April 14, 2005 NURSING THEORY
Why the interest in theory? 1. The no. 1 requisi requisite te if we we have to be be on the level level of being a profes professional sional.. 2. To guide us us in how to go about about the diffe different rent nursing nursing actions actions.. 3. It becom becomes es a frame framewor work k for org organi anizin zing g data. data.
Theory – speculative in nature Nursing Theory – mental conceptualization where the perspective is a nursing aspect - expla explain in & desc descri ribe be a parti particul cular ar nurs nursin ing g actio action n - can also also predic predictt its its eff effect ectss on client clients’ s’ outcome outcome - primar primary y purp purpose ose is to generat generatee scien scientif tific ic know knowled ledge ge - serv servee seve severa rall esse essent ntia iall purpos purposes es 1. Description Description – clarify clarifying ing ideas, phenomena, phenomena, experien experience ce or circumstance circumstancess that are not well well understood. E.g. meaning of pain to patient 2. Exploration Exploration – how ideas ideas are related. related. E.g. relations relationship hip of pain to patient’ patient’ss physiologica physiologicall & psychological conditions 3. Explana Explanatio tion n – the whys whys of of events events & occur occurren rences ces 4. Prediction Prediction & Control Control – knowing knowing & foretel foretelling ling correctly correctly what will will happen & also also how to make it happen. E.g. how to control the severity of the client’s pain Components of a Theory a. Concepts Concepts – basic unit in the the language language of of theoreti theoretical cal thinkin thinking g - can be empirical or concrete (can be observed through the senses) or abstract (not observable) b. Definitions Definitions – statement statementss of the meaning meaning of a word c. Assum Assumpt ptio ions ns – acc accept epted ed fac facts ts d. Phen Phenom omen enaa – rea reali lity ty Types Types of Theories a. Grand Grand Theo Theorie riess – does does not not presc prescrib ribee action actionss - provide structural framework b. Middle Middle Range Theories Theories – more more helpful helpful to to nursing nursing practice practice - narrower focus than grand theory theor y, more precise than grand theories & focus on developing theoretical statements to answer questions about nursing c. Descri Descripti ptive ve Theory Theory – specul speculati ative; ve; predi predicti ctive ve d. Prescripti Prescriptive ve – can anticipate anticipate what what might might be the consequences consequences of nursing nursing actions actions What are included in the nursing paradigm? a. Client/Pati Client/Patient/P ent/Person/ erson/Indivi Individual dual – control control to all nursing nursing models models because it is the the client who is the primary recipient of nursing care b. Health – a continuum continuum ranging ranging from a completel completely y healthy healthy state state where there there is no diseas diseasee to a completely unhealthy state which results to a multifactorial phenomena. - always ask client client what is their their definition definition of health health to guide guide you you to make decisi decisions ons regarding their care c. Environment Environment – from from simple simple physical physical environmen environmentt to include include elements elements such such as living living conditions, public sanitation, air & water quality to factors such as IPR & social interactions, internal environment & factors that affect health (psychological, religious beliefs, etc.) d. Nursing Nursing – nurse-client nurse-client relatio relationship nship,, the client is no longer longer the passive passive recipient recipient of nursing nursing care
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CONCEPTS ON PERSON
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Judeo-Christian View a. Genesis Genesis 1:26-28 1:26-28 – “man is made made in the image image of God; God; man is to increas increasee in number, number, fill the earth and subdue it” b. Colossians Colossians 3:12-17 3:12-17 – “We “We are Gods’ chosen people; people; we have to clothe clothe ourselves ourselves with with compassion, kindness, humility, humility, gentleness & patience; be forgiving & over all these virtues put on love…Whatever we do whether in word or in deed, we do it all in the name of the Lord.” c. Spirit Spiritual ual Virtues irtues of of man/p man/pers erson on c.1. Faith – the unquestioning belief in someone or something or the complete trust & confidence or reliance reliance on places in a person or thing. Example, faith in doctors, hospitals… c.2. Hope – nourishes no urishes faith, its presence or absence often plays a p art in determining the patient’s prognosis, illness, state of well-being & acceptance of dying process c.3. Charity – love for one’s one’s fellowman. It allows one to give up his own pleasures while serving another without even thinking of the sacrifices it entails.
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The The Sci Scien enti tiffic Persp erspec ecttive ive (HC (HC1 1 Han Hando dout utss) a. Biological Biological Being Being – a living organi organism, sm, who from from birth birth is destined destined to die, die, until he he does he has to contend continually with forces forces in his environment. Man responds to the environmental stimuli as a particular unit – be it a solitary cell, a component organism or a member of conglomerate of individuals a.1. Organismic Behavior a.2. Man as a System a.3. The energy-matter exchange of man
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The At Atomistic Ap Approach Man is viewed as an organism composed of different organ systems & each system is composed of organs & each organ is made up of tissue cells. The cell is the basic unit of the human body.
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Holistic Ap Appro proach (T (Total) The study of the total behavior of man in relation to society. society. Stimuli in the environment provide the necessary forces to enable man to demonstrate consciously or unconsciously the nature of his responses & the subsequent quality & relationship with his environment. Address questions like – How How does he cope with stresses? stresses? What makes one fail or succeed?
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Human Needs Model Maslow’s framework of basic needs is based on the theory that something is a basic need if its absence results in illness, its presence prevents illness or signals health, & meeting an unmet need restores health
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Man Man as as a Rati Ration onal al Bein Being g – The The Psy Psych chos osoci ocial al Per Persp spec ecti tive ve Man, the psychosocial being is capable of rational, logical thinking most of the time but can become irrational & illogical when when provoked. His rational side makes him merciful, kind & compassionate, while his irrational nature may make him commit criminal acts against another man. According to Travelbee, Man is “a unique, irreplaceable (cannot b e exchanged for another, even with transplants), a one-time being in this world, when he dies he ceases to exist.
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Theorist’s Concept on Person
1. Rosema Rosemari riee Riz Rizzo zo Pars Parsee – HUMAN BECOMING – influe influenced nced by const constant ant inter interact action ion of human human and ones ones environ environmen mentt – Human being being is is an open open being being in mutual process process with with the universe, universe, co-crea co-creating ting patterns of relating with others, “lives at multidimensional realms of the universe all at once, freely choosing ways of becoming, as meaning is given given to situations. The human being and the universe are inseparable in the creation of the living experience – Co-crea Co-creatin ting g – man and unive univers rsee are aff affect ecting ing each each othe other r – Rhythm Rhythmica icall pattern pattern happe happens ns when when man intera interacts cts with with anoth another er man man – Behavi Behavior or of a perso person n is influ influence enced d by one’ one’s ancest ancestors ors – Man has has a pass passive ive rela relatio tionsh nship ip with with the the envir environme onment nt 2. Flor Floren ence ce Nigh Nighti tinga ngale le – ENVIRONMENTAL THEORY - consid considers ers the environm environment ent as an impo importa rtant nt factor factor - refe referr rred ed to the the per perso son n as as the the patie patient nt - man inher inherent ently ly has has the capaci capacity ty to heal heal itsel itself, f, given given the righ rightt environ environmen mentt - for most most part, part, the the descri descripti ptions ons desc describ ribee a passiv passivee patien patientt 3. Virgi irgini niaa Hen Hende ders rson on - DEFINITION OF NURISNG THEORY st - 1 theorist to attempt to define what is nursing - “A person person is a whole whole,, is comple complete, te, & indepe independen ndentt being being who has 14 14 fundame fundamenta ntall needs.” 1. breathe normally 5. sleep & rest 2. eat & drink adequately 6. select suitable clothes 3. eliminate body waste 7. maintain body temp. 4. move & maintai maintain n desirab desirable le position position 8. keep keep the body clean & well-g well-groomed roomed 4. Mart Martha ha Roge Rogerrs – UNITARY HUMAN BEINGS AS ENERGY FIELD - psyc psychi hic, c, physi physica call or mole molecu cula larr ene energ rgy y - energy energy field field – funda fundamen mental tal unit unit of both both livi living ng & non-l non-livi iving. ng. - Field Field is a unifyin unifying g concept concept & energy energy signifi signifies es the the dynamic dynamic nature nature of the field field - A pers person on is irr irred educ ucib ible le - The perso person n is in cont continu inuous ous exchan exchange ge with with ener energy gy (matt (matter er & energy energy)) - Pattern Pattern – identifies identifies the energy energy field. field. It is the distinguish distinguishing ing characteris characteristic tic of an energy field & is perceived as a single wave - In the the unitary unitary bein being, g, the the whole whole is great greater er than than the the individ individual ual parts parts 5. Sist Sister er Calli Callist staa Roy Roy – ADAPTATION MODEL - person person is a biopsych biopsychosocia osociall being being who is in in constant constant interaction interaction with the environm environment ent & that has four models of adaptation based on physiologic needs - man cope copess wi with stres tresssors ors Coping mechanisms to stressors 1. Regulator Regulator – coping coping subsystem subsystem that respond respondss automaticall automatically y through through the neural neural & endocrine system inherently responds 2. Cognator Cognator – control control processes processes related related to higher higher brain brain functions functions of perception perception or information processing, judgment & emotion. Adaptive Mode 1. Physiologic Physiologic – physical physical respons responsee to environmental environmental stimuli stimuli & primari primarily ly involves involves the regular subsystems. The basic needs met in this this mode are physiologic integrity integrity & is composed of needs associated with ox ygenation, nutrition, elimination, etc. 2. Self-Concept Self-Concept – basic basic need for psychic psychic integrity integrity,, its focus is on on the psychologica psychologicall & spiritual aspects of the person. 3. Role-Functio Role-Function n Mode – defines defines how the person relates relates with with another another as a coping coping mechanism
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4. Interdependen Interdependence ce – affectio affectional nal needs needs are are met. Identifies Identifies patterns patterns of human values, values, affection, love & affirmation Coping can be: 1. Adaptive Adaptive response response (Effecti (Effective ve Coping) Coping) – goal is achieved achieved;; those that that promote promote the integrity of a person 2. Ineff Ineffect ective ive resp respons onsee – goal is is not achi achieve eved d 6. Doro Doroth thea ea B. Orem Orem – SELF-CARE DEFICIT THEORY - man is is a unity unity of sever several al syst systems ems & can can be able able to do do self-c self-care are activ activiti ities es - self-care self-care activities activities – those those which which are are perform performed ed by the person person for himself himself that that contribute to health. Self care must be learned learned & deliberately performed continuously continuously according to the stages of development - Univer Universal sal SelfSelf-Car Caree Requisit Requisites es – Activ Activiti ities es of Daily Daily Livin Living g (ADLs) (ADLs) - Normal Normalcy cy – that that which which is essen essentia tially lly huma human n and that that which which is in accor accordanc dancee with genetics & constitutional characteristics and talents of individuals 7. Imog Imogen enee King King – GOAL ATTAINMENT ATTAINMENT THEORY - believes believes that that there there are 3 interacting interacting systems: systems: Individual Individual (Personal (Personal System); System); Group (Interpersonal System); and Society (Social Systems) 8. Bett Betty y Neum Neuman an – HEALTH CARE SYSTEMS MODEL - human human being being is an open open system system consi consisti sting ng of basic basic struc structur turee or central central core core of survival factors surrounded by concentric rings that are bounded by lines of resistance, a normal line of defense, & a flexible line of defense - person person has a core & outside outside the core core are are rings rings of of defenses defenses which can be flexible flexible at certain times, when the normal defenses are low, low, the normal person gets sick The basic structure energy resources contain the following features: 1. Ability Ability to to maintain maintain body body temperat temperature ure within within the the normal normal range range 2. geneti geneticc characte characteris ristic tics/ s/str struct ucture uress 3. resp respon onse se patt patter ern n 4. orga organ n stre strengt ngth/ h/we weakn aknes esse sess 5. ego ego str struc uctture ure 6. knowns or commonaliti commonalities es (inter-r (inter-relati elationshi onship) p) April 15, 2005
9. Patt Patter erso son n & Zde Zdera rad d – HUMANISTIC THEORY - man man is rela relate ted d to othe otherr man man in in time time and and spac spacee - a person person is is beholded beholded to to other other person person from from birth birth until he becomes becomes capable (from time of birth until development) 10. Jean Watson Watson – NURSING & HUMAN SCIENCE AND HUMAN CARE - a person person as as he/she he/she grows grows up up is confr confronte onted d with with differ different ent conf conflic licts ts - conf confli lict ctss are are inher inherent ent to to the the grow growth th pro proce cess ss - all all thes thesee conf confli lict ctss are are stre stress ss pro provo voki king ng 11. Ann Boykin Boykin & Savina Schoenhofer Schoenhofer – NURSING AS CARING - human human beings beings are are perso persons ns who who are cari caring ng from from moment moment to to moment moment & are are whole whole and complete in the moment - all person personss are are caring caring,, altho although ugh not not all all acti actions ons are caring caring Seven assumptions underlie the theory 1. Person Personss are carin caring g by virtue virtue of thei theirr humanne humanness ss 2. Person Personss are caring caring from from moment moment to to moment moment 3. Personhood Personhood is a process process of living, living, grounded grounded in caring caring
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4. Personhood Personhood is enhanced enhanced through through participati participating ng in nurturing nurturing relationshi relationship p with caring caring others 5. nursin nursing g is both both a disci discipli pline ne and and a profess profession ion 6. Personhood Personhood are are viewed as already already complete complete & continuously continuously grow in complete completeness, ness, fully caring & unfolding caring possibilities moment to moment
CONCEPTS ON ENVIRONMENT
Virginia Henderson – everything that is outside of the patient but is connected to the patient is considered the environment & the environment should support the 14 fundamental needs. Dorothea Orem – environment is linked to the individual, forming an integrated & interactive system. It is any setting in which a patient has unmet self-care needs. - A healthy healthy person person is one one who who can can do self self-ca -care re acti activit vities ies - The nurse/car nurse/caregiver egiver would have to provide provide for any deficit deficit in the person’ person’ss self-care self-care deficits Rosemarie Parse – the environment is viewed as inseparable from the human being, each element participates in the co-creation of a lived experienced; nurse is part of the environment. - the univ univers ersee is insepar inseparabl ablee but complem complement entary ary & evolve evolvess - the nurse nurse is import important ant because because the nurse nurse co-c co-crea reates tes Florence Nightingale – cleanliness & good drainage system is also important - star starte ted d to to do do pro profe fess ssio iona nall nur nursi sing ng April 16, 2005
Theories on Environment According to Different Theorists 1. Florence Florence Nighti Nightingale ngale – ENVIRON ENVIRONMENT MENTAL AL Theory - The major major concepts concepts of of health health are ventilation, ventilation, warmth, warmth, light, light, diet, diet, cleanlin cleanliness ess & absence absence of noise. It is external to the person but affecting affecting health of both sick & well persons. The environment is one of the chief c hief resources of infection & must include fresh air, fresh water, efficient efficient drainage, cleanliness & light. light. Little emphasis was given to social & emotional aspects. -
Addressed Addressed psychologi psychological cal aspects aspects on her writings writings on on “Chatteri “Chattering ng Hopes Hopes and Advises” Advises” and and “Variety” “Variety” but stressed the physical environment more
Different Aspects in the Environment 1. Health of Houses Houses – presence presence of pure air (elimin (eliminate ate the source source of offensive offensive smells smells rather rather than fumigate), pure water, pure drainage, cleanliness & light. 2. Ventilation entilation & Warmin Warming g – consider the source source of air in the patient’s patient’s room… “Keep “Keep the air he breathes as pure as external ex ternal air without chilling him”; not to warm, not too cold Effluvia – refers to noxious or foul odors that come from excrements and equipment used to discard excrements (bedpan, urinals) - At presen present, t, people people exper experien ience ce “build “building ing sick sicknes ness” s” due to to absence absence of fresh fresh air air 3. Light Light – used used for direct direct sunlig sunlight ht Implication during the present times- Intensive care psychosis or confusion related to the lack of the accustomed cycling of day & night. 2. Sister Sister Callista Callista Roy – all the conditi conditions, ons, circumsta circumstances nces & influences influences surround surrounding ing the person person 3. Betty Neuman – environmen environmentt is viewed as stres stressors sors
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4. Imogene King King – environment environment is constantly constantly changing; changing; focus focus on what really really is the the desire of the the person; if the person’s goal is not attained, illness comes in.
CONCEPTS ON HEALTH
Definitions: HEALTH HEALTH – “State of complete physical, mental & social well-being, a nd not merely the absence of disease or infirmity” (WHO, 1947) Health is a state of being that people define in relation to their own values, personality & lifestyle. Each person has a personal concept of health. Individual’s Individual’s view of health can vary among different age groups, gender, race, and culture. Pender (1996) explains that “all people free of disease are not equally healthy”. ILLNESS – is a process in which the functioning func tioning of a person is diminished or impaired in o ne or more dimensions when compared with the person’s person’s previous condition. It is not synonymous with disease; although nurses must be familiar with different kinds of diseases and treatments, they are concerned more with illness, which may include disease, but also the effects on functioning and well-being in all dimensions. Human experience of disease; and may be perceived as loss, challenge, threat, punishment or gain. RISK FACTORS FACTORS – any situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other variable that increase the vulnerability of an individual or groups to an illness or accident. The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction Risk factors can be placed in the following categories: genetic & physiologic ph ysiologic factors, age, physical environment & lifestyle WELLNESS – an integrated method of functioning which is oriented toward maximizing the potential of which the individual perceives or views the experience of health HEALTH HEALTH BELIEFS – are a person’s ideas, convictions, and attitudes about health & illness They may be based on factual information or misinformation, common sense or myths, or reality or false expectations HEALTH BEHAVIORS – client’s attitudes towards health HEALTH HEALTH PROMOTION – anticipating guidance Health promotion activities such as routine exercise and good nutrition, helps clients maintain or enhance their present levels of health; motivate people to act positively to reach more stable levels of health. Models of Health and Illness
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Health – Illness Continuum Model -
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Health is a dynamic dynamic state that fluctua fluctuates tes as a person person adapts adapts to changes in the the internal internal & external environment to maintain a state of physical, emotional, social development & spiritual well-being. Illness Illness is a process process in in which which the functi functioning oning of of a person person is is diminished diminished or impaired impaired in one or more dimensions when compared to the person’s previous condition According According to to Neuman, Neuman, “health “health on a continuum continuum is is the the degree degree of client wellness wellness that that exists exists at any point in time, ranging from optimal op timal wellness condition, with available energy at its maximum, to death, which represents total energy depletion.” Central Central to the the health-il health-illness lness continuum continuum model model are are risk risk factors, factors, which are are importan importantt in identifying the level of health The way clients clients view view their their levels of health health depends on their their attitudes attitudes toward toward health, health, values, beliefs & perceptions of their physical, emotional, intellectual, social, developmental & spiritual well-being. Most effective effective when used used to compare compare a client’ client’ss present present health health with with the the client’ client’ss own previous level of health Useful Useful as the nurse nurse helps helps the the client client set set goals goals to attain attain a future future level level of health health Health Belief Model
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address addresses es the the relati relations onship hip betw between een a perso person’ n’ss belief belief & behav behavior iorss it provides provides a way of understa understanding nding & predicting predicting how how a client client will behave in in relation relation to to their health & how they will comply with health care therapies. First First component component on on this model involves involves the individual’ individual’ss perception perception of suscepti susceptibili bility ty to an illness. Second component component is is the individual’ individual’ss perception perception of the the seriousn seriousness ess of the the illness illness Third component, component, which which is also called called “cue to to action”, action”, is is the likelihood likelihood that that a person person will take preventive action – results from the person’s person’s perception of the benefits & barriers of taking action. This model model helps helps nurse nursess to underst understand and factors factors influencing influencing client’ client’s perceptions perceptions,, beliefs beliefs & behaviors in order to plan care ca re that will most effectively assist clients in maintaining or restoring health & preventing illness. Basic Hu Human Ne Needs Mo Model
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basic human needs are elemen elements ts that that are are necessary necessary for human survival survival & death – the extent to which basic needs are met in a major factor in determining a person’s level of health this model can can provide provide a basis for nursi nursing ng clients clients of of all ages in in all health settings settings Maslow’ Maslow’ss hierarchy hierarchy of needs needs is a model that nurses nurses can use use to underst understand and the the interinterrelationships of basic human needs. According to this model, certain human needs are more basic than others; that is, some needs must be met before other needs. This model model is is useful useful for for designati designating ng prioriti priorities es of care & for planning planning individualiz individualized ed care care for a client. Role Pe Performance Mo Model
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Health is the abilit ability y to perfor perform m all all those those roles which one has been sociali socialized. zed. Health is defined in terms of the individual’s ability to fulfill societal roles, that is, to perform work. People who can fulfill their their roles are healthy even if if they appear clinically ill. Example, a man who works all day at his job as expected is healthy even though an x-ray of his lung indicates tumor.
Levels of Preventive Care
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Primary Prevention - “true prevention”, prevention”, it precedes precedes disease disease or dysfunction dysfunction & is applied to clients clients considered physically & emotionally healthy - aimed at health health promotion promotion includes includes health health education education programs programs,, immuniza immunization, tion, & physical & nutritional fitness activities
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Secondary Pr Prevention - focuses focuses on individuals individuals who are are experienci experiencing ng health health problems problems or illnes illnesses ses and who who are at risk for developing complications or worsening conditions - activities activities are directed directed at diagnosis diagnosis & prompt prompt intervention intervention,, thereby thereby reducing reducing severity & enabling the client to return to a normal level of health as easy eas y as possible
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Tertiary Pr Prevention - occurs occurs when when a defe defect ct or disabi disabilit lity y is permane permanent nt & irr irrever eversib sible. le. It invo involve lvess minimizing the effects of long-term disease or disability by interventions directed at preventing complications & deteriorations. - Activities Activities are directed directed at rehabilitat rehabilitation ion rather rather than diagnos diagnosis is & treatment; treatment; care at this level aims to keep clients achieve as high a level of functioning as possible despite the limitations caused by illness or impairments.
Impact of Illness on the Client & Family: Changes that take place on the patients when there is illness: 1. BEHA BEHAVIORAL VIORAL & EMOTI EMOTIONA ONAL L CHANGE CHANGES S - people react differently differently to illness illness or the threat of illness illness;; reactions reactions depend on on the nature of the illness; the client’s attitude toward it; the reaction of others to it, & the variables of illness behavior - short term, non-life non-life threatening threatening illnesses illnesses evoke few behavioral behavioral changes in the the functioning of the client or family - severe illness, illness, particularl particularly y one one that that is life threatening, threatening, can lead lead to more extensive extensive emotional & behavioral changes such as anxiety, shock, denial, anger & withdrawal 2. IMP IMPACT ACT ON BODY BODY IMAG IMAGE E - Body imag imagee is the subj subjecti ective ve concept concept of of physic physical al appear appearance ance;; some some illness illnesses es result in changes in physical appearance, & clients & families react differently to these changes. - These These reactio reactions ns of clie clients nts & fami familie liess to chang changee in body image image depend depend on the the following: a. the types types of chan changes ges (e.g. (e.g. loss loss of a limb/ limb/or organ gan)) b. thei theirr adapt adaptiv ivee capa capaci city ty c. the rate rate at at whic which h chang changes es take take place place d. supp suppor ortt serv servic icee avail availab able le - When a change in body body image image occurs, occurs, the client client generally generally adjust adjustss in the follow following ing phases: shock, withdrawal, acknowledgement, acceptance, & rehabilitation. 3. IMPACT IMPACT ON SELFSELF-CON CONCEP CEPT T - one’s one’s ment mental al image image – proj project ected ed as person personali ality ty - self-concept self-concept is a mental self-image self-image of strength strengthss & weaknesses weaknesses in all aspects aspects of personality; depends in part on body bod y image & roles but also includes other aspects of psychology & spirituality. spirituality. - The impact impact of of illness illness on the the self-conce self-concepts pts of clients clients & family family members members may be more complex & less readily observed than role changes. - A client whose self-concept self-concept changes because of illness illness may no longer longer meet meet family family expectations, leading to tension or conflict
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4. IMPACT IMPACT ON ON FAMI FAMIL LY ROLE ROLES S - People have many roles in life. life. When an illnes illnesss occurs, occurs, parents parents & children children try try to adapt to major changes resulting from a family member’s illness - Role reversa reversall is common; common; such as reversal reversal of the usual situation situation can can lead to stress stress,, conflicting responsibilities for the adult child, or direct conflict over decision making. 5. IMPACT IMPACT ON FAMIL FAMILY Y DYNAMICS DYNAMICS - Family Family dynamics dynamics is the the process process by which which the the family family functions, functions, makes decisions, decisions, give support to individual members & copes with everyday change & challenges. - If a parent in a family becomes ill, family family activit activities ies & decision decision making making often often come to a halt as a s the other family members wait for the illness to pass, or they delay action because they are reluctant to assume the ill person’s roles or responsibilities.
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