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Betty Neuman's System Model

This page was last updated on November 9, 2010

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INTRODUCTION
Betty Neuman’s system model provides a comprehensive flexible holistic and system based
perspective for nursing.
It focuses attention on the response of the client system to actual or potential environmental
stressors.
And the use of primary, secondary and tertiary nursing prevention intervention for retention,
attainment, and maintenance of optimal client system wellness.
HISTORY AND BACKGROUND OF THE THEORIST
Betty Neuman was born in 1924, in Lowel, Ohio.
She completed BS in nursing in 1957 and MS in Mental Health Public health consultation, from
UCLA in 1966. She holds a Ph.D. in clinical psychology
She was a pioneer in the community mental health movement in the late 1960s.
Betty Neuman began developing her health system model while a lecturer in community health
nursing at University of California, Los Angeles.
The models was initially developed in response to graduate nursing students expression of a
need for course content that would expose them to breadth of nursing problems prior to focusing
on specific nursing problem areas.
The model was published in 1972 as “A Model for Teaching Total Person Approach to Patient
Problems” in Nursing Research.
It was refined and subsequently published in the first edition of Conceptual Models for Nursing
Practice, 1974, and in the second edition in 1980.
DEVELOPMENT OF THE MODEL
Neuman’s model was influenced by a variety of sources.
The philosophy writers deChardin and cornu (on wholeness in system).
Von Bertalanfy, and Lazlo on general system theory.
Selye on stress theory.
Lararus on stress and coping.
BASIC ASSUMPTIONS
Each client system is unique, a composite of factors and characteristics within a given range of
responses contained within a basic structure.
Many known, unknown, and universal stressors exist. Each differ in it’s potential for disturbing a
client’s usual stability level or normal LOD
The particular inter-relationships of client variables at any point in time can affect the degree to
which a client is protected by the flexible LOD against possible reaction to stressors.
Each client/ client system has evolved a normal range of responses to the environment that is
referred to as a normal LOD. The normal LOD can be used as a standard from which to measure
health deviation.
When the flexible LOD is no longer capable of protecting the client/ client system against an
environmental stressor, the stressor breaks through the normal LOD
The client whether in a state of wellness or illness, is a dynamic composite of the inter-
relationships of the variables. Wellness is on a continuum of available energy to support the
system in an optimal state of system stability.
Implicit within each client system are internal resistance factors known as LOR, which function to
stabilize and realign the client to the usual wellness state.
Primary prevention relates to G.K. that is applied in client assessment and intervention, in
identification and reduction of possible or actual risk factors.
Secondary prevention relates to symptomatology following a reaction to stressor, appropriate
ranking of intervention priorities and treatment to reduce their noxious effects.
Tertiary prevention relates to adjustive processes taking place as reconstitution begins and
maintenance factors move the back in circular manner toward primary prevention.
The client as a system is in dynamic, constant energy exchange with the environment.
CONCEPTS
Content: - the variables of the person in interaction with the internal and external environment
comprise the whole client system
Basic structure/Central core: - common client survival factors in unique individual
characteristics representing basic system energy resources.
The basis structure, or central core, is made up of the basic survival factors that are common to
the species (Neuman,2002).
These factors include:- - Normal temp. range, Genetic structure.- Response pattern. Organ
strength or weakness, Ego structure
Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being
used by the system.
A homeostatic body system is constantly in a dynamic process of input, output, feedback, and
compensation, which leads to a state of balance.
Degree to reaction: - the amount of system instability resulting from stressor invasion of the
normal LOD.
Entropy: - a process of energy depletion and disorganization moving the system toward illness
or possible death.
Flexible LOD: - a protective, accordion like mechanism that surrounds and protects the normal
LOD from invasion by stressors.
Normal LOD: - It represents what the client has become over time, or the usual state of
wellness. It is considered dynamic because it can expand or contract over time.
LOR: - The series of concentric circles that surrounds the basic structure.
Protection factors activated when stressors have penetrated the normal LOD, causing a reaction
symptomatology. E.g. mobilization of WBC and activation of immune system mechanism
Input- output: - The matter, energy, and information exchanged between client and
environment that is entering or leaving the system at any point in time.
Negentropy: - A process of energy conservation that increase organization and complexity,
moving the system toward stability or a higher degree of wellness.
Open system:- A system in which there is continuous flow of input and process, output and
feedback. It is a system of organized complexity where all elements are in interaction.
Prevention as intervention: - Interventions modes for nursing action and determinants for
entry of both client and nurse in to health care system.
Reconstitution: - The return and maintenance of system stability, following treatment for
stressor reaction, which may result in a higher or lower level of wellness.
Stability: - A state of balance of harmony requiring energy exchanges as the client adequately
copes with stressors to retain, attain, or maintain an optimal level of health thus preserving
system integrity.
Stressors: - environmental factors, intra (emotion, feeling), inter (role expectation), and extra
personal (job or finance pressure) in nature, that have potential for disrupting system stability.
A stressor is any phenomenon that might penetrate both the F and N LOD, resulting either a
positive or negative outcome.
Wellness/Illness: - Wellness is the condition in which all system parts and subparts are in
harmony with the whole system of the client.
Illness is a state of insufficiency with disrupting needs unsatisfied (Neuman, 2002).
Illness is an excessive expenditure of energy… when more energy is used by the system in its
state of disorganization than is built and stored; the outcome may be death (Neuman, 2002).
PREVENTION
According to Neuman’s model, prevention is the primary nursing intervention. Prevention focuses
on keeping stressors and the stress response from having a detrimental effect on the body.
PRIMARY PREVENTION
Primary prevention occurs before the system reacts to a stressor. On the one hand, it
strengthens the person (primary the flexible LOD) to enable him to better deal with stressors
On the other hand manipulates the environment to reduce or weaken stressors.
Primary prevention includes health promotion and maintenance of wellness.
SECONDARY PREVENTION
Secondary prevention occurs after the system reacts to a stressor and is provided in terms of
existing system.
Secondary prevention focuses on preventing damage to the central core by strengthening the
internal lines of resistance and/or removing the stressor.
TERTIARY PREVENTION
Tertiary prevention occurs after the system has been treated through secondary prevention
strategies.
Tertiary prevention offers support to the client and attempts to add energy to the system or
reduce energy needed in order to facilitate reconstitution.
FOUR MAJOR CONCEPTS
PERSON
The focus of the Neuman model is based on the philosophy that each human being is a total
person as a client system and the person is a layered multidimensional being.
Each layer consists of five person variable or subsystems:
Physiological- Refer of the physicochemical structure and function of the body.
Psychological- Refers to mental processes and emotions.
Socio-cultural- Refers to relationships; and social/cultural expectations and activities.
Spiritual- Refers to the influence of spiritual beliefs.
Developmental- Refers to those processes related to development over the lifespan.
ENVIRONMENT
The environment is seen to be the totality of the internal and external forces which surround a
person and with which they interact at any given time.
These forces include the intrapersonal, interpersonal and extra-personal stressors which can
affect the person’s normal line of defense and so can affect the stability of the system.
The internal environment exists within the client system.
The external environment exists outside the client system.
Neuman also identified a created environment which is an environment that is created and
developed unconsciously by the client and is symbolic of system wholeness.
HEALTH
Neuman sees health as being equated with wellness. She defines health/wellness as “the
condition in which all parts and subparts (variables) are in harmony with the whole of the client
(Neuman, 1995)”.
The client system moves toward illness and death when more energy is needed than is available.
The client system moved toward wellness when more energy is available than is needed
NURSING
Neuman sees nursing as a unique profession that is concerned with all of the variables which
influence the response a person might have to a stressor.
The person is seen as a whole, and it is the task of nursing to address the whole person.
Neuman defines nursing as “action which assist individuals, families and groups to maintain a
maximum level of wellness, and the primary aim is stability of the patient/client system, through
nursing interventions to reduce stressors.’’
Neuman states that, because the nurse’s perception will influence the care given, then not only
must the patient/client’s perception be assessed, but so must those of the caregiver (nurse).
The role of the nurse is seen in terms of degree of reaction to stressors, and the use of primary,
secondary and tertiary interventions
STAGES OF NURSING PROCESS (BY NEUMAN)
NURSING DIAGNOSIS
It depends on acquisition of appropriate database; the diagnosis identifies, assesses, classifies,
and evaluates the dynamic interaction of the five variables.
Variances from wellness (needs and problems) are determined by correlations and constraints
through synthesis of theory and data base.
Broad hypothetical interventions are determined, i.e. maintain flexible line of defense.
NURSING GOALS
These must be negotiated with the patient, and take account of patient’s and nurse’s
perceptions of variance from wellness.
NURSING OUTCOMES
Nursing intervention using one or more preventive modes.
Confirmation of prescriptive change or reformulation of nursing goals.
Short term goal outcomes influence determination of intermediate and long – term goals.
A client outcome validates nursing process.
Neuman’S SYSTEM MODEL FORMAT
Neuman’s nursing process format designates the following categories of data about the client
system as the major areas of assessment.
ASSESSMENT
Potential and actual stressors.
Condition and strength of basic structure factors and energy sources.
Characteristics of flexible and normal line of defenses, lines of resistance, degree of reaction and
potential for reconstitution.
Interaction between client and environment.
Life process and coping factors (past, present and future) actual and potential stressors (internal
and external) for optimal wellness external.
Perceptual difference between care giver and the client.
NURSING DIAGNOSIS
The data collected are then interpreted to condition and formulate the
Nursing diagnosis.
Health seeking behaviors.
Activity intolerance.
Ineffective coping.
Ineffective thermoregulation.
GOAL
In Neuman’s systems model the goal is to keep the client system stable.
PLANNING
Planning is focused on strengthening the lines of defense and resistance.
IMPLEMENTATION
The goal of stabilizing the client system is achieved through three modes of prevention
Primary prevention : actions taken to retain stability
Secondary prevention : actions taken to attain stability
Tertiary prevention : actions taken to maintain stability
EVALUATION
The nursing process is evaluated to determine whether equilibrium is restored and a steady state
maintained.
ACCEPTANCE BY THE NURSING COMMUNITY
Neuman’s model has been described as a grand nursing theory by walker and Avant.
Grand theories can provide a comprehensive perspective for nursing practice, education, and
research and Neuman’s model does.
PRACTICE
The Neuman systems model has been applied and adapted to various specialties include family
therapy, public health, rehabilitation, and hospital nursing.
The sub specialties include pulmonary, renal, critical care, and hospital medical units. One of the
model’s strengths is that it can be used in a variety of settings
Using this conceptual model permits comparison of a nurse’s interpretation of a problem with
that of the patient, so the patient and nurse do not work on two separate problems.
The role of the nurse in the model is to work with the patient to move him as far as possible
along a continuum toward wellness.
Because this model requires individual interaction with the total health care system, it is
indicative of the futuristic direction the nursing profession is taking.
The patient is being relabeled as a consumer with individual needs and wants.
EDUCATION
The model has also been widely accepted in academic circles.
It has often been selected as a curriculum guide for a conceptual framework oriented more
toward wellness than toward a medical model and has been used at various levels of nursing
education.
In the associate degree program at Indiana University.
One of the objectives for nursing graduate is to demonstrate ability to use the Neuman health
care system in nursing practice. This helps prepare the students for developing a frame of
reference centered on holistic care.
At northwestern State University in Shreveport, Louisiana, the faculty determined that a systems
model approach was preferred for their master’s program because of the universality framework.
Acceptance by the nursing community for education therefore is evident.
RESEARCH
A study was published by Riehl and Roy to test the usefulness of the Neuman model in nursing
practice.
There were two major objectives of the study.
To test the model/assessment’ tool for its usefulness as a unifying method of collecting and
analyzing data for identifying client problems.
To test the assessment tool for its usefulness in the identification of congruence between the
client’s perception of stressors and the care giver’s perception of client stressors.
Results indicated that the model can help categorize data for assessing and planning care and
for guiding decision making.
Neuman’s model can easily generate nursing research.
It does this by providing a framework to develop goals for desired outcomes. Acceptance by the
nursing community for research applying this model is in the beginning stages and positive.
Neuman’S AND THE CHARACTERISTICS OF A THEORY
Theories connects the interrelated concepts in such a way as to create a different
way of looking at a particular phenomenon.
The Neuman model represents a focus on nursing interest in the total person approach to the
interaction of environment and health.
The interrelationships between the concepts of person, health, nursing and society/environment
are repeatedly mentioned throughout the Neuman model and are considered to be basically
adequate according to the criteria.
Theories must be logical in nature
Neuman’s model in general presents itself as logically consistent.
There is a logical sequence in the process of nursing wherein emphasis on the importance of
accurate data assessment is basic to the sequential steps of the nursing process.
Theories should be relatively simple yet generalizable.
Neuman’s model is fairly simple and straightforward in approach.
The terms used are easily identifiable and for the most part have definitions that are broadly
accepted.
The multiple use of the model in varied nursing situations (practice, curriculum, and
administration) is testimony in itself to its broad applicability.
The potential use of this model by other health care disciplines also attests to its generalizability
for use ion practice.
One drawback in relation to simplicity is the diagrammed model since it presents over 35
variables and tends to be awesome to the viewer.
Theories can be the bases for hypotheses that can be tested.
Neuman’s model, due to its high level and breadth of abstraction, lends itself to theory
development.
One are for future consideration as a beginning testable theory might be the concept of
prevention as intervention, subsequent to basis concept refinement in the Neuman model.
Theories contribute to and assist in increasing the general body of knowledge within
the discipline through the research implemented to validate them.
The model has provided clear, comprehensive guidelines for nursing education and practice in a
variety of settings; this is its primary contribution to nursing knowledge.
The concept within the guidelines is clearly explicated and many applications of the theory have
been published, little research explicitly derived from this model has been published to date.
Theories can be utilized by the practitioner to guide and improve their practice.
One of the most significant attributes of the Neuman model is the assessment/intervention
instrument together with comprehensive guidelines for its use with the nursing process.
These guidelines have provided a practical resource for many nursing practitioners and have
been used extensively in a variety of setting in nursing practice, education and administration.
Theories must be consistent with other validated theories, laws and principles but will
leave open unanswered questions that need to be investigated.
In general, there is no direct conflict with other theories. There is, however, a lack of specificity in
systems concepts such as “boundaries” which are indirectly addressed throughout the model.
Research Articles
“Using the Neuman Systems Model for Best Practices’’--Sharon A. DeWan, Pearl N.
Ume-Nwagbo, Nursing Science Quarterly, Vol. 19, No. 1, 31-35 (2006).
The purpose of this study was to present two case studies based upon Neuman systems model;
one case is directed toward family care, and the other demonstrates care with an individual.
Theory-based exemplars serve as teaching tools for students and practicing nurses.
These case studies illustrate how nurses' actions, directed by Neuman's wholistic principles,
integrate evidence-based practice and generate high quality care
Melton L, Secrest J, Chien A, Andersen B. “A community needs assessment for a
SANE program using Neuman's model” J Am Acad Nurse Pract. 2001 Apr;13(4):178-86.
The purpose of the study was to present guidelines for a community needs assessment for a
Sexual Assault Nurse Examiner (SANE) program using Neuman's Systems Model.
Sexual assault is a problem faced by almost every community. A thorough community
assessment is an important first step in establishing programs that adequately meet a
community's needs.
Guidelines for conducting such an assessment related to implementation of a SANE program are
rare, and guidelines using a nursing model were not found in the literature
REFERENCES
Timber BK. Fundamental skills and concepts in Patient Care, 7th edition, LWW, NY.

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Current Reviews OBJECTIVES
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Nursing Specialities • to assess the patient condition by the various methods explained by the
Nursing Resources nursing theory
Find@Current • to identify the needs of the patient
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• to demonstrate an effective communication and interaction with the
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standard • to select a theory for the application according to the need of the patient
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• to apply the theory to solve the identified problems of the patient
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y health • to evaluate the extent to which the process was fruitful.
informatio
n verify INTRODUCTION
here. SYSTEM MODEL- BETTY NEUMAN
Disclaimer • The Neuman’s system model has two major components:stress and
Articles published in this site are based on the reaction to stress.
references made by the editors. Information
provided in these articles are meant for general • The client in the Neuman’s system model is viewed as an open system
information only, and not suggested as in which repeated cycles of input, process, out put and feed back
replacement to standard references. Any constitute a dynamic organizational pattern.
inaccurate/doubtful information, if found, may be • The client may be an individual, a group, a family, a community or an
communicated to the editor. aggregate.
Contact us at:
currentnursing@gmail.com • In the development towards growth and development open system
continuously become more differentiated and elaborate or complex.
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• As they become more complex, the internal conditions of regulation
become more complex.
Introduction to Nursing Theories • Exchange with the environment are reciprocal, both the client and the
environment may be affected either positively or negatively by the other.
Development of Nursing Theories
• The system may adjust to the environment to itself.
Virginia Henderson’s Need Theory
• The ideal is to achieve optimal stability.
Theory if Interpersonal Relations
Faye Glenn Abdellah's Theory • As an open system the client, the client system has propensity to seek
or maintain a balance among the various factors, both with in and out
Jean Watson's theory side the system, that seek to disrupt it. Neuman seeks these forces as
Johnson’s behavior system model stressors and views them as capable of having either positive or
negative effects.
Theory of Goal Attainment
• Reaction to the stressors may be possible or actual with identifiable
Betty Neuman’s system model responses and symptom.
Levin's Four Conservation Principles MAJOR CONCEPTS
Nursing Theorists I. PERSON VARIABLES
Martha Roger’s Science of unitary human beings Each layer, or concentric circle, of the Neuman model is made up of the five
person variables. Ideally, each of the person variables should be considered
Theories Based on Interactive Process simultaneously and comprehensively.
Orem's Self-Care Deficit Theory 1. Physiological - refers of the physicochemical structure and function of
Nursing Theories: An Overview the body.
Research and Nursing Theories 2. Psychological - refers to mental processes and emotions.
Roy's Adaptation Model 3. Sociocultural - refers to relationships; and social/cultural expectations
and activities.
Orlando's Nursing Process
4. Spiritual - refers to the influence of spiritual beliefs.
Notes on Nursing: What it is, What it is not:
Nightingale 5. Developmental - refers to those processes related to development over
the life span.
Understanding the works of Nursing Theorists: A
creative beginning II. CENTRAL CORE
Health Promotion Model • The basic structure, or central core, is made up of the basic survival
factors that are common to the species (Neuman, 1995, in George,
Health Belief Model
1996).
Theories used in Community Health Nursing
• These factors include: system variables, genetic features, and the
Application of Nursing Theories strengths and weaknesses of the system parts. Examples of these may
include: hair color, body temperature regulation ability, functioning of
Application Goal Attainment Theory body systems homeostatically, cognitive ability, physical strength, and
Application Orem's Self-care Deficit Theory value systems.
Application of Suchman’s Stages of Illness Model • The person's system is an open system and therefore is dynamic and
constantly changing and evolving.
Application of Betty Neuman's Systems Model in
Nursing Care • Stability, or homeostasis, occurs when the amount of energy that is
available exceeds that being used by the system.
Application of Roy's Adaptation Model in Nursing
Process • A homeostatic body system is constantly in a dynamic process of input,
output, feedback, and compensation, which leads to a state of balance.
Application of Peplau's Interpersonal theory in
Nursing ProcessApplication of Health Belief Model III. FLEXIBLE LINES OF DEFENSE-
in Nursing Practice • The flexible line of defense is the outer barrier or cushion to the normal
Transcultural Nursing line of defense, the line of resistance, and the core structure.
Helping and Human Relationships Theory: • If the flexible line of defense fails to provide adequate protection to the
Robert R. Carkhuff normal line of defense, the lines of resistance become activated.
Models of Prevention • The flexible line of defense acts as a cushion and is described as
accordion-like as it expands away from or contracts closer to the normal
Care, Cure and Core: The Three C’s of Lydia Hall line of defense.
Human Becoming Theory:Rosemarie Rizzo Parse • The flexible line of defense is dynamic and can be changed/altered in a
From Novice to Expert: Patricia Benner relatively short period of time.
IV. NORMAL LINE OF DEFENSE
• The normal line of defense represents system stability over time.
• It is considered to be the usual level of stability in the system.
• The normal line of defense can change over time in response to coping
or responding to the environment. An example is skin, which is stable
and fairly constant, but can thicken into a callus over time.
V. LINES OF RESISTANCE
The lines of resistance protect the basic structure and become activated when
environmental stressors invade the normal line of defense. Example: activation of
the immune response after invasion of microorganisms. If the lines of resistance
are effective, the system can reconstitute and if the lines of resistance are not
effective, the resulting energy loss can result in death.
VI. RECONSTITUTION-
Reconstitution is the increase in energy that occurs in relation to the degree of
reaction to the stressor. Reconstitution begins at any point following initiation of
treatment for invasion of stressors. Reconstitution may expand the normal line of
defense beyond its previous level, stabilize the system at a lower level, or return it
to the level that existed before the illness.
VII. STRESSORS
The Neuman Systems Model looks at the impact of stressors on health and
addresses stress and the reduction of stress (in the form of stressors). Stressors
are capable of having either a positive or negative effect on the client system. A
stressor is any environmental force which can potentially affect the stability of the
system: they may be:
• Intrapersonal - occur within person, e.g. emotions and feelings
• Interpersonal - occur between individuals, e.g. role expectations
• Extra personal - occur outside the individual, e.g. job or finance
pressures
The person has a certain degree of reaction to any given stressor at any given
time. The nature of the reaction depends in part on the strength of the lines of
resistance and defense. By means of primary, secondary and tertiary
interventions, the person (or the nurse) attempts to restore or maintain the
stability of the system.
VII. PREVENTION
As defined by Neuman's model, prevention is the primary nursing intervention.
Prevention focuses on keeping stressors and the stress response from having a
detrimental effect on the body.
Primary -Primary prevention occurs before the system reacts to a stressor. On
the one hand, it strengthens the person (primarily the flexible line of defense) to
enable him to better deal with stressors, and on the other hand manipulates the
environment to reduce or weaken stressors. Primary prevention includes health
promotion and maintenance of wellness.
Secondary-Secondary prevention occurs after the system reacts to a stressor
and is provided in terms of existing systems. Secondary prevention focuses on
preventing damage to the central core by strengthening the internal lines of
resistance and/or removing the stressor.
Tertiary -Tertiary prevention occurs after the system has been treated through
secondary prevention strategies. Tertiary prevention offers support to the client
and attempts to add energy to the system or reduce energy needed in order to
facilitate reconstitution.
NURSING METAPARADIGM
A. PERSON
The person is a layered multidimensional being. Each layer consists of five
person variables or subsystems:
• Physical/Physiological
• Psychological
• Socio-cultural
• Developmental
• Spiritual
The layers, usually represented by concentric circle, consist of the central core,
lines of resistance, lines of normal defense, and lines of flexible defense.
The basic core structure is comprised of survival mechanisms including: organ
function, temperature control, genetic structure, response patterns, ego, and what
Neuman terms 'knowns and commonalities'.
Lines of resistance and two lines of defense protect this core. The person may in
fact be an individual, a family, a group, or a community in Neuman's model.
The person, with a core of basic structures, is seen as being in constant, dynamic
interaction with the environment.
Around the basic core structures are lines of defense and resistance (shown
diagrammatically as concentric circles, with the lines of resistance nearer to the
core.
The person is seen as being in a state of constant change and-as an open
system-in reciprocal interaction with the environment (i.e. affecting, and being
affected by it).
B. THE ENVIRONMENT-
The environment is seen to be the totality of the internal and external forces
which surround a person and with which they interact at any given time. These
forces include the intrapersonal, interpersonal and extra personal stressors which
can affect the person's normal line of defense and so can affect the stability of the
system.
• The internal environment exists within the client system.
• The external environment exists outside the client system.
Neuman also identified a created environment which is an environment that is
created and developed unconsciously by the client and is symbolic of system
wholeness.
C. HEALTH-
• Neuman sees health as being equated with wellness. She defines
health/wellness as "the condition in which all parts and subparts
(variables) are in harmony with the whole of the client (Neuman, 1995)".
• As the person is in a constant interaction with the environment, the state
of wellness (and by implication any other state) is in dynamic
equilibrium, rather than in any kind of steady state.
• Neuman proposes a wellness-illness continuum, with the person's
position on that continuum being influenced by their interaction with the
variables and the stressors they encounter.
• The client system moves toward illness and death when more energy is
needed than is available. The client system moves toward wellness
when more energy is available than is needed.
D. NURSING
• Neuman sees nursing as a unique profession that is concerned with all
of the variables which influence the response a person might have to a
stressor.
• The person is seen as a whole, and it is the task of nursing to address
the whole person.
• Neuman defines nursing as actions which assist individuals, families
and groups to maintain a maximum level of wellness, and the primary
aim is stability of the patient/client system, through nursing interventions
to reduce stressors.
• Neuman states that, because the nurse's perception will influence the
care given, then not only must the patient/client's perceptions be
assessed, but so must those of the caregiver (nurse).
• The role of the nurse is seen in terms of degrees of reaction to
stressors, and the use of primary, secondary and tertiary interventions.
Neuman envisions a 3-stage nursing process:
• 1. Nursing Diagnosis - based of necessity in a thorough assessment,
and with consideration given to five variables in three stressor areas.
• 2. Nursing Goals - these must be negotiated with the patient, and take
account of patient's and nurse's perceptions of variance from wellness
• 3. Nursing Outcomes - considered in relation to five variables, and
achieved through primary, secondary and tertiary interventions.
NURSING PROCESS BASED ON SYSTEM MODEL
• Assessment: Neuman’s first step of nursing process parallels the
assessment and nursing diagnosis of the six phase nursing process.
Using system model in the assessment phase of nursing process the
nurse focuses on obtaining a comprehensive client data base to
determine the existing state of wellness and actual or potential reaction
to environmental stressors.
• Nursing diagnosis- the synthesis of data with theory also provides the
basis for nursing diagnosis. The nursing diagnostic statement should
reflect the entire client condition.
• Outcome identification and planning- it involves negotiation between
the care giver and the client or recipient of care. The overall goal of the
care giver is to guide the client to conserve energy and to use energy as
a force to move beyond the present.
• Implementation – nursing action are based on the synthesis of a
comprehensive data base about the client and the theory that are
appropriate to the client’s and caregiver’s perception and possibilities
for functional competence in the environment. According to this step the
evaluation confirms that the anticipated or prescribed change has
occurred. Immediate and long range goals are structured in relation to
the short term goals.
• Evaluation – evaluation is the anticipated or prescribed change has
occurred. If it is not met the goals are reformed.
ASSESSMENT
PATIENT PROFILE
• 1. Name- Mr. AM
• 2. Age- 66 years
• 3. Sex-Male
• 4. Marital status-married
• 5. Referral source- Referred from ------- Medical College, -------
STRESSORS AS PERCEIVED BY CLIENT
• (Information collected from the patient and his wife)
• Major stress area, or areas of health concern
• Patient was suffering from severe abdominal pain, nausea, vomiting,
yellowish discolorations of eye, palm, and urine, reduced appetite and
gross weight loss(8kg with in 4 months)
• Patient is been diagnosed to have Periampullary carcinoma one week
back.
• Patient underwent operative procedure i.e. WHIPPLE’S PROCEDURE-
Pancreato duodenectomy on 27/3/08.
• Psychologically disturbed about his disease condition- anticipating it as
a life threatening condition. Patient is in depressive mood and does not
interacting.
• Patient is disturbed by the thoughts that he became a burden to his
children with so many serious illnesses which made them to stay with
him at hospital.
• Patient has pitting type of edema over the ankle region, and it is more
during the evening and will not be relieved by elevation of the affected
extremities.
• He had developed BPH few months back (2008 January) and
underwent surgery TURP on January 17. Still he has mild difficulty in
initiating the stream of urine.
• Patient is a known case of Diabetes since last 28 years and for the last
4 years he is on Inj. H.Insulin (4U-0-0). It is adding up his distress
regarding his health.
Life style patterns
• patient is a retired school teacher
• cares for wife and other family members
• living with his son and his family
• active in church
• participates in community group meeting i.e. local politics
• has a supportive spouse and family
• taking mixed diet
• no habits of smoking or drinking
• spends leisure time by reading news paper, watching TV, spending time
with family members and relatives
Have you experienced a similar problem?
• The fatigue is similar to that of previous hospitalization (after the surgery
of the BPH)
• Severity of pain was some what similar in the previous time of surgery
i.e. TURP.
• Was psychologically disturbed during the previous surgery i.e. TURP.
• What helped then- family members psychological support helped him to
over come the crisis situation
Anticipation of the future
• Concerns about the healthy and speedy recovery.
• Anticipation of changes in the lifestyle and food habits
• Anticipating about the demands of modified life style
• Anticipating the needs of future follow up
What doing to help himself?
• Talking to his friends and relatives
• Reading the religious materials i.e. reading the Bible
• Instillation of positive thoughts i.e. planning about the activities to be
resume after discharge, spending time with grand children, going to the
church, return back to the social interactions etc
• Avoiding the negative thoughts i.e. diverts the attentions from the pain
or difficulties, try to eliminate the disturbing thoughts about the disease
and surgery etc
• Trying to accept the reality etc..
What is expected of others?
• Family members visiting the patient and spending some time with him
will help to a great extent to relieve his tension.
• Convey a warm and accepting behaviour towards him.
• Family members will help him to meet his own personal needs as much
as possible.
• Involve the patient also in taking decisions about his own care,
treatment, follow up etc
STRESSORS AS PERCEIVED BY THE CARE GIVER.
Major stress areas
• Persistent fatigue
• Massive weight loss i.e.( 8 kg of body weight with in 4 months)
• History of BPH and its surgery
• Persistence of urinary symptoms (difficulty in initiating the stream of
urine) and edema of the lower extremities
• Persistent disease- chronic hypertensive since last 28 years
• Depressive ideations and negative thoughts
• Present circumstances differing from the usual pattern of living
• Hospitalization
• acute pain ( before the surgery patient had pain because of the
underlying pathology and after the surgery pain is present at the
surgical site)
• nausea and vomiting which was present before the surgery and is still
persisting after the surgery also
• anticipatory anxiety concerns the recovery and prognosis of the disease
• negative thoughts that he has become a burden to his children
• Anticipatory anxiety concerning the restrictions after the surgery and the
life style modifications which are to be followed.
Clients past experience with the similar situations
• Patient verbalized that the severity of pain, nausea, fatigue etc was
similar to that of patient’s previous surgery. Counter checked with the
family members that what they observed.
• Psychologically disturbed previously also before the surgery. (collected
from the patient and counter checked with the relatives)
• Client perceived that the present disease condition is much more
severe than the previous condition. He thinks it is a serious form of
cancer and the recovery is very poor. So patient is psychologically
depressed.
Future anticipations
• Client is capable of handling the situation- will need support and
encouragement to do so.
• He has the plans to go back home and to resume the activities which he
was doing prior to the hospitalization.
• He also planned in his mind about the future follow up ie continuation of
chemotherapy
What client can do to help himself?
• Patient is using his own coping strategies to adjust to the situations.
• He is spending time to read religious books and also spends time in
talking with others
• He is trying to clarify his own doubts in an attempt to eliminate doubts
and to instill hope.
• He sets his major goal i.e. a healthy and speedy recovery.
• Client's expectations of family, friends and caregivers
• he sees the health care providers as a source pf information.
• He tries to consider them as a significant members who can help to
over come the stress
• He seeks both psychological and physical support from the care givers,
friends and family members
• He sees the family members as helping hands and feels relaxed when
they are with him.
Evaluation/ summary of impressions-
• There is no apparent discrepancies identified between patients
perception and the care givers perceptions.
INTRAPERSONAL FACTORS
1. Physical examination and investigations
• Height- 162 cm
• Weight – 42 kg
• TPR- 37o C, 74 b/m, 14 breaths per min
• BP- 130/78 mm of Hg
• Eye- vision is normal, on examination the appearance of eye is normal.
Conjunctiva is pale in appearance. Pupils reacting to the light.
• Ear- appearance of ears normal. No wax deposition. Pinna is normal in
appearance and hearing ability is also normal.
• Respiratory system- respiratory rate is normal, no abnormal sounds on
auscultation. Respiratory rate is 16 breaths per min.
• Cardiovascular system- heart rate is 76 per min. on auscultation no
abnormalities detected. Edema is present over the left ankle which is
non pitting in nature.
• GIT- patient has the complaints of reduced appetite, nausea; vomiting
etc. food intake is very less. Mouth- on examination is normal. Bowel
sounds are reduced. Abdomen could not be palpated because of the
presence of the surgical incision. Bowel habits are not regular after the
hospitalization
• Extremities- range of motion of the extremities are normal. Edema is
present over the left ankle which is non pitting in nature. Because of
weakness and fatigue he is not able to walk with out support
• Integumentary system- extremities are mild yellowish in color. No
cyanosis. Capillary refill is normal.
• Genitor urinary system- patient has difficulty in initiating the urine
stream. No complaints of painful micturation or difficulty in passing
urine.
• Self acre activities- perform some of his activities, for getting up from
the bed he needs some other person’s support. To walk also he needs
a support. He do his personal care activities with the support from the
others
• Immunizations- it is been told that he has taken the immunizations at
the specific periods itself and he also had taken hepatitis immunization
around 8 years back
• Sleep –. He told that sleep is reduced because of the pain and other
difficulties. Sleep is reduced after the hospitalization because of the
noisy environment.
• Diet and nutrition- patient is taking mixed diet, but the food intake is less
when compared to previous food intake because of the nausea and
vomiting. Usually he takes food three times a day.
• Habits- patient does not have the habit of drinking or smoking.
• Other complaints- patient has the complaints of pain fatigue, loss of
appetite, dizziness, difficulty in urination, etc...
2. Psycho- socio cultural
• Anxious about his condition
• Depressive mood
• Patient is a retired teacher and he is Christian by religion.
• Studied up to BA
• Married and has 4 children(2sons and 2 daughters)
• Congenial home environment and good relationship with wife and
children
• Is active in the social activities at his native place and also actively
involves in the religious activities too.
• Good and congenial relationship with the neighbors
• Has some good and close friend at his place and he actively interact
with them. They also very supportive to him
• Good social support system is present from the family as well as from
the neighborhood
3. Developmental factors
• Patient confidently says that he had been worked for 32 years as a
teacher and he was a very good teacher for students and was a good
coworker for the friends.
• He told that he could manage the official and house hold activities very
well
• He was very active after the retirement and once he go back also he will
resume the activities
4. Spiritual belief system
• Patient is Christian by religion
• He believes in got and used to go to church and also an active member
in the religious activities.
• He has a personal Bible and he used to read it min of 2 times a day and
also whenever he is worried or tensed he used to pray or read Bible.
• He has a good social support system present which helps him to keep
his mind active.
INTERPERSONAL FACTORS
• has supportive family and friends
• good social interaction with others
• good social support system is present
• active in the agricultural works at home after the retirement
• active in the religious activities.
• Good interpersonal relationship with wife and the children
• Good social adjustment present
EXTRAPERSONAL FACTORS
• All the health care facilities are present at his place
• All communication facilities, travel and transport facilities etc are present
at his own place.
• His house at a village which is not much far from the city and the
facilities are available at the place.
• Financially they are stable and are able to meet the treatment
expenses.
Summary
• Physiological- thin body built pallor of extremities, yellowish
discoloration of the mucus membrane and sclera of eye. Nausea,
vomiting, reduced appetite, reduced urinary out put. Diagnosed to have
periampullary carcinoma.
• Psycho socio cultural factors- patient is anxious abut his condition.
Depressive mood. Not interacting much with others. Good support
system is present.
• Developmental –no developmental abnormalities. Appropriate to the
age.
• Spiritual- patient’s belief system has a positive contribution to his
recovery and adjustment.
CLINICAL FEATURES
• pain abdomen since 4 days
• Discoloration of urine
• Complaints of vomiting
• Fatigue
• Reduced appetite
• on and off fever
• Yellowish discoloration of eye, palms and nails
• Complaints of weight loss
• Edema over the left leg
Investigations Values
Hemoglobin(13- 6.9
19g/dl)
HCT (40-50%) 21.9
WBC (4000-11000 12200
cells/cumm)
Neutrophil (40-75%) 77.2
Lymphocyte (25-45%) 10.5
Monocyte (2-10%) 4.5
Eosinophil (0-10%) 2.6
Basophil (0-2%) .2
Platelet (150000- 345000
400000 cells/cumm)
ESR (0-10mm/hr) 86
RBS (60-150 mg/dl) 148
Pus C/S _
USG USG shows mild diffuse cell growth at the Ampulla of Vater
which suggests peri ampullary carcinoma of Grade I with
out metastasis and gross spread.
Urea (8-35mg/dl) 28
Creatinine (0.6-1.6 1.8
mg/dl)
Sodium (130-143 136
mEq/L)
Potassium (3.5-5 4
mEq/L)
PT (patient)(11.4-15.6 12.3
sec)
APTT- patient (24- 26.4
32.4 sec)
Blood group A+
HIV Negative
HCV Negative
HBsAg Negative
Urine Protein Negative
(negative)
Urine WBC (0-5 Nil
cells/hpf)
RBC (nil ) Nil

Initial Treatment Post operative period (immediate


post op)

• Inj Pethedine 1mg


SOS
• Inj Phenargan SOS
Patient got admitted to ---- • Inj Pantodac 40 mg
Medical college for 3 days and IV OD
the symptoms not relieved. So • Inj Clexane 0.3 ml
they asked for discharge and S/C OD
came to ---this hospital. There • Inj Vorth P 40 mg
he was treated with: IM Q12H
• Inj Tramazac IV SOS
• IV fluids – DNS
• Inj calcium
Gluconate 10 ml over
Treatment at this hospital...
10 min
Pre operative period
• IV fluids – DNS
• Tab Clovipas 75 mg 0-1-0
• Tab Monotrate 1-0-1 Late post op period after 3
• Tab Metalor XL 1-0-0
days of surgery)
• Inj H Insulin S/C 6-0-6U • Inj H Insulin S/C 6-0-6U
• Inj Tramazac 50 mg IV Q8H • Tab Pantodac 40 mg 1-0-0
• Inj Emset 4 mg Q8H • Cap beneficiale 0-1-0
• Tab Pantodac 40 mg 1-0-0
• Tab Clovipas 75 mg 0-1-0
• Cap beneficiale 0-1-0
• Tab Monotrate 1-0-1
• Syp Aristozyme 1-1-1
• Tab Metalor XL 1-0-0
• K bind I sachet TID
Surgical management
Other instructions
Patient underwent Whipple’s
procedure (pancreato • Incentive spirometry
duodenectomy)
• Steam inhalation

• Eearly ambulation

• Diabetic diet

NURSING PROCESS
I. NURSING DIAGNOSIS
Acute pain related to the presence of surgical wound on abdomen
secondary to periampullary carcinoma
Desired Outcome/goal : Patient will get relief from pain as evidenced by a
reduction in the pain scale score and verbalization.

Nursing Actions
Primary secondary Tertiary
Prevention Prevention Prevention
• Assess severity • Teach the • educate the
of pain by using patient about client about the
a pain scale the relaxation importance of
techniques and cleanliness and
• Check the
make him to do encourage him
surgical site for
it to maintain
any signs of • Encourage the good personal
infection or patient to divert hygiene.
complications his mind from
• Involve the
pain and to
• Support the family members
engage in
areas with extra in the care of
pleasurable
pillow to allow patient
activities like
the normal
taking with • Encourage
alignment and
others relatives to be
to prevent
with the client
strain • Do not allow
in order provide
the patient to
• Handle the area a psychological
do strenuous
gently. Avoid well being to
activities. And
unnecessary patient .
explain to the
handling as this
patient why • Educate the
will affect the
those activities family members
healing process
are about the pain
• lean the area contraindicated management
around the . measures.
incision and do
• Involve the • Provide the
surgical
patient in primary and
dressing at the
making secondary
site of incision
decisions about preventive
to prevent any
his own care measures to
form of
and provide a the client
infections
positive whenever
• Provide non- psychological necessary.
pharmacologica support
l measures for
• Provide the
pain relief such
primary
as diversional
preventive care
activity which
when ever
diverts the
necessary.
patients mind.
• Administer the
pain
medications as
per the
prescription by
the pain clinics
to relieve the
severity of pain.
• Keep the
patients body
clean in order
to avoid
infection

Evaluation – patient verbalized that the pain got reduced and the pain scale
score also was zero. His facial expression also reveals that he got relief from
pain.
II. NURSING DIAGNOSIS
Activity intolerance related to fatigue secondary to pain at the surgery
site, and dietary restrictions
Outcome/ goals: Client will develop appropriate levels of activity free from
excess fatigue, as evidenced by normal vital signs & verbalized understanding of
the benefits of gradual increase in activity & exercise.

Nursing actions
Secondary
Primary prevention Tertiary prevention
prevention
• Adequately • Instruct • Encourage
oxygenate the the client the client to
client to avoid do the
• Instruct the the mobility
client to activities exercises
avoid the which • Tell the
activities causes family
which causes extreme members to
extreme fatigue. provide
fatigue • Advice the nutritious
• Provide the client to diet in a
necessary perform frequent
articles near exercises intervals
the patients to • Teach the
bed side. strengthen patient and
the the family
• Assist the extremitie
patient in about the
s& importance
early promote
ambulation of
activities psychologica
• Monitor • Tell the l well being
client’s client to in recovery.
response to avoid the
the activities • Provide the
activities primary and
in order to such as
reduce secondary
straining level care if
discomforts. at stool etc necessary.
• Provide • Teach the
nutritious client
diet to the about the
client. importanc
• Avoid e of early
psychological ambulatio
distress to the n and
client. Tell assist the
the family patient in
members to early
be with him. ambulatio
n
• Schedule rest
periods • Teach the
because it mobility
helps to exercises
alleviate appropria
fatigue te for the
patient to
improve
the
circulation
Evaluation – patient verbalized that his activity level improved. He is able to do
some of his activities with assistance. Fatigue relieved and patient looks much
more active and interactive.
NURSING DIAGNOSIS-III
Impaired physical mobility related to presence of dressing, pain at the
site of surgical incision
Outcomes/goals: Patient will have improved physical mobility as evidenced by
walking with minimum support and doing the activities in limit.

Nursing actions
Primary Secondary
Tertiary prevention
prevention prevention
• Provide • Provide • Educate
active and positive and
passive reinforcem reeducate
exercises ent for the client
to all the even a
and family
extremitie small
s to improvem about the
improve ent to patients
the muscle increase care and
tone and the recovery
strength. frequency • Support the
• of the
Make the patient, and
patient to desired
family
perform activity.
towards the
the • Teach the attainment
breathing mobility
of the goals
exercises exercises
which will appropriat • Coordinate
strengthen e for the the care
the patient to activities
respirator improve with the
y muscle. the family
• Massage circulation members
the upper and to
and other
and lower prevent
contractur disciplines
extremitie like
s which es
physiothera
help to • Mobilize
py.
improve the patient
the and • Teach the
circulation encourage importance
. him to do of
• Provide so psychologic
articles whenever al well
possible being which
near to the influence
• Motivate
patient indirectly
the client
and
to involve the physical
encourage
in his own recovery
doing
care
activities
activities • Provide
within primary
limits • Provide preventive
which primary
measures
promote a preventive
measures whenever
feeling of
well being. whenever necessary
necessary
CONCLUSION
The Neuman’s system model when applied in nursing practice helped in
identifying the interpersonal, intrapersonal and extra personal stressors
AM from various aspects. This was helpful to provide care in a comprehensive
manner. The application of this theory revealed how well the primary, secondary
and tertiary prevention interventions could be used for solving the problems in
the client.
REFERENCES

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