Dorothea Orem Self Care Model In Regards to the Dialysis Patient, Case Study Example

Dorothea Orem was a nursing theorist who conceptualized a self-care deficit model of nursing derived from three separate theories. The first theory involves the natural tendency for patients to care for themselves, learning new lifestyle modifications and other skills necessary for survival. The second theory involves the deficit of self-care, which calls for nursing interventions where the patient is no longer able to perform self-care. The third theory involves nursing systems, which are derived from a framework of nursing methodology, systematic care of patients as a result of their training (Hartweg, 2005). Together, these theorems form the basis of Orem’s theory which has been a invaluable as a model for nursing.

Self-Care Deficit Nursing Theory (SCDNT) serves as a fundamental conceptual framework for nurses. The philosophical premise of the general theory of nursing includes the expansion of basic knowledge with the continuing education and empirical studies. The model of nursing has four concepts that serve as the fundamental basis of SCDNT care: patients, environment, health, and nursing (Fawcett, 2005).

The humanity described by Orem involves “internal physical psychological and social nature with varying degrees of self-care ability” (Hartweg, 2005). Nursing in the dialysis unit of my clinic involves keeping the patient informed of his or her condition. The patient must be kept aware of changes to condition as well as being taught how to properly maintain health despite the affliction suffered. All efforts must be made to help the patient in rehabilitation.

In the domain of health, patient is in need of dialysis, most often, they are suffering from renal failure. The pathogenesis of the effects of the kidneys shutting down is the rapid increase in the level of serum creatinine (Rubin, 1198). This is result of the oliguria, the decreased output of urine. Urinalysis will show degenerated epithelial cells, containing debris that manifests itself in brown, granular casts. The color is generated cytochrome pigments (Rubin, 354). Renal disease may be acute or chronic. The worsening of renal function over days or hours is the acute form and the chronic condition is more suitably called chronic kidney disease (McPhee, 1134).

Simple cuboidal epithelial tissues function in absorption and secretion – two essential functions for the kidneys. The kidneys role is to provide a huge amount of the body’s homeostatic mechanisms via the excretion of urine. In the process, the kidneys gauge the levels of different nutrients and eliminate the excess from the body via urine. Any nutrients the kidney recognizes as necessary are reabsorbed into the bloodstream where they can travel to the rest of the body. The human body relies so heavily on the proper function of the kidneys in maintaining its homeostasis that even mild damage to one of the kidneys can have devastating effects on the rest of the body.

Prognosis for patients with renal failure is often bleak due to the kidney’s limited regenerative capacity. However, the restructuring of the damaged cortical tubules is dependent on the integrity of the basement membrane avoiding damage. Therefore, this patient will likely recover. Tubular function is restored in 3 to 4 weeks if no damage has occurred to the basement membrane. The areas of disrupted membranes rely on intact cuboidal cells to flatten out – appearing more like squamous membranes as they spread the necrotic areas of damage. At this point, mitosis becomes frequent and eventually the cortical renal tubules thicken again, resembling their original cuboidal appearance. Once this has taken place, the kidneys will have returned to their normal function again with their structure restored.

The environment domain of Orem’s theory involve the place where the patient is making his recovery. The elements of the environment entail the accommodations made for the patient’s specific limitations. There are developmental protocols for the care facilities that work with each stage of the patient’s condition. Each move made by the nurse in the care of this patient must be deliberate and with the purpose of easing the patient’s troubles psychologically, physically, and emotionally.

In conclusion, the Orem model of self-care is an essential concept for nurses in all fields of medicine. As a registered nurse in the dialysis unit, I see patients struggling to maintain their autonomy after being rendered feeble from the exhausting procedure of dialysis. In using the methodology derived from the self-care deficit nursing, I am better able to assess the level of development as well as the prognosis for the patient.

The theory we will use to try to encourage more mothers to breastfeed will be the Theory of Reasoned Action. The theory of reasoned action takes place once the patient knows exactly what the benefits of changing her behavior. The modified behavior in this case is the mother’s adoption of breastfeeding for infants as opposed to alternatives. The function of intent will be gauged by the mother’s attitude and anticipated benefits from learning to bond with her child through the use of breast milk. It is assumed that the mother will want the best possible choices to be made in the development of her newborn infant. If the behavior of breastfeeding is introduced as a social norm for any mother who wants her child to be healthy and bonded to her, the societal influence will also prompt the mother toward wanting to breastfeed to conform to the  social standards.

Once the patient has been thoroughly educated about all of the benefits of breastfeeding newborn infants, the healthcare professional has an obligation to help her learn how to breastfeed the child. Change theory indicates the need for edification to support the desired change. There are various strategies to breastfeeding. Although the bond and the initiation of suckling the breast for milk can take a long time, the patient should be reassured that this difficulty is common and that the baby will eventually adapt to take the breast on instinct. If the mother becomes too discouraged, she may give up on the attempts to breastfeed in favor of some alternative. The healthcare professional is then encouraged to remind the mother of all of the benefits shown in an increasing number of studies. While some scientists have stated the importance and benefits of breastfeeding have been exceedingly exaggerated, the assumption will hold that the trend of healthy babies, higher neurological development and overall sanguinity will stress the predicted outcome.

Explanatory theory informs the patient of the reasons for breastfeeding. Upon the acknowledgement of this information, the patient will then need to be shown exactly how to change her behavior in order to ensure proper breastfeeding for her child. There are a number of ways breastfeeding can be facilitated. There are breast pumps if the mother gives up on showing the infant her breast and urging the child to take it.

Patients also must be educated on the contraindications of breastfeeding. This is an area where many healthcare professionals forget to educate their patients thoroughly. They include cracked nipples, Hepatitis B, mastitis, breast abscesses, HIV, Hepatitis C and illicit drug use (Leavitt et al, 2009). The use of coffee, alcohol, spicy foods and raw fish are also discouraged while the mother is breastfeeding for the first six months.

Patient With Renal Failure

Renal disease may be acute or chronic. The need for Dithiazide (a diuretic) is indicated in cases in where the kidney is not excreting enough urine. Diuretics are typically used in conjunction with hypertensive medications to aid the lowering of blood pressure. (McPhee, 2008)

Various findings on the urinalysis are indicative of certain patterns of renal disease. A bland urinary sediment is common in cases of renal failure, pre-renal and other indicators of renal insufficiency (Rubin, 678). This can be used to determine the problems that would prohibit use of gadolinium. When the kidneys can’t properly excrete the waste, the gadolinium builds up and causes the often-fatal nephrogenic systemic fibrosis.

Radiographic contrast media can be directly nephrotoxic. Contrast nephropathy is the third leading cause of new acute renal failure in hospitalized patients. It probably results from the synergistic combination of direct renal tubular epithelial cell toxicity and renal medullary ischemia (Grobner, 342). Predisposing factors include advanced age, preexisting renal disease, volume depletion, diabetic nephropathy, congestive heart failure, multiple myeloma, repeated doses of contrast and recent exposure to other nephrotoxic agents such as NSAIDs, and ACE inhibitors (Itoh, 524).

References

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Rubin, Emanuel et. al.. Rubin’s Pathology: Clinicopathologic Foundations of Medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2005

Itoh K, Nishimura K, Togashi K, et al. Hepatocellular carcinoma: MR imaging. Radiology 1987;164:21 -25

McPhee, Stephen J. and Maxine A. Papadakis. 2008 Current Medical Diagnosis and Treatment. New York: McGraw Hill Companies Inc., 716, 800, 812-14, 1033-34