oriented. He is anxious about the disease condition. Like to go home as early as possible. Showing signs of stress. Touch and pain sensation decreased in lower extremity. Thinking and memory is intact.

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(9) ENDOCRINE FUNCTION

He

is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands.

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1B. Self Concept -Group

Identity Mode: . Self- concept- Refers to beliefs and feelings about oneself

.Comprises the -physical self (includes sensation and body image) -personal self (includes selfconsistency and selfideal)and -moral and ethical self (includes self-observation and self-evaluation)
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1B.SELF CONCEPT MODEPhysical self

He

is anxious about changes in body image, but accepting treatment and coping with the situation. Belongs to a Nuclear family. 5 members. Stays along with wife and three children. Good relationship with the neighbours. Good interaction with the friends. Moderately active in local social activities
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1C. ROLE PERFORMANCE MODE

Involves

behavior based on a persons

position in society
Is

dependent on how a person interacts

with others in a given situation

Can

be classified as primary (age, sex),

secondary (husband, wife), or tertiary

(temporary role of a coach)

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 He

was the earning member in the family. His role shift is not compensated. His son doesnt have any work. His role clarity is not achieved.

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1D. INTERDEPENDANCE MODE

.Involves a persons relationship with significant others and support systems .Strikes a balance between dependent behaviors (seeking help, attention, and affection) and independent behaviors (taking initiative and obtaining satisfaction from work) .Meets a persons needs for love, nurturing, and affection
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INTERDEPENDENCE MODE
has good relationship with the neighbours. Good interaction with the friends relatives. But he believes, no one is capable of helping him at this moment. He says all are under financial constrains. He was moderately active in local social activities 3/17/2014 ARUN PIRAVOM
He

2. SECOND LEVEL ASSESSMENT 2A. FOCAL STIMULUS:

Non-healing wound after amputation of great and second toe of left leg- 4 week. A wound first found on the junction between first and second toe-4 month back. The wound was non-healing and gradually increased in size with pus collected over the area. He first showed in a local (---) hospital. From there, they referred to ---- medical college; where he was admitted for 1 month and 4 days. During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour. So the physician suggested for below knee amputation. That made them to come to --Hospital, ---. He underwent a plastic surgery 3 week before.
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2B. CONTEXTUAL STIMULI

Known

case DM for past 10 years. Was on oral hypoglycemic agent for initial 2 years, but switched to insulin and using it for 8 years now. Not wearing foot wear in house and premises.

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2C. 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 knowledge on health matters.

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3. DIAGNOSIS / CONCLUSION
Mr.NR

who was suffering with 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.

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INTREVENTION
Wound

started healing and he planned to discharge on 25th april. He studied how to use crutches and mobilized at least twice in a day. Patients anxiety reduced to a great extends by proper explanation and reassurance. He gained good knowledge on various aspect of diabetic foot ulcer for the future self care activities.
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KESIMPULAN
Menggunakan desain pre-implementasi untuk mencapai implemetasi anda 2. Memberikan rasionalisasi (logika: fakta dan teori) dalam memilih teori 3. Mendefinisikan secara jelas strategi anda supaya bisa dipergunkan dan diterima orang lain. 4. Adanya keseimbangan komponen teori dengan penerapan EBP.
1.

TERIMAKASIH

Nursalam-07