Application of Roy's Adaptation Model (RAM)

INTRODUCTION

• Theorist, Sr. Cakkista Roy, was born at Los Angeles on October 14, 1939; earned Bachelor of Arts with a major in nursing from Mount St. Mary's College, Los Angeles in 1963; Master's degree program in pediatric nursing at the University of California ,Los Angeles in 1966; Master’s & PhD in Sociology in 1973 & 1977.
  
• RAM is one of the widely applied nursing models in nursing practice, education and research.
  

TERMS

• System- a set of parts connected to function as a whole for some purpose.
• Stimulus- something that provokes a response, point of interaction for the human system and the environment
• Focal Stimuli- internal or external stimulus immediately affecting the system
• Contextual Stimulus- all other stimulus present in the situation.
• Residual Stimulus- environmental factor, that effects on the situation that are unclear.
• Regulator Subsystem- automatic response to stimulus (neural, chemical, and endocrine)
• Cognator Subsystem- responds through four cognitive responds through four cognitive-emotive channels (perceptual and information processing, learning, judgment, and emotion)
• Behavior- internal or external actions and reactions under specific circumstances
• Physiologic-Physical Mode
  

• Behavior pertaining to the physical aspect of the human system
  
• Physical and chemical processes
  
• Nurse must be knowledgeable about normal processes
  
• 5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)
  

• Self Concept-Group Identity Mode
  
  • The composite of beliefs and feelings held about oneself at a given time. Focus on the psychological and spiritual aspects of the human system.
    
  • Need to know who one is, so that one can exist with a state of unity, meaning, and purposefulness of 2 modes (physical self, and personal self)
    
• Role function Mode
  
  • Set of expectations about how a person occupying one position behaves toward a occupying another position. Basic need-social integrity, the need to know who one is in relation to others
    
• Interdependence Mode
  
  • Behavior pertaining to interdependent relationships of individuals and groups. Focus on the close relationships of people and their purpose.
    
  • Each relationship exists for some reason. Involves the willingness and ability to give to others and accept from others.
    
  • Balance results in feelings of being valued and supported by others. Basic need - feeling of security in relationships
    
• Adaptive Responses- promote the integrity of the human system.
  
• Ineffective Responses- neither promote not contribute to the integrity of the human system
  
• Copping Process- innate or acquired ways innate or of interacting with the changing of environment.
  

Roy's Adaptation Model

Sister Callista Roy (1984), Introduction to Nursing: An Adaptation Model (2nd ed)

ASSUMPTIONS OF ROY’S ADAPTATION MODEL

Scientific

• Systems of matter and energy progress to higher levels of complex self-organization
  
• Consciousness and meaning are constitutive 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 crated in human consciousness
  
• Integration of human and environment meanings results in adaptation
  

Philosophical

• Persons have mutual relationships with the world and God
  
• Human meaning is rooted in an 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
  

METAPARADIGMS

PERSON

• An adaptive system with coping processes
  
• Described as a whole comprised of parts
  
• Functions as a unity for some purpose
  
• Includes people as individuals or in groups (families, organizations, communities, nations, and society as a whole)
  
• An adaptive system with cognator and regulator subsystems acting to maintain adaptation in the four adaptive modes: physiologic-physical, self-concept-group identity, role function, and interdependence.
  

ENVIRONMENT

• All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and earth resources
  
• Three kinds of stimuli: focal, contextual, and residual
  
• Significant stimuli in all human adaptation include stage of development, family, and culture
  

HEALTH AND ADAPTATION

• Health: a state and process of being and becoming integrated and whole that reflects person and environmental mutuality
  
• Adaptation: the process and outcome whereby thinking and feeling persons, as individuals and in groups, use conscious awareness and choice to create human and environmental integration
  
• Adaptive Responses: responses that promotes integrity in terms of the goals of the human system, that is, survival, growth, reproduction, mastery, and personal and environmental transformation
  
• Ineffective Responses: responses that do not contribute to integrity in terms of the goals of the human system
  
• Adaptation levels represent the condition of the life processes described on three different levels: integrated, compensatory, and compromised
  

NURSING

• Nursing is the science and practice that expands adaptive abilities and enhances person and environment transformation
  
• Nursing goals are to promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity
  
• This is done by assessing behavior and factors that influence adaptive abilities and by intervening to expand those abilities and to enhance environmental interactions
  

NURSING PROCESS

A problem solving approach for gathering data, identifying the capacities and needs of the human adaptive system, selecting and implementing approaches for nursing care, and evaluation the outcome of care provided

Assessment of Behavior: the first step of the nursing process which involves gathering data about the behavior of the person as an adaptive system in each of the adaptive modes.

Assessment of Stimuli: the second step of the nursing process which involves the identification of internal and external stimuli that are influencing the person’s adaptive behaviors.

Stimuli are classified as:

1) Focal- those most immediately confronting the person,
2) Contextual-all other stimuli present that are affecting the situation and
3) Residual- those stimuli whose effect on the situation are unclear.

Nursing Diagnosis: step three of the nursing process which involves the formulation of statements that interpret data about the adaptation status of the person, including the behavior and most relevant stimuli

Goal Setting: the forth step of the nursing process which involves the establishment of clear statements of the behavioral outcomes for nursing care.

Intervention: the fifth step of the nursing process which involves the determination of how best to assist the person in attaining the established goals

Evaluation: the sixth and final step of the nursing process which involves judging the effectiveness of the nursing intervention in relation to the behavior after the nursing intervention in comparison with the goal established.

DEMOGRAPHIC DATA

Name Age Sex IP number 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

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.
  
• 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.
  

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 have any work. His role clarity is not achieved.
  

INTERDEPENDENCE MODE:

• He 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
  

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 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.

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

ASSESS. OF BEHAVIOUR	ASSESSMENT OF STIMULI	NURSING DIAGNOSIS	GOAL	INTERVENTION	EVALUATION
Ineffective protection and sense in physical-physiological mode (No pain sensation from the wound site.)	Focal stimuli: Non-healing wound after amputation of great and second toe of left leg- 4 week	1.  Impaired skin integrity related to fragility of the skin secondary to vascular insufficiency	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	-   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.	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
Impaired activity in  physical-physiological mode	Focal stimuli: During hospital stay great and second toe amputated. But surgical wound turned to non- healing with pus and black colour.	2.    Impaired physical mobility related to amputation of the left forefoot and presence of unhealed wound	Long term Objective: Patient will attain maximum possible physical mobility with in 6 months. Short term objective:   i. Correct use of crutches with in 22/4/08 ii.      walking with minimum support-22/4/08 iii.      He will be self motivated in activities- 20/4/08.	-   Assess the level of restriction of movement -   Provide active and passive exercises to all the extremities to improve the muscle tone and strength. -   Make the patient to perform the ROM exercises to lower extremities which will strengthen the muscle. -   Massage the upper and lower extremities which help to improve the circulation. -   Provide articles near to the patient and encourage performing activities within limits which promote a feeling of well being. -   Provide positive reinforcement for even a small improvement to increase the frequency of the desired activity. -   Measures for pain relief should be taken before the activities are initiated as pain can hinder with the activity.	Short term goal: Met: used crutches correctly on 22/4/08. he is self motivated in doing minor excesses Partially Met: walking with minimum support. Long term goal: Unmet: not attained maximum possible physical mobility- Continue plan Reassess goal and interventions
Alteration in Physical self in  Self-concept mode (He is anxious about changes in body image) Change in Role performance mode. (He was the earning member in the family. His role shift is not compensate)	Contextual stimuli: Known case DM for past 10 years and on treatment with insulin for 8 years. Residual stimuli: no special knowledge in health matters	3. Anxiety related to hospital admission and unknown Outcome of the disease and financial constrains.	Long term Objective: The client will remain free from anxiety Short term objective: i.       demonstrating appropriate range effective coping in the treatment ii.     Being able to rest and iii.    Asking fewer questions	-    Allow and encourage the client and family to ask questions. Bring up common concerns. -    Allow the client and family to verbalize anxiety. -    Stress that frequent assessment are routine and do not necessarily imply a deteriorating condition. -    Repeat information as necessary because of the reduced attention span of the client and family -    Provide comfortable quiet environment for the client and family	Short term goal: Met: demonstrated appropriate range effective coping with treatment He is able to rest quietly. Long term goal: Unmet: client not completely remained free from anxiety due to financial constrains- Continue plan Reassess goal and interventions
------	Contextual stimuli: Known case DM for past 10 years and on treatment with insulin for 8 years. Residual stimuli: no special knowledge in health matters	4. deficient knowledge regarding the foot care, wound care, diabetic diet, and need of follow up care.	Long term Objective: Patient will acquire adequate knowledge regarding the t foot care, wound care, diabetic diet, and need of follow up care and practice in their day to day life. Short term objective: i.       Verbalization and demonstration of foot care. ii. Strictly following diabetic diet plan iii.     Demonstration of wound care.	-    Explain the treatment measures to the patient and their benefits in a simple understandable language. -    Explain about the home care. Include the points like care of wounds, nutrition, activity etc. Clear the doubts of the patient as the patient may present with some matters of importance. -    Repeat the information whenever necessary to reinforce learning.	Short term goal: Met: Verbalization and demonstration of foot care. Strictly following diabetic diet plan Unmet: Demonstration of wound care. Long term goal: Unmet: not completely acquired and practiced the required knowledge. Continue plan Reassess goal and interventions

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