Ida Jean Orlando Nursing Theory

By Filua oluwakemi and Jaja Florence

CALLISTA ROY ADAPTATION MODEL
Description of The Nursing Theorist
Callista Lorraine Roy was born October 14th, 1939 in Los Angeles, California
She is a member of the Sister of St. Joseph of Carondelet, she is a nun, a nurse theorist, writer, lecturer, researcher and teacher. Professor and Nurse Theorist at the Boston College of Nursing in Chestnut Hill
Received her BSN from Mount Saint Mary's College in Los Angeles in 1963, received her MSN from University of California, Los Angeles in 1966
Worked as a pediatric staff nurse, where she noticed the amazing resiliency of the children she cared for, and their ability to adapt to the major physical and psychological changes they were experiencing. lmpressed by this adaptation, Roy worked towards an appropriate conceptual framework for nursing.
It was there that her Adaptation Model was developed, in a seminar with fellow theorist Dorothy E. Johnson in 1965.
In 1968, her alma mater Mount Saint Mary's adopted her model as the philosophical foundation for their nursing curriculum
Roy was an associate professor and chairperson of the Department of Nursing at Mount Saint Mary’s College until 1982 and was promoted to the rank of professor in 1983 at both Mount Saint Mary’s College and the University of Portland. She helped initiate and taught in a summer master’s program at the University of Portland.
She was a Robert Wood Johnson postdoctoral fellow at the University of California, San Francisco from 1983 to 1985 as a clinical nurse scholar in neuroscience. It was during this time she conducted research on nursing interventions for cognitive recovery in head injuries and on the influence of nursing models on clinical decision making.
In 1991, she founded the Boston Based Adaptation Research in Nursing Society (BBARNS), which would later be renamed the Roy Adaptation Association.
Got award as a Living Legend in 2007 by the American Academy of Nursing, she is presently still alive. On December 6, 2017, the Connell School community gathered in Gasson 100 to celebrate her retirement from Boston College.

Metaparadigm of The Theory
PERSON
Based on Roy, humans are holistic beings that are in constant interaction with their environment. Humans use a system of adaptation, both innate and acquired, to respond to the environmental stimuli they experience. Human systems can be individuals or groups, such as families, organizations, and the whole global community.
PHYSIOLOGIC ADAPTIVE MODE- sleeping, eating ,drinking are Physiological needs of humans in which they have adapted with.
FIVE NEEDS are: Oxygenation, Nutrition, Elimination, Activity, Rest and protection on four regulatory processes.
SELF-CONCEPT MODE: determined by interaction with others. For example, we feel happy when will hear someone say, “You look beautiful today.”
ROLE FUNCTION MODE : refers to the performance of duties based on given societal forms or expectations. For example, today's society has increase the role of mothers from being a receiver to  being a breadwinner and so a working woman needs to return to her work soon after the delivery of her baby.
INTERDEPENDENCE MODE: involves ways of seeking help, affection, and attention. It is also the ability to love, respect, value and accept. For example, When a Child wants something he/she cries to get what he/she wants.
Therefore,Human systems have thinking and feeling capacities, rooted in consciousness and meaning, by which they adjust effectively to changes in the environment and, in turn, affect the environment.”
ENVIRONMENT
 The environment is defined as conditions, circumstances, and influences that affect the development and behavior of humans as adaptive system. The environment is a stimulus or input that requires a person to adapt. This stimuli can be positive or negative.
Roy categorized this stimuli as focal, contextual, and residual.
 Focal stimuli are that which confronts the human system, and requires the most attention.
Contextual stimuli are characterized as the rest of the stimuli that present with the focal stimuli, and contribute to its effect.
Residual stimuli are the additional environmental factors present within the situation, but whose effect is unclear. This can include previous experience with certain stimuli.
HEALTH
HEALTH is a state of being and becoming an integrated whole. Conversely, illness is lack of integration.
Health is defined as the state where humans can continually adapt to stimuli. Because illness is a part of life, health is the result of a process where health and illness can coexist. If human can continue to adapt holistically, they will be able to maintain health to reach completeness and unity within themselves. If they cannot adapt accordingly, the integrity of the person can be affected negatively.
Roy therefore concluded that “Health is not freedom from the inevitability of death, disease, unhappiness, and stress , but the ability to cope with them in a competent way".
NURSING
Nursing is an external regulatory force that can modify stimuli which produce adaptations. It can either maintain, increase or decrease stimuli. The consequence of nursing is the person’s adaptation to these stimuli depending on his position on the health-illness continuum.
GOAL OF NURSING – to promote the person’s adaptation along the four adaptive modes and the person must be able to adapt if he is able to cope with the constantly changing environment. There are two types of systems at work.
Regulator
The regulator subsystem is a person’s physiological coping mechanism. It’s the body’s attempt to adapt via regulation of our bodily processes, including neurochemical, and endocrine systems.
Cognator
The cognator subsystem is a person’s mental coping mechanism. A person uses his brain to cope via self-concept, interdependence, and role function adaptive modes.

MODEL OF THE THEORY
Model of the theory was explained in four adaptive modes where are:

Physiologic-physical mode: physical and chemical processes involved in the function and activities of living organisms; the underlying need is physiologic integrity as seen in the degree of wholeness achieved through adaptation to changes in needs. In groups, this is the manner in which human systems manifest adaptation relative to basic operating resources. The basic need of this mode is composed of the needs associated with oxygenation, nutrition, elimination, activity and rest, and protection. The complex processes of this mode are associated with the senses, fluid and electrolytes, neurologic function, and endocrine function.
Self-Concept Group Identity Mode: In this mode, the goal of coping is to have a sense of unity, meaning the purposefulness in the universe, as well as a sense of identity integrity. This includes body image and self-ideals. It focuses on psychological and spiritual integrity and a sense of unity, meaning, purposefulness in the universe.
Role Function Mode: This mode focuses on the primary, secondary and tertiary roles that a person occupies in society, and knowing where he or she stands as a member of society. It involves  fulfilling the need for social integrity; it is knowing who one is, in relation to others.
Interdependence Mode: This mode focuses on attaining relational integrity through the giving and receiving of love, respect and value. This is achieved with effective communication and relations.
Six-Step Nursing Process
A nurse’s role in the Adaptation Model is to manipulate stimuli by removing, decreasing, increasing or altering stimuli so that the patient
1. Assess the behaviors manifested from the four adaptive modes.
2. Assess the stimuli, categorize them as focal, contextual, or residual.
3. Make a statement or nursing diagnosis of the person’s adaptive state.
4. Set a goal to promote adaptation.
5. Implement interventions aimed at managing the stimuli.
6. Evaluate whether the adaptive goal has been met.

GENERAL ASSUMPTION OF THE THEORY
Scientific Assumptions
Systems of matter and energy progress to higher levels of complex self-organization.
Consciousness and meaning are constructive of person and environment integration.
Awareness of self and environment is rooted in thinking and feeling.
Humans by their decisions are accountable for the integration of creative processes.
Thinking and feeling mediate human action.
System relationships include acceptance, protection, and fostering of interdependence.
Persons and the earth have common patterns and integral relationships.
Persons and environment transformations are created in human consciousness.
Integration of human and environment meanings results in adaptation.
Philosophical Assumptions
Persons have mutual relationships with the world and God.
Human meaning is rooted in the omega point convergence of the universe.
God is intimately revealed in the diversity of creation and is the common destiny of creation.
Persons use human creative abilities of awareness, enlightenment, and faith.
Persons are accountable for the processes of deriving, sustaining, and transforming the universe.
Application of the Roy Adaptation model In research studies
Case 1:
Application of Roy Adaptation Model in the care of a patient who has been diagnosed with breast cancer and had breast-conserving surgery. Patient data was evaluated in the four modes of Roy adaptation model (physiologic, self-concept, role function, and interdependence modes) and the nursing process was applied.The patient had undergone breast conserving surgery (BCS) 45 days ago and was interviewed in the first course of her chemotherapy treatment. A verbal informed consent was obtained from the patient before the interview.
Figure 1 below
Patient demographic and clinical data
BCS: Breast conserving surgery; USG: Ultrasonography; MRI: Magnetic Resonance Imaging

Figure 2 below
Patient data related to physiologic mode of RAM and nursing interventions

Figure 3 below
Patient data related to self-concept mode of RAM and nursing interventions

Figure 4 below
Patient data related to role function mode of RAM and nursing interventions

Figure 5 below
Patient data related to interdependence mode of RAM and nursing interventions

In this case, nursing interventions including holistic care according to the Roy Adaptation Model were described, with a patient who had undergone breast conserving surgery. Being diagnosed with and undergoing treatment for cancer may lead to bio-psycho-social problems. It is expected that the development of interventions specific to the individual by nurses, will yield positive results in the adaptation of patients who are trying to cope with these problems. By this means, the patients will be adapted to their new life and their quality of life will improve. The utilization of The Model will facilitate the situation and will provide a means for the nurses to focus on their profession of nursing, and develop a holistic care in biopsychosocial approach to the patients they are taking care of. For that reason, it is essential that the use of theories in nursing care, should be encouraged and their implementation into practice should be enhanced.

Case 2:
Mr.NR who was suffering with diabetes mellitus for past 10 years. He developed a diabetic foot ulcer and had to undergo amputation. He was admitted in the Hospital. Mr. NR was selected for application of RAM in providing nursing care.

DEMOGRAPHIC DATA
NAME
Mr RN

AGE
53years

SEX
Male

EDUCATION
Degree

OCCUPATION
Bank Clerk

MARITAL STATUS
Married

RELIGION
Hindu

INFORMANTS
Patient and wife

DATE OF ADMISSION
21/01/08


FIRST LEVEL ASSESSMENT
PHYSIOLOGIC-PHYSICAL MODE
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. NVBS. S1& S2 heard. No abnormal heart sounds.Delayed capillary refill+. JVP0.
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.
S1& S2 heard.No abnormal heart sounds. BP- Normotensive. .
Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.

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
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.
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.
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.
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. 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.
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.
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.
Neurological function:
He is conscious and oriented, 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.
Endocrine function:
He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands.
SELF CONCEPT MODE
Physical self:
He is anxious about changes in body image, but accepting treatment and coping with the situation. He deprived of sexual activity after amputation.
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
Personal self:
Self esteem disturbed because of financial burden and hospitalization. He believes in god and worshiping Hindu culture.
ROLE PERFORMANCE MODE:
He was the earning member in the family. His role shift is not compensated. His son doesn't’t have any work. His role clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbors. 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
SECOND LEVEL ASSESSMENT
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 consulted 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.
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.
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. . Mother’s brother had DM. Mother had history of PTB. He is a graduate in humanities, no special knowledge on health matters.
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. 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. Patient’s 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.

NURSING CARE PLAN OF MR NR

ASSESSMENT OF BEHAVIOUR
Ineffective protection and sense in physical-physiological mode
(No pain sensation from the wound site.)
ASSESSMENT OF STIMULI
Focal stimuli:
Non-healing wound after amputation of great and second toe of left leg- 4 week
NURSING DIAGNOSIS
1. Impaired skin integrity related to fragility of the skin secondary to vascular insuffiency
GOAL
Long-term objective :
1. amputated area will be completely healed by 20/5/08
2.Skin will remain
intact with no ongoing ulcerations.
 Short-Term Objective:
i. Size of wound decreases to 1x1 cm within 24/4/08.
ii. No signs of infection over the wound within 1-wk
iii. Normal WBC values within 1-wk
iv. Presence of healthy granular tissues in the wound site within 1-wk
INTERVENTIONS
- Maintain the wound area clean as contamination affects the healing process.
- Follow sterile technique while providing cares to prevent infection and delay in healing.
- Perform wound dressing with Betadine which promote healing and growth of new tissue.
- Do not move the affected area frequently as it affects the granulation tissue formation.
- Monitor for signs and symptoms of infection or delay in healing.
- Administer the antibiotics and vitamin C supplementation which will promote the healing process.
EVALUATION
Short term goal:
Met: size of wound decreased to less than 1x1 cms.
WBC values became normal on 24/4/08
Long term goal:
Partially Met: skin partially intact with no ulcerations.
Continue plan Reassess goal and interventions
Unmet: not achieved complete healing of amputated area. Continue plan Reassess goal and interventions



Reference
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THE JOURNAL OF BREAST HEALTH(2014). Nursing Approach Based on Roy Adaptation Model in a Patient Undergoing Breast Conserving Surgery for Breast Cancer. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351537/
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