Nursing cannot exist without theory, and the concepts that define those principles. Every intervention a nurse organizes is based off of theory, and revolves directly around the patient. The current practice used as a Registered Nurse in the emergency room setting is similar, but less complicated than that of an Advanced Practice Nurse Practitioner.
Emergency room nurses firstly ask the patient what their chief complaint is upon arrival. The chief complaint labels the patient, and gives them a triage level based on the amount of resources needed to intervene. The chief complaint (or illness) is the nurse’s focus of his/her practice. The nurse also takes into consideration the need to educate the patient and his or her own readiness to learn. All of these factors help reach the goal of making the patient “feel” better and regain health. Below is a model of how nurses in the emergency room revolve directly around the patient. Figure 1.1: Emergency Room Registered Nurse Conceptual Framework Making the decision to use this framework of nursing and theory helps organize the nurse and prioritize his/her actions. Without knowing the chief complaint, the nurse cannot treat. Furthermore, the nurse must ask the patient the reasoning for his visit in the emergency room today. Often, patients have many symptoms regarding their illness; nurses must prioritize which symptoms are most concerning, and ask the patient what his bothering him/her the most (i.e. headache versus shortness of breath). After learning what the patient has arrived for, the nurse must start gathering data that relates to the patient’s chief complaint. For example, if the patient presents with shortness of breath, it is important to gather data such as: oxygen saturation, respiratory rate and effort, lung auscultation, presence of cough, and observing patient color. In addition to objective data, it is important to gather subjective data.
This type of data includes: patient symptoms, health history, and social history (such as smoking). Next, the nurse will implement her plan of care and intervene by: providing supplemental oxygen, if needed, elevate head of bed, and encourage the patient to breathe slowly if breathing appears to be labored or fast. After each intervention, the nurse must reassess the patient to see if his/her interventions worked; if not, the plan of care must be changed to improve patient status. Subsequently, the nurse must take into account the need to educate the patient and his/her ability and readiness to learn. If a patient is not ready to learn, it makes it difficult to for the nurse to teach and help reach the overall goal of restoring health. This cycle continues each time the patient gets ill; the nurse always forms her plan of care around the patient. For example, if a patient is mentally handicapped, the nurse might direct her education towards the patient’s caregiver to ensure the patient has the greatest success of reaching health. This conceptual framework is applicable to emergency room nurses’ practice because it is a constant cycle, organized, direct, and patient-focused. In the emergency room setting, it is vital that nurses are able to prioritize and organize symptoms and data. If a nurse forgets to obtain an oxygen saturation (in the data section), this can be life-threatening to the shortness of breath patient!
Furthermore, nursing interventions are always tailored around the initial chief complaint and data gathered. It is a cycle that starts over each time a patient presents with an illness. Even though this framework is frequently utilized, there are many areas in which it could improve. What about a patient’s environment, social stability, and body’s response to the illness? In addition, there are no interrelationships noted on this model. There are many ways this framework could improve, be more in depth, and help reach goals by learning about other nursing theories and theorists. Nursing theorist Myra Estrin Levine goes into great depth on the relationships between nurse and patient, and the holistic view on healthcare. Levine had many roles as a nurse and was well educated; additionally, her views on nursing are broad and theoretical. Levine defined “three major concepts of the Conservation Model,” including: “(1) wholeness, (2) adaptation, and (3) conservation” (Alligood & Tomey, 2010, p. 227). The current model shown in Figure 1.1 does not take into account the patient as a whole; it only takes into account particular parts of the patient and current complaints/ailments. The current theory used by emergency room nurses (as explained above) could be greatly improved by understanding Levine’s major concepts, and how much environment alone can influence patients.
This portion of the metaparadigm is defined as an “organismic response;” something nurses learn in anatomy and physiology classes, but often is forgotten when they begin practicing (Alligood & Tomey, 2010, p. 228). This type of response is our autonomic nervous system telling the body to have a “fight or flight” response. This fight or flight response to stress, illnesses, and a patient’s consciousness of what is happening around him/her can induce this response. Fight or flight can increase or decrease one’s heart rate, blood pressure, anxiety, and/or stress. This response is different in all persons, and can vary greatly depending on a person’s previous experiences and if they feel a “threat actually exists” (Alligood & Tomey, 2010, p. 228). Other than the holistic approach to healthcare, Levine understood the importance of a nurse and patient relationship. Whether or not nurses and patients realize it, they are constantly utilizing Levine’s conservation models. When taking care of several patients, nurses need to conserve on energy so that they do not get tired quickly. Often, things such as IV trays or kits are used to make it easier for nurses to conserve on energy (walk less) and complete tasks efficiently. In addition, when patients are sick, they must conserve on energy and rest so that the human body can fight off an illness. Conservations like this and of many different types are needed for both the nurse and patient. The conservation of structural integrity and personal integrity are utilized within each nurse and patient interaction. When a patient has a massive head trauma, for example, the nurse must keep his/her own personal integrity to protect the patient from increasing his/her own anxiety/stress; which would utilize more energy in the patient and decrease the body’s ability to heal.
The nurse might be overcome with feelings when seeing a large amount of blood, but realizes that he/she must be well-informed of his/her non-verbal cues towards the patient. Personal integrity also includes the nurse putting importance on patient requests such as: do not resuscitate, HIPPA compliance, patient privacy, and educating the patient on procedures and interventions that are being done. With the head trauma patient, the nurse can maintain structural integrity by holding pressure on the wound to prevent further blood loss. This type of nursing intervention can be life-saving, and prevent the patient from further deterioration. Conservation of energy, structural integrity, and personal integrity are crucial in all nursing interactions. Furthermore, it is the nurse’s responsibility to take into account and conserve social integrity as well. Society thrives on social well-being; additionally, Levine concluded that “health is socially determined” (Alligood & Tomey, 2010, p. 229). When the nurse educates the patient in a fashion that makes the patient regain independence, this makes the patient increase personal integrity and become socially accepted in that he/she is regaining health. In society, people tend to define others by their illnesses. Whether it is cancer, obesity, limb amputation, or pregnancy, society will judge a person based on those health issues; moreover, the person will then be socially accepted or rejected. Part of the profession of a nurse is to help guide a patient’s family members and friends on how to perceive and react to that patient and his/her illness (youtube.com, 2011). Furthermore, it is important that the nurse improves a patient’s social integrity while in the hospital setting by proving social media and communication tools such as: magazines, television, newspapers, or telephone (University of the Philippines Open University [UPOU], 2011). This can help improve a patient’s self-esteem, and decrease the stress illnesses can create. Understanding the nurse-patient relationship and conservation models helps the nurse and patient succeed in regaining health within a patient. Simple models such as Figure 1.1 do not include the personal feelings of a patient or nurse, and how that can affect the overall result of a patient’s health/illness.
Figure 1.2: Primary care nursing that utilizes Levine’s concepts of Conservation Model (Alligood and Tomey, 2010, p. 227)
Levine’s conservation model explains what the primary care nurse has to take into account when assessing a patient (Fig 1.2). The nurse must base her care and decisions on the patient and his/her family. Figure 1.2 also helps explain the connection of a model to nursing metaparadigm; the well-being, person as a whole, education, and nursing aspects. In addition, seeing the patient as a “whole” helps the primary care nurse remember to look at the patient’s overall health. This comprehensive assessment includes: clinical problems (body), psychological aspects (mind), and spiritual beliefs that may affect the plan of care. The interrelationships between wholeness, adaptation, and environment helps primary care nurses understand the bigger picture and how the advanced practice nurse can increase the outcome for the patient. “Adaptation” describes the patient’s variables that can affect the patient as a whole, or be affected by his/her environment. For example, a patient may increase in age, quit smoking, or increase in weight; these variables and/or variations in a patient can greatly change the patient and/or treatments and interventions. A patient’s environment must be understood “both internally and externally” by the medical team (Alligood & Tomey, 2010, p. 227). Again, this deals with the patient as a whole and is comparable to adaptation and a holistic plan of care. Knowing the environment that the patient resides in can affect his or her own health. If the patient doesn’t understand the notion that he/she is terminally ill, it may be difficult to explain the importance of a hospice program to the patient.
Figure 1.3: Levine’s “Conservation Principles” and their interrelationships within a nurse and client connection (Alligood & Tomey, 2010, p. 229).
Levine also understood the nurse-patient relationship and how that can affect many areas within the ill-or-well patient. In this relationship, it is learned that nurses and patients often want to keep their integrity during any interaction. For example, a patient’s mother named Sarah brings her three-year-old daughter Claire in to the emergency room because Claire had a seizure at home. The patient is no longer having a seizure, and has been diagnosed with seizures over 1 year ago. Claire has a prescription for anti-seizure medicine, but her mother does not feel comfortable administering the medication; instead, Sarah brings Claire directly to the emergency room with each seizure occurrence. Now, Sarah is attempting to keep her own integrity by not having to administer anti-seizure medications in her daughter’s rectum in such a high stress situation. In addition, she wants Claire’s condition to be controlled in order for her to be accepted within the community. On the other hand, the primary care nurse practitioner must keep her personal integrity by not getting upset each time this patient visits the emergency room. It is the professional’s responsibility to re-educate Sarah on the plan of care, or tailor it towards the individual and family. This would be an opportune time to discuss other options for anti-seizure medicines, education on how to administer the current medication available, and give a referral to a neurologist. When tailoring the plan of care, Levine’s four conservations come into effect (Fig 1.3). The patient’s energy is utilized with each seizure activity, and possibly structural integrity—due to depletion of oxygenation to the brain and possible neuro deficits. The nurse tries to preserve personal integrity and educate the family of Claire in a way that is skilled and direct so that they may understand the concepts and accept the plan of care. Nursing interventions and education in situations like this can be life-changing, and decrease stress for the patient’s family. It is important to remember that there are always assumptions made to any nursing model, but learning from that model is what is truly essential.
Assumptions made to Levine’s conservation theory are that nursing interventions and implementation of those interventions can affect both the ill and/or well patient. Patients do not need to be ill in order to fit within the guidelines of conservation. Most patients feel compelled to be accepted, while maintaining personal authenticity (Fawcett, Schaefer, & Moore, 1991). Moreover, the “environment” section of the model in Figure 1.2 can be falsely understood; that patients might only be able to learn in stress-free situations. Sometimes, stressful situation are where patients, families, and nurses learn best! Lastly, it appears that all human beings act in the same manner, and that patients and nurses alike utilize the same processes (UPOU, 2011). This cannot be true because all patients are diverse, and so are all nurses and primary care professionals. “Nursing intervention must be founded not only on scientific knowledge, but specifically on recognition of the individual’s behavioral responses” (Cardwell, 2013). The response to nursing interventions and the “trial and error” processes are absent in the model (explained in Figure 1.2) of advanced practice nursing based on Levine’s theories. Advanced practice nurses are constantly intervening to improve the health and wellness of a patient; however, those interventions are not always successful. Furthermore, the advanced nurse practitioner must modify her plan of care constantly. This type of framework of nursing is more of a cycle than a process. “Holistic nursing is dedicated to the humanizing experience that the nurse can bring to the bedside, certain in her knowledge and skilled in her techniques, but sensitive and responsive to the person she finds there”(Cardwell, 2013). In this phrase, Levine is summarizing the approach and goal of the advanced practice nurse practitioner.
Advancing from the role of a registered nurse, primary care nurse practitioners increase their competence, knowledge, and skills. This increase in knowledge helps nurse practitioners in decision making, treatment options, and educating the patient. The primary function of the nurse practitioner is to educate patients across the lifespan, and help patients maintain health. Prevention is the best intervention. Since nurse practitioners begin their careers as bedside registered nurses, advanced nurse practitioners agree with Levine’s “holistic approach to healthcare” and healing (Fawcett, Schaefer, & Moore, 1991). In conclusion, primary care nurse practitioners can benefit from viewing the patient as a whole, while spending a large amount of time listening and educating the patient. No two patients, medical cases, or plan of care can be exactly the same. Nurse practitioners thrive because they spend time with their patients and getting to know their needs; this helps increase patient success and healing. Nursing theory and the interrelationships between a patient’s conservation of energy, social integrity, structural integrity, and personal integrity are essential to the nurse practitioner. The increase of knowledge in the nurse practitioner helps him/her understand all aspects of the patient, and the most efficient way of approaching those patient needs. Levine once stated, “Confront reality of environment, and maintain well-being” (youtube.com, 2011) It is the purpose of a nurse practitioner to challenge the internal and external factors and environments distressing a patient, while providing resources and education to increase that patient’s health. The cycle and theories between nurses and patients will continue to transform and be challenged; it is the nurse practitioner’s role to put those theories into practice.
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