PEMILIHAN DAN PENERAPAN TEORI MODEL KEPERAWATAN DALAM INTERVENSISeminar 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 PhylosophyHUMANISMHOLISMCAREPERSON CENTER OF NURSINGCARING AS BASIC OF NURSINGPARADIGMA KEPERAWATANMANHEALTHENVNURSINGNURSING PHYLOSOPHYNursalam (2006)

NURSINGSCIENCEPROFESSIONARTTHE HEALTH SCIENCE OF CARINGHEALTH SCIENCE NURSING SCIENCE / CARING SCIENCEBASIC NURSING SCIENCESCLINICAL NURSING SCIENCES COMMUNITY NURSING SCIENCESBEHAVIORAL SCIENCESSOCIAL SCIENCESBIOMEDICAL SCIENCESPUBLIC HEALTH SCIENCESContI. PSIKOLOGII. KEDOKTERANPatobiologi: Perub Biologis (imbalance)Fisiobiologis: Perub Biologis (balance)

Our PhilosophyIndividual(Human) Balance (Health)Harmony (Environment)Necessity ResearchA need (Nursing)Necessity

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 TargetWho 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 tujuanStrategi 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 rasionalImplementasi 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.a. Menganalisis impelementasi sebelumnya

b. Mengkaji Beberapa TeoriMengkaji beberapa teori (keperawatan dan non keperawatan yang relevan) dan komponen utamanya yang mungkin sesuai dengan situasi yang dihadapiMengidentifikasi 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) Kolcaba (2007)

Self-careSelf-care capabilities (self-care agency)Therapeutic self-care demand Nursing Agency (supportive Educative)R R R R R < FIG. OREM SELF CARE DEFICIT2. SELF CARE (OREMDeficitConditioning factors

3.CARING The Structure of CaringThe 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.) Philosoohical attitudes towards persons (in general) and the designated client (in specific)Informed understanding of the clinical condition (in general) and the situation and client (in specific)Message conveyed to clientTherapeutic actionsIntendedoutcomeClient well-being( )

4. Human Interaction for Goal Attainment (King)NURSEPATIENTPERCEPTIONACTIONJUDGMENTREACTIONINTERACTIONTRANSACTIONPERCEPTIONJUDGMENTACTIONFEEDBACKFEEDBACK

Diverse health systemsProfessional system 5. SUNRISE (LEININGER)

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

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

7. SERVEQUALPERCEIVED SERVICE QUALITY (Parasuraman)

8. MODEL OF PERCEIVED UNCERTAINTY IN ILLNESS Stimulati frame Symptom pattern Event familiarity Even congruencyModel of perceived uncertainty in illness. (from Mishel, M. H. [1988, Winter]. Uncertainty in illnes. Image: The Journal of Nursing Scholarship, 20, 226) Structure providers Credible authority Social support EducationCoping:buffering strategiesAdaptationCoping:MobilizingStrategies Affect-control strategiesInterferenceIllusionOpportunityDangerCognitivecapacities(+)(+)(+)(+)(-)(-)Uncertainty

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

How do you expect to get fromCURRENT EBPPRACTICE 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

(Burns & Grove, 2001; Melnyk & Fineout-Overholt, 2005)5 Steps to EBPAsk the burning clinical questionCollect the most relevant and best evidenceCritically appraise the evidenceIntegrate all evidence with ones clinical expertise, patient preferences, and values in making a practice decision or changeEvaluate the practice decision or change

(Burns & Grove, 2001; Melnyk & Fineout-Overholt, 2005)

(Burns & Grove, 2001; Melnyk & Fineout-Overholt, 2005)Forming A Good Questions: EVIDENCE BASED - PICOP = 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) not turning patients every 2 hours?

(Burns & Grove, 2001; Melnyk & Fineout-Overholt, 2005)

d. Memberikan Rasional pada Teori yang Dipilih

DeterminanTeori/modelKomponen program intervensiRasionalRasa nyamanTheory of Comfort (Kolcaba)Pengembangan nurse-led clinic untuk mengatasi nyeri neuropatiKolcaba 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 pasienSelf care deficit theory (Orem)Supportive-educative system: melatih teknik purse lips breathing pada pasien dengan PPOKTeori 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.Kemampuan adaptasiAdaptation model (Roy)Penggunaan polyethylene wrap pada BBLRCaring terhadap adaptasi pada pasien HIVTeori Roy menjelaskan upaya individu untuk dapat beradaptasi dengan situasi atau lingkungan sekitar. BBLR diupayakan untuk dapat beradapasi dengan suhu ruangan yang berbeda dengan ketika masih dalam kandungan.

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

FeedbackInputEffectorsOutputControl processesStimuliAdaptationlevel

Coping mechanisms Regulator CognatorPhysiological functionSelf-conceptRole functionInterdependenceAdaptive and ineffective response

STRESSOR(Enviromental stimuli External)Role FunctionSell-ConceptInterdepen-dencePhysiological ModeBehaviorPredisposing (Demographics)-Enabling-ReinforcingTreatment Regimen Severity of Deseast functional status psychological stateInterpersonal RelationsIMMUNE STATUS MODEL - ADAPTASI DARI ROY(Nursalam, 2007)Caring ?INDIVIDUPsychosocialRESP. PERCEPTION (COGNATOR)RESP. BIOLOGICAL

Psychosocial Functioning

Quality of Life

Physical HealthHEALTH Psychosocial ModeratorsCoping PatternsPerson FactorsPre tx: Critical FactorsPotential Co-Factors Neuro-EndocrineMediatorsImmunological MediatorsPerceived StressPNI

(Thorton & Andersen, 2006)

Internal stimuliExternal stimuliIntact pathways and apparatus for Perceptual/ information processingLearning Judgement Emotion Processes for Selective attention, coding, and memory Imitation, reinforcement, insight Defenses to seek relief , affective appraisal & attachement Psychomotor choice of response Effectors Response COGNATORC

A

R

I

N

GPerceptionProblem Solving & Decision MakingPAKARADAPTIF

Internal stimuli Neural Chemical Intac

Chemical Neural External stimuli Intact Pathways to & from CNS Spinal cord;brainstem and autonomic reflexesResponsiveness of endocrine glands Perception Effectors Hormonal output Short term memoryLong term memory Responsiveness of target organs or tissuesAutomatic reflex responseBody responseEffectors Psychomotor choice of responseCirculation REGULATOR

Biologis: IO, UPSosial (interaksi)Nursalam (2007)Th-1(CD4 )Respons Spiritual Respons SosialRESPONS PERSEPSI(KOGNISI)HOSTCARING (PAKAR)Psikologis (coping)Respons Penerimaan diri Harapan TabahHikmahEmosiCemasInteraksiDenialAngerBargainingDepression-Acceptance

Adrenal(Cortisol )HPA-AXISTh-2(CD4 )Sel PlasmaAb- HIVNK-cellCTLIFN- KOPING PENERAPAN TOERI ROY & PNI TERHADAP RESPON ADAPTASI BIOPSIKOSIOSPIRITUAL PADA PASIEN HIV AIDSRESPONSBIOLOGISDabbaMcEnwee2001IL2,IFN-Spiritual (mengambil hikmah)

nursalam-MASALAH Counseling for patient with Stress pre op

Learning process (cognator)

Cognition - Emotion

Pituitary(ACTH) - endorphinStress

Hypotalamus(CRF)Adrenal Cortex(Cortisol )IMMUNE RESPONSE MODULATION (CD4; cytokin; IgG) Perception (+)

Coping (+)

Adrenal medulla (Catecolamines

FRAMEWORK (p.403 ADAPTATION & PNI)HP AAXISADAPTATIONVital signs(T, P, R, PB)

nursalam-MASALAH

Pencapaian peran ibuBecoming a Mother (Mercer)Mengajarkan teknik kangaroo mother careTeori Mercer sebagai acuan untuk 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 Interaksi sosialInterpersonal relation (Peplau)Intervensi cognitive behavior therapy (CBT) pada pasien menarik diri 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

Holistic CareCaring (Swanson)Penerapan caring dalam meningktkan mutu dan keselamatan pasienTeori 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 kesenjanganMemetakan 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.

Cont3. Develop tailored implementation strategy4. Execute tailored implmentation strategy5. Evaluate effectiveness of implementation strategy6. Assess fit of finding with initial theory

PEMETAAN PROSEDUR PENERAPAN 0. Needs Assessment3. Design Program1. Matrices4. Adoption and2. Theorybased Implementation Planmethods and practical 5. Evaluation Planstrategies

Pemetaan Need assessment 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 diperlukanTahap 4: Adopsi EBP dan Penerapan Tahap 5: Evaluasi (Evaluasi proses dan hasil)

OtherS StrategyIdentify Implementation Tools to Support Implementation StrategyT: TeachingO: OthersO: tOL: Live withS: Stroke

Other Approaches to Applying Theory to Implementation Interventions1. 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 forImplementation Research (CFIR) Refer to CFIR Constructs with Short Definitions handout Consult with knowledgeable stakeholdersDetermine highpriority constructsAdapt 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 ContextSee 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 diagnosticsEvaluate the implementation climateAssess 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 TailorUtilize results from context evaluation to tailor to the siteAny combination of information or change strategies intended to reach a group based on group/organization characteristics Adapt a ProgramEssential Core componentsAdaptable componentsAdapting 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 ExamplesTailoring 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 ManagementGet 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 INTERVENSI

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PERSON

Is the recipient of nursing care; Roy implies that a client has an active role in the careIs a BIOPSYCHOSOCIAL BEING who constantly interacts with a changing environment Is an adaptive system who uses innate and acquired coping mechanisms to deal with STRESSORSCan be an individual, family, group, community, or society

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ENVIRONMENT is defined by Roy as all conditions, circumstances, and influences surrounding and affecting the development and behavior of person and groupsConsists of internal and external environments, which provide input in the form of stimuliIs always changing and constantly interacting with the person

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HEALTH

1. 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 life2. 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

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NURSING

1. is required when a person expends more energy on coping, leaving less energy available for achieving the goals of survival, growth, reproduction, and mastery2. uses the four adaptive modes to increase a persons adaptation level during health and illness3. employs activities that promote adaptive, not ineffective, responses in situations of health and illness4. 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.

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THE NURSING PROCESS

RAM offers guidelines to nurse in developing the nursing process. The elements : First level assessment Second level assessment Diagnosis Goal setting Intervention Evaluation

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Demographic data

Name Age Sex Education Occupation Marital status Religion Informants Date of admission Mr. NR 53 years Male Degree Bank clerk Married Hindu Patient and Wife 21/01/08

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Contoh: SBAR21/5/2013NURSALAM-MAKP-2013*

Situation Back GroundIdentifikasi data pasien dengan jelas, keluhan dan diagnosa penyakit, dst 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.

NURSALAM-MAKP-2013

21/5/2013NURSALAM-MAKP-2013*

AssesmentRecomendation Jelaskan kondisi / DATA pasien TERKINI (saat ini) : TTV, GCS, Pain scale, Risk fallJelaskan 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 infeksiContoh:Hari ini sudah dilakukan rawat luka, injeksi cefazoline 1g, asam traneksamat 1 ampul, antrain 1 ampul.Direncanakan ambil kultur darah, menunggu tabung.

NURSALAM-MAKP-2013

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

.Is less abstract than the other three adaptive modes

PHYSIOLOGIC ADAPTATION*ARUN PIRAVOM1. FIRST LEVEL ASSESSMENT

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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 crepitusS1& 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

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(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. *ARUN PIRAVOM

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Cont..Now, 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.

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(5) PROTECTION:

Left 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

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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. *ARUN PIRAVOM

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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 self-consistency and self-ideal)and -moral and ethical self (includes self-observation and self-evaluation)

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1B.SELF CONCEPT MODE-Physical 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 MODEInvolves behavior based on a persons position in societyIs dependent on how a person interacts with others in a given situationCan be classified as primary (age, sex), secondary (husband, wife), or tertiary (temporary role of a coach)*ARUN PIRAVOM

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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 MODEHe 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

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2. SECOND LEVEL ASSESSMENT2A. 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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INTREVENTIONWound 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.*ARUN PIRAVOM

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KESIMPULANMenggunakan desain pre-implementasi untuk mencapai implemetasi anda Memberikan rasionalisasi (logika: fakta dan teori) dalam memilih teori Mendefinisikan secara jelas strategi anda supaya bisa dipergunkan dan diterima orang lain. Adanya keseimbangan komponen teori dengan penerapan EBP.

Nursalam-07TERIMAKASIH

***DEMI MORE BEFORE AND AFTER MAKE UP**************************************