With concerns of our day to day living we do not have enough time and budget to be choosy of the type of food or the nutritional value of it, what we think of nowadays is just to have something to satisfy our hunger without considering the nutrients that our body needs each day. When we hear diet nowadays often we see it as losing weight by means of controlling food intake, but the truth is diet could also mean eating nutritious foods to supplement our body’s needs of nutrients and the type of foods that we are going to consume.
As statistics report show that in the United States as many as 20% of hospitalized patients are hypokalemic; however, hypokalemia is clinically significant in only about 4-5% of these patients. Severe hypokalemia is relatively uncommon. Up to 14% of outpatients who undergo laboratory testing are found to be mildly hypokalemic .Approximately 80% of patients who are receiving diuretics become hypokalemic. Sex Incidence is equal in males and females.
The researcher chose hypokalemia as a topic for a case study in acute adult diseases for the reason that hypokalemia is a fatal disease that is often neglected by the people in the sense that people does not know what the disease is all about. The researcher believes that through studying the whole course of illness, insights and new information can be obtained in dealing with hypokalemia which could help students, nurses and any researcher who would endeavor in the study of hypokalemia
The researcher aimed to utilize Neuman Systems Model in a client with hypokalemia.
This theory holistically developed to meet or complement for the client’s needs the researcher wants to verify and to validate the theory by using it on an acute condition called hypokalemia. The unique focus of the Neuman Systems Model is the wellness of the client/client system in relation to environmental stress and reactions to stress (Fawcett,1995).
In relation to its wholistic approach According to the Neuman Systems Model and systemic perspective in general, health and wellness is defined as the coordination or the degree of system stability, that is, the condition in which all parts and subparts (variables) are in balance or harmony with the whole of the client/client system (Neuman,2002)
Betty Neuman’s Systems Model is based on concepts related to stress and reaction to stress. The Neuman Systems Model includes the physiological, psychological, sociocultural, developmental, and spiritual variables at all levels of the system (Neuman, 2002). The physiological variable deals with mental relationships and processes. The sociocultural variable deals with those functions of the system that involve social and cultural interactions and expectations. The developmental variable deals with developmental processes and needs that vary as the system matures. The spiritual variable deals with the system’s beliefs and their influence and is, according to Neuman, the least understood despite its importance (Frisch, 2006).
Basic Structure consists of common client survival factors, as well as unique individual characteristics. It represents the basic system energy resources (Neuman, 2002). Client/client system a composite of variables (physiological, psychological, sociocultural, developmental, and spiritual), each of which is a subpart of all parts, forms the whole of the client. The client as a system is composed of a core or basic structure of survival factors and surrounding protective concentric rings.
The concentric rings are composed of similar factors, yet serve varied and different purposes in either retention, attainment, or maintenance of system stability and integrity or combination of these. The client is considered an open system in total interface with the environment. The client is viewed as a system, and the term can used interchangeably with the client/client system (Neuman, 2002). Content the variables of a person in interaction with the internal and external environment comprise the whole client system (Neuman, 2002)
Degree of reaction the degree of reaction is the amount of system instability resulting from stressor invasion of the normal lines of defense. Environment is defined as “all factors affecting and affected by the system” and is “all internal and external factors or influences surrounding the identified client or client system”. Neuman has identified three relevant environments. The internal environment “ consists of all forces or interactive influences internal to or contained solely within the boundaries of the defined client/client system”. The external environment “ consists of all forces or interactive influences external to or existing outside the defined client/client system” and is interpersonal and extrapersonal in nature(Neuman, 2002). Feedback the process within which matter, energy, and information, as system output, provide feedback for corrective action to change, enhance or stabilize the system.
Flexible lines of defense is a protective buffer for the client’s normal or a stable state. Ideally, it prevents invasion of stressors and keeps the client system free from stressor reactions or symptomatology (Fawcett, 1995). Goal the system goal is stability for the purpose of client survival and optimal wellness. Health a continuum of wellness to illness, dynamic in nature, that is constantly subject to change. Optimal wellness or stability indicates that total system needs are being met. A reduced state of wellness is the result of unmet needs. The client is in a dynamic state either wellness or illness, in varying degrees, at any point in time. Input/Output the matter, energy, and information exchanged between client and environment that is entering or leaving the system at any point in time. Lines of resistance contain certain known and unknown internal and external resource factors that support the client’s basic structure and normal defense line thus protecting system integrity.
An example is the body’s mobilization of white blood cells or activation of immune system mechanisms. Effectiveness of the lines of resistance in reversing the reaction to stressors allows the system to reconstitute; ineffectiveness leads to energy depletion (Neuman, 2002). Normal line of defense is the solid boundary line that encircles the broken internal lines of resistance. This line represents what the client has become, the state to which the client has evolved over time, or the usual wellness level. The normal defense line is a standard against any deviancy from the usual wellness state can be determined (Neuman, 2002). Prevention as intervention typology or modes for nursing action and determinants for entry of both client and nurse into the health care system. Primary prevention: before a reaction to stressors occurs. Secondary prevention: treatment of symptoms following a reaction to stressors Tertiary prevention: maintenance of optimal wellness following treatment.
Reconstitution represents the return and maintenance of system stability, following treatment of stressor reaction, which may result in higher or lower level of wellness than previously. Stability a state of balance or 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 are environmental factors, intra-, inter-, extrapersonal factor in nature that have potential for disrupting system stability. A stress is any phenomenon that might penetrate both the flexible and normal lines of defense, resulting in either positive or negative outcome (Neuman, 2002).
Intrapersonal stressors are within the internal environment of the client/client system and include such forces as conditioned and autoimmune responses. Interpersonal stressors are in the external environment. They occur at the boundary between the client/client system and the proximal external environment an include such forces as role expectations and communication patterns. Extrapersonal stressors also are in the external environment. They occur at the boundary of the client/client system and the distal external environment and include such forces as financial concerns or social policies (Fawcett, 1995).
Wellness/Illness wellness is the condition in which all system parts and subparts are in harmony with the whole system of the client. Wholeness is based on interrelationships of variables, which determine the amount of resistance an individual has to any stressor. Illness indicates disharmony among the parts and subparts of the client system. Wholistic a system is considered wholistic when any parts or subparts can be organized into an interrelating whole. Wholistic organization is one of keeping parts whole or stable in their intimate relationships; individuals are viewed as wholes whose component parts are in dynamic interdependent interaction.
The researcher in this study utilized the case study method. The case study design involves an intensive exploration of a single unit of study, such as a person, very small number of subjects, family, group, community, or institution ( Burns & Grove, 2003).
The study was conducted in Cebu City Medical Center located at N. Bacalso Avenue,Cebu City. Cebu City Medical Center (CCMC) is a 300 bed capacity government hospital that caters all residents of Cebu City. The client was admitted at the stroke ward, third floor which accommodates clients with physical complaints, classified under Internal Medicine (IM) as cardiovascular problems. It is a 10 bed capacity ward which caters patients admitted with cardiovascular problems.
The researcher utilized Gordons functional health pattern as a research instrument which is categorized in 11 domains namely health perception management pattern which explains of what the client perceives in her condition, nutritional-metabolic pattern explains for the diet of the client and regarding food groups and the number of servings per day, elimination pattern pertains to urinary and bowel patterns, exercise- activity pattern points out to the activities of daily living of the client which also includes exercise, sleep-rest pattern defines the number of hours the client sleeps or on what time of the day the client takes his rest/ either its continuous or disturbed, cognitive perceptual pattern refers to the level of cognitive maturation of the client, self-perception pattern means on how the client perceives or sees herself, role-relationship pattern explains the role of the client in her family and society, sexuality-sexual functioning this domain explains if the client is sexually active or not and the number and age gap of the children the client has, coping-stress management pattern means on how the client would react to stress and what would the client do to resolve it , and values-belief system identifies the belief or religion of the client and their religious practices.
A transmittal letter was sent to the chief nurse of cebu city medical center. The researcher chose a client which had an acute condition to be interviewed, prior to the interview the researcher explained to the client the purpose and the goals of the interview, wherein the client agreed with her full consent and understanding. The researcher conducted a chart review of the client followed by doing a physical assessment and did an interview utilizing Gordon’s Health pattern tool.
This chapter presents an appraisal utilizing the Neuman Systems Model in assessing and dealing with clients with hypokalemia. Situational Appraisal
The client is a 38-year old female, which currently resides at baranggay ylaya talamban Cebu City. She was born on march 10, 1975, she is a Roman Catholic by faith and is the youngest amongst two daughters of the second family her father had, and is now an orphan and a widow. She perceives her current condition as a payment for her sins, the client’s sister said that the client had times where she had epilepsy and sometimes with seizures but it disappeared later in time .She is currently unemployed and only works as an extra even though she had an unstable source of income she still managed to eat 3 times daily but with limitation of food intake vegetable is the main food source that they can afford and is only in a single food group drinks water depending on her needs or if she is thirsty.
Elimination pattern is on a daily basis or depending upon the urge. Her daily activity includes waking up, sleeping, and goes to work which is considered as sedentary. Sleep and rest patterns are altered she sleeps 6-9 hours daily but is interrupted she wakes up at night and has difficulties in falling back to sleep. The client was a third year high school level but it was not a hindrance to her to find a job. The client views herself as helpless and hopeless at some times due to her illness. She was the youngest daughter she sought all the attention of her parents but she did not rely on them she worked hard to be employed and she found a job as a factory worker her elder sister was had a child and which she also loved as her own, and later was married.
She was married but never had a child but she acted as a mother to her sister’s son, in her current state she has no partner in life and is not sexually active for her living a single life free of obligations is fine, following by the loss of both her parents she was on depressed and drowned herself in her work just to get over following her loss, it was also aggravated when her husband died in an accident which she had the hard time to accept and was depressed which made her let go of her job, the most depressed moment of her life where she resorted to the use of prohibited drugs happened when her nephew died it was the most painful loss for her because she treated her nephew as her own son. The only family member that is left with her is her elder sister all of her siblings on her father’s first family is not close to them. The client believed that her present condition is a punishment to her since she forgot her obligations in the church and thought being a creditor is a sin and she is paying for it.
Physiological loss of system stability demonstrated in muscle weakness as seen in difficulty in breathing and inability to ambulate
Psychological loss of system stability demonstrated in feelings of uselessness and helplessness
Sociocultural loss of system stability seen in lack of financial support upon hospitalization and relative support
Developmental loss of system stability seen in unemployment, dependence, and a decrease in competency in current age bracket.
Spiritual loss of system stability in feelings of uselessness
The first is deficient intake. Poor potassium intake alone is an uncommon cause of hypokalemia but occasionally can be seen in very elderly individuals unable to cook for themselves or unable to chew or swallow well. Over time, such individuals can accumulate a significant potassium deficit. Another clinical situation where hypokalemia may occur due to poor intake is in patients receiving total parenteral nutrition (TPN), where potassium supplementation may be inadequate for a prolonged period of time. The second is increased excretion. Increased excretion of potassium, especially coupled with poor intake, is the most common cause of hypokalemia. The most common mechanisms leading to increased renal potassium losses include enhanced sodium delivery to the collecting duct, as with diuretics; mineralocorticoid excess, as with primary or secondary hyperaldosteronism; or increased urine flow, as with an osmotic diuresis.
Gastrointestinal losses, most commonly from diarrhea, also are common causes of hypokalemia. Vomiting is a common cause of hypokalemia, but the pathogenesis of the hypokalemia is complex. Gastric fluid itself contains little potassium, approximately 10 mEq/L. However, vomiting produces volume depletion and metabolic alkalosis. These 2 processes are accompanied by increased renal potassium excretion. Volume depletion leads to secondary hyperaldosteronism, which, in turn, leads to enhanced cortical collecting tubule secretion of potassium in response to enhanced sodium reabsorption. Metabolic alkalosis also increases collecting tubule potassium secretion due to the decreased availability of hydrogen ions for secretion in response to sodium reabsorption. The third is due to a shift from extracellular to intracellular space.
This pathogenetic mechanism also often accompanies increased excretion, leading to a potentiation of the hypokalemic effect of excessive loss. Intracellular shifts of potassium often are episodic and frequently are self-limited, for example, with acute insulin therapy for hyperglycemia. Regardless of the cause, hypokalemia produces similar signs and symptoms. Because potassium is overwhelmingly an intracellular cation and because a variety of factors can regulate the actual serum potassium concentration, an individual can incur very substantial potassium losses without exhibiting frank hypokalemia. Conversely, hypokalemia does not always reflect a true deficit in total body potassium stores.
Variance from wellness| Nursing intervention| Reconstitution| Weak extremitiesSubjective cues: “dili nako malihok ako mga tiil” as verbalized by the client.Objective cues: * Client lying on bed * Foot plantar flexed. * Weak muscle strength and low muscle tone on extremities.Difficulty in breathingSubjective cues: “ usahay mag lisod ko ug ginhawa” as verbalized by the clientObjective cues: * Enlarged chest cavity. * Use of accessory muscles in breathing * Fast deep breaths * Presence of nasal prongs at the bedside.Risks for muscle atrophy and foot droppingSubjective cues: mura ug ning gamay akong mga bati-is” as verbalized by the client.Objective cues: * Client is lying on bed * Foot plantar flexed * Immobility of the lower extremities
* No presence of foot board * No ROM exercises done.| * Promote ROM exercises to prevent muscle atrophy on the affected limb * Provide foot board to support the foot and avoid plantarflexion which causes foot drop. * Encourage the client to eat a balanced diet paired with bananas for potassium replacement * Administer medications as prescribed * Monitor the client for any complications * Position the client on semi-fowlers position. * Instruct client to do abdominal breathing or pursed lip breathing. * Monitor for signs of hypoxia
* Administer oxygen prn as prescribed. * Promote ROM exercises. * Provide foot board. * Encourage the S.O. to do sponge bathing to promote circulation. * Encourage the client to move the and exercise the toes of the feet.| Goal: demonstrated techniques and lifestyle changes to meet physiologic needs.Reconstitution: lines of resistance building.Goal: promoted techniques and exercises to meet physiologic needsReconstitution: lines of resistance buildingGoal: promoted techniques and exercises to prevent the occurrence of physiologic problemsReconstitution: lines of resistance building and strengthening the flexible lines of defense.
Response of the client on the Interventions Provided
The client was able to see through herself on identifying and prioritizing the problems through based on her judgment and of the researcher’s appraisal of her identified stressor the client was able to recuperate in the treatment, the client was able to come up with solutions on the problems that were most attainable and most important to her which is attaining the optimum level of functioning. The client was able to gain a boosted self-esteem and a positive outlook in life, reconstitution of her lines of defense and strengthening each lines is in progress, through positive feedback the client was able to see through it all that the physiological body is not just the only factor in healing but it should comprise the mind, the spirit, the society, and development to achieve a wholistic and faster recovery from illness.
The Neuman Systems Model was effective, efficient in providing a wholistic nursing care to the client with hypokalemia. The assessment made was thorough and was based on the what the client and the care provider perceives thereby giving a collaborative and specific hint as to what the problem is wherein effective solutions can be brought up. Though the system is quite complicated and challenging at some times, it just needs practice in implementing the model to be able to familiarize it.
The research concluded that the Neuman Systems Model is an effective tool which can enhance the nurses critical and analytical thinking by the data gathered based on the client’s initial response and the nurses judgment thereby minimizing the occurrence of an error in identifying problems and providing nursing care.
Based on the findings, observations and the conclusion utilizing the Neuman Systems Model is effective and wholistic enough in the approach of a client with hypokalemia. The following are the researchers suggestions and recommendations
nurse practitioners should do a thorough assessment on their clients not only by identifying the main problems but also by assessing the person as a whole it could be done through the use of the Neuman Systems assessment and evaluation tool.
Interventions differ from client to client others may vary but there is no such thing as a uniformed intervention thereby it is necessary for the nurse to assess for the needs of the client.
Burns and Grove (2003) Understanding Nursing research 3rd edition W. B. Saunders,
Fawcett, Jacqueline (1995) Analysis and Evaluation of Conceptual Models of Nursing 3rd ed. F.A. Davis Company
Frisch N., Frisch L. (2006) Psychiatric Mental Health Nursing 3rd ed. Thomson Delmar Learning Company
Karch, Amy (2008) Lippincotts Nursing Drug Guide: Wolters Kluwer Lippincott Williams & Wilkins Company
Medical-Surgical Nursing Made Incredible Easy (2004). Lippincott Williams & Wilkins Company Springhouse
Neuman, Betty and Fawcett, Jacqueline 2002 The Neuman Systems Model 4th edition Prentice Hall Company
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