Case Study Theory

Nursing Theory: Case Study Mike Cowell NSG 403 National University

Case Study

Kim is a 35 year old who was admitted to the oncology unit for evaluation after palpating a lump in her right breast. She also observed dimpling around the nipple, a unusual drainage from the breast and was experiencing moderate pain. A mammography and biopsy were performed and revealed stage III breast cancer. Kim’s right breast tumor is 7 cm, there is fixed lymph node involvement in the axillary and there is no metastasis present . Kim was found to have infiltrating ductal carcinoma of the right breast. Soon after the diagnosis was made Kim underwent a total mastectomy to her right breast. Kim’s past medical history shows that physical examinations by her primary physician were infrequent, and she also denies ever performing self breast examinations. She stated that she only noticed the lump after the other sign and symptoms were observed. She is 5 feet, 8 inches tall and weighs 110 lbs. Her usual weight is around 130 lbs. She has smoked 1 pack of cigarettes a day for 12 years. She is gravida 3, para 3. Her first pregnancy was at age 22, her second at age 25, and her last at age 28. Since her last pregnancy she has been regularly taking oral contraceptives. Kim finished the 10th grade, but dropped out of high school to work. She has been married for 15 years, and currently lives with her husband and three children in her motherin-law’s home. She doesn’t appear to be happy about the living arrangements and states that the house is unsanitary. She is a stay-at-home mother, and her husband is currently unemployed. She describes her husband as emotionally distant and emotionally and physically abusive at times. Kim is stable after surgery and doing well except for being unable to fully empty her urinary bladder. She has 2 JP tubes in place for drainage. She is complaining of constant postoperative pain that she rates as a 7/10 on the numerical pain scale, and is also experiencing nausea and emisis. She is on a clear liquid diet, but cannot keep anything down. When she is discharged home, it will be necessary for her to perform intermittent self-catheterization and also to empty and record her JP drainage. Her current medications are (1) a prophylactic antibiotic

(2) an analgesic PRN for pain and (3)an antiemetic PRN for nausea. In addition to these medications she will be receiving chemotherapy on an outpatient basis. Kim is extremely tearful and upset. She expresses serious concern over her future and the future of her three children. She is upset about her relationship with her husband and the current living arrangements of her family. Kim states that she believes this cancer is a punishment for her past life. King’s Conceptual System and Theory of Goal Attainment Imogene King believed that "the goal of nursing is health: it's promotion, maintenance, and/or restoration; the care of the sick or injured; and the care of the dying" (Khowaja, 2006). She also proposed that the universal concepts of nursing discipline are social systems, health, interpersonal relationships, and perception (Khowaja, 2006). King’s model uses the nursing process, critical thinking, communication, and interaction to achieve patient goals. King's nursing model is composed of two parts: (1)conceptual systems (2)theory of goal attainment. The conceptual system is "based on the assumption that human beings are the focus of nursing" (Alligood & Tomey, 2006, p.183). King proposed three separate systems that define the conceptual system: personal, interpersonal, and social. King believed these systems "demonstrate the interactions of human beings in their social world" (King, 2007). In the conceptual model the personal, interpersonal, and social systems “should operate as a whole to achieve maximum benefit for the patient. When all members of the conceptual systems communicate, interact, transact, and

use critical thinking for decision-making, they design an integrated clinical pathway”(Khowaja, 2006). She concluded that “nurses must have the knowledge and skill to observe and interpret behavior and intervene in the behavioral realm to assist individuals and groups cope with health, illness, and crisis (Alligood & Tomey, 2006, p.183). The personal system represents the individual. "Each individual is an open, total, unique system in constant interaction with the environment" (Alligood & Tomey, 2006, p.183). In order to understand the person, the nurse must consider the individuals concepts of perception, self, growth and development, time, and personal space ( Killeen & King, 2007). The nurse must understand perception in order to utilize the nursing process in achievement of goals. “Perception gives meaning to one’s experiences, represents one’s image of reality, and influences one’s behavior” (Killeen & King, 2007). The interpersonal system consist of two or more individuals. King's nursing process occurs in this system between the nurse and patient. “Nursing acts are directed toward health and can be observed as a process of interaction between nurses and patients in specific situations’ (Killeen & King, 2007).Interpersonal concepts important in this system to help understand interactions between the nurse and patient are: communication, interactions, role, stress, stressors, and transaction (Alligood & Tomey, 2006, p.185). The social system is comprised of a large group of individuals with a common goal or interest (Alligood & Tomey, 2006, p. 185). Organization,

authority, power, status, and decision making are concepts useful in understanding interactions within a social system (Alligood & Tomey,2006, p. 185). King’s view was that interactions with social systems impact individuals throughout their entire lives. Examples of social systems are hospital settings, work environments, religious groups ( Alligood & Tomey, 2006, p.185). Critical thinking is an important component of King’s theory. She knew that only when nurses utilized critical thinking would they understand how to care for their patients. “ King explicitly links critical thinking to the mental acts of judgement that are implicit in perception, communication, and interactions that lead to transaction and the concept of decision making” (Alligood & Tomey, 2006, p.188). She believed that critical thinking and actions taken by the nurse have a direct influence on patient outcomes. She noted that it is also important to use critical thinking to monitor patient outcomes, and to prevent negative outcomes from reoccurring. King's theory of goal attainment "addresses nursing as a process of human interaction" (Alligood & Tomey, 2006, 186). “This theory “presents a standard where nurses purposefully interact with patients, mutually establish goals, and agree to means to achieve goals” (Killeen & King, 2007). King believed that this theory utilized the nursing process based on nurse and patient interactions. She theorized that goal attainment can only be achieved through patient and nurse interactions (Khowaja, 2006). "The nurse and patient form an interpersonal system in which each affects the other and in which both are affected by situational factors in the environment" (Alligood & Tomey, 2006, p.186). King's theory of goal attainment, in practice, is a nursing process, or a system of interrelated concepts. King’s nursing process, or goal attainment theory, is as follows: (1) the perception of the nurse and patient (2) communication of nursepatient (3) interaction of nurse-patient (4) decision-making about goals by nurse-patient (5) agreement of means to attain goals (6) transactions made between nurse-patient (7) goals met, and if not, why not (King, 2007).

"Goals cannot be mutually achieved unless the nurse and the patient share their perceptions, feelings, values, and conclusions" (Alligood & Tomey, 2006, p.191). With today's multidisciplinary health care teams, the theory of goal attainment, "facilitates mutual goal-setting with patients based on each member of the team's specific knowledge and functions" (Killeen & King, 2007). Applying King’s Model to Case Study Using King’s conceptual systems and theory of goal attainment in the care of Kim, it is important to first understand the nursing process. The first step in the nursing process would be for the nurse and Kim and meet each other and interact (Alligood & Tomey, 2006, p.189). An assessment is done by observing data about Kim based on pertinent concepts. The nurse would utilize critical thinking to understand Kim’s situation. The nurse would conclude that Kim is fearful and upset about her health, unsure about the future and her prognosis, and unhappy with her marriage relationship. This initial meeting is important to understand what all of this information means to the patients health and for the nurse to come to conclusions about Kim’s situation The second step in the nursing process is to determine and plan goals (Alligood & Tomey, 2006, p.190). In this step it is up to the nurse to use critical thinking to understand what goals are going to benefit Kim. It is important to understand what goals the patient wants to work towards and to understand the ways teamwork can achieve these goals.

The third step in the nursing process is transactions. “Transactions occur as a result of perceiving the other persons and the situation, making judgements about those perceptions, and taking some action in response” (Alligood & Tomey, 2006, p.190). It is important for the nurse to consider if the goals are mutually agreeable between patient and nurse. The nurse must consider and use critical thinking to understand how, why, and when actions are being carried out (Alligood & Tomey, 2006). The fourth step in the nursing process is the theory of goal attainment, or in some cases the revision of goals. In this step, the nurse must decide whether actions taken are helping the patient achieve desired goals. It is important to consider if the nursing actions are working, or not working, and what needs to be changed in order to achieve goals (Alligood & Tomey, 2006, p.190).. The nurse might have to revise goals based on the patients response to nursing actions. It is important to communicate with the patient in order to get feedback and to agree on goals. In terms of the conceptual systems, Kim is and individual in interaction with other systems, and these interactions have an effect on her health and behavior. Kim’s cancer, hospitalization, and outpatient treatment plan have put stress into her life. The nurse and Kim would utilize the nursing process to “interact , communicate, engage in mutual goal setting, and make decisions about the means to achieve goals” (Alligood & Tomey, 2006, p.193). In Kim’s case a goal may be to reduce anxiety and stress associated with her diagnosis.

The interpersonal system is formed between Kim and nurse. “The transactions process begins with perception, judgements, mental actions, and reactions of both individuals” (Alligood & Tomey, 2006, p.193). The nurse would utilize her perceptions of Kim in order to gather and interpret information. Kim’s perceptions are influence by her present situation, her past, and thoughts about the future. Communication with Kim is important in order for the nurse to describe her personal perceptions and to explain what perceptions she has observed in Kim. Once the nurse recognizes and describes perceptions, then communication between Kim and nurse can be open to set and achieve desired goals. “Perceptions form the basis for development of the self” (Alligood & Tomey, 2006, p.194). Kim is tearful and upset. She states she is scared of the future, unhappy with her marriage/ living arrangement, and blames herself for her current diagnosis. Kim is also experiencing pain, nausea, and inability to void. She is experiencing psychological and physical stressors at the same time. The nurse would communicate and work with Kim to explore perceptions and decrease stressors. Other interpersonal systems in occurring in Kim’s life is with her husband. Her husband is emotionally distant and sometimes both emotionally and physically abusive. He is unemployed and their living arrangements are currently undesirable. It is obvious to see that this situation adds stress to Kim’s life and may interfere with her health after discharge from the hospital. “ Coping with personal and interpersonal

stressors is likely to influence both health and illness outcomes” (Alligood & Tomey, 2006, p.194). The nurse and Kim must communicate and work together to find solutions to Kim’s personal and interpersonal stressors. Kim may need outside support from friends or family, or a possible social services consult. King defined communication as “the interchange of thoughts and opinions individuals” (Khowaja, 2006). Communication is key to establish trust between the patient and the multidisciplinary health care team. "The nurse has a responsibility to communicate and interact with the patients to ensure that their thinking is transparent to one another" (Alligood & Tomey, 2006, p.191).King emphasized that the nurse must use critical thinking, observation and collection in order to make decisions that will benefit the needs of the patient. " King's theory provides direction for nursing practice by emphasizing the process of multidisciplinary collaboration, communication, interaction, transaction and use of critical thinking" (Khowaja, 2006). Kim and the nurse needs to establish mutually agreeable goals. In Kim’s case it will be important to control pain and nausea. The nurse will also have to educate Kim in terms of how to self catheterize at home, and to empty and record JP drainage.. Communication will have to be open, and Kim/nurse will have to assess goals based upon the situation. The nurse and Kim must assess her fear/anxiety and understand its relevance in terms of achieving goals. In conclusion, if communication is open and transactions are made

between Kim and nurse, then goals should be achieved. If goals are not achieved then the nurse-patient must re-evaluate the nursing process and goals. In King’s model, it is important to understand the patient’s perceptions and how they relate to their medical situation. However, the nurse must also assess her own perceptions and how they relate to the patients situation. The nurse must also understand how the patients perceptions influence their ability to improve their health. It is up to the nurse to utilize the nursing process, critical thinking, and transactions to improve patient outcomes. Only in utilizing these tools will Kim’s health improve and her stressors decline.

References Alligood, M.R. and Tomey, A.M. (2006). Nursing Theory Utilization & Application. St. Louis: Elsevier, Mosby.Khowaja, K. (2006). Utilization of King's interacting systems framework and theory of goal attainment with new multidisciplinary model: Clinical pathway. Australian Journal of Advanced Nursing, 24(2), 44-50. Retrieved from ProQuest database on April 14, 2009.Killeen, M.B., & King, I.M. (2007). Viewpoint: Use of King's conceptual system, nursing informatics, ans nursing classification systems for global communication. International Journal of Nursing Terminologies and Classifications, 18(2), 51-57. Retrieved from ProQuest database on April 14, 2009.King, I.M. (2007). King's conceptual system, theory of goal attainment, and transaction process in the 21st century. Nursing Science Quarterly, 20(2), 109-116. Retrieved from ProQuest database on April 14, 2009.