APPLICATION OF OREMS SELF CARE DEFICIT NURSING THEORY IN THE CARE OF AN ASTHMATIC PATIENT AND A CRITIQUE OF THE THEORY. R1606049 PATIENT PROFILE Master X came to the hospital in the company of this parents with complaints of difficulty in breathing, wheezing, tightness of the chest, cough and vomiting exacerbated by the cough. He states he is not been sleeping well for the past two days because of the above symptoms. This will be his sixth visit with similar complaints. In the past he was admitted, treated and discharged home. Master X is 16years old. He lives with both parents and a sibling in a compound house rented by his parents. The house has an untarred road running right in front of it. He is an adolescent in third year in junior high school. He is Christian and worships every Sunday with the Catholic Church. He likes to pay football, has a pet dog and his favourite meal is fufu with light soup. His father is very worried and states that he sleeps bare chested at night despite this being warned not to do so all the time. He and parents cannot tell if there are situations or incidents that aggravate attacks. He states that he is aware of his condition but does not carry his medication with him because he doesn’t want his friends to see him as weak and always sick. Both he and parents express concerns that condition seems to be recurring. On assessment client is agitated and irritable, cyanotic with vital signs reading; respiration-40cpm, heart rate 130bpm, oxygen saturation 85%, temperature 37.7, blood pressure 130/90mmhg, use of accessory muscles in breathing with wheezing breath sounds. DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT 1. BASIC CONDITIONING FACTORS Age 16years Gender Male Developmental state Identity versus confusion Health state Acute onset of chronic illness Sociocultural orientation Formal education, Christian, Ghanaian Health care treatment/ system Institutional care, diagnosis, treatment plan, self-care transitioning. Family system Lives with both parents and a sibling Patterns of living Spends 8 hours of the day in school on weekdays. Likes to play football daily and sleeps mostly bare chested at night Environment Urban, clean, dusty road, has a pet dog Resources Parents 2. UNIVERSAL SELF CARE REQUISATES Air Difficulty in breathing Water No restrictions, fluid intake insufficient due to vomiting Food No restrictions, adequate intake. Weight 57kg, height 170cm Elimination Normal pattern Activity and rest Interrupted sleep patterns due to persistent cough Solitude/ social interaction Interacts with peers, likes to play football. Prevention of hazards Needs instructions on avoiding triggers. He sleeps bare chested most nights Promotion of normalcy Has a healthy relationship with both parents 3. DEVELOPMENTAL SELF CARE REQUISATES Maintenance of developmental Carries out activities of daily living by environment himself, holds views of peers high Prevention/ management of conditions Not complaint with treatment regimen threatening normal development for chronic condition, not avoiding triggers 4. HEALTH DEVIATION SELF CARE REQUISATES Seeking medical assistance when health Seeks health care frequently when status altered health state is altered Awareness/ management of disease Aware of condition. No evidence process however of knowledge on how to avoid having attacks or manage them. Adherence to medical regimen Cooperates with treatment. Not aware of how to use metred dose inhaler(spacer) and nebulizer Awareness/ potential problems Not aware of side effects of medication associated with regimen and the need to always have sprays or inhaled bronchodilators around him. Modification of self-image to Portrays same self-image. Concerned incorporate changes to health status that his peers might consider him a weak person if they know Adjustment of lifestyle to accommodate No changes made. Passionate about changes in health status and medical playing football and concerned about regimen always carry medication on him. NURSING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT Diagnostic operations Therapeutic self-care demand Air Maintain effective respiration Adequacy of self-care agency Inadequate Prescriptive operations Regulatory operations Control Nursing diagnosis Desired outcomes Nursing system design Methods of helping Nursing orders Rational Implementation Evaluation Ineffective breathing pattern related to swelling and spasm of the bronchial tubes as evidenced by dyspnoea Client will maintain optimal breathing pattern as evidenced by normal respiratory rate and absence of dyspnoea Partly compensatory Support Guidance Teaching Positioningelevate head end of bed, assess breath and adventitious sounds such as wheezes and stridor, Administer intra nasal oxygen, Monitor vital signs, oxygen saturation and arterial blood gases every 15 minutes, Encourage pursed lip breathing for exhalation, administer prescribed medication, assess response to medication To promote maximum lung expansion, boast oxygen supply, diminishing wheezing and indistinct breath sounds may indicate early respiratory failure, oxygen saturation determines amount of oxygen in the blood and arterial blood gases for respiratory acidosis, pursed lip breathing improves breathing pattern, medications to relax the lung muscles and reduce inflammation and mucus secretion. Head end of bed elevated, breath and adventitious sounds assessed, intra nasal oxygen administered at 5L, vital signs, oxygen saturation and arterial blood gases monitored every 15 minutes, pursed lip breathing for exhalation encouraged, prescribed medication administered, medication response assessed Goal fully met as normal breathing pattern was restored. Water Maintain electrolyte balance Inadequate Potential for fluid volume deficit related to vomiting Food Inadequate Potential for imbalanced Patient will maintain normal fluid volume as evidenced by normal systolic blood pressure (systolic blood pressure greater than or equal to 90 mm HG), normal heart rate (60-100 beats per minute), urine output greater than 30 ml/hour and normal skin turgor Patient will maintain Supportive educative Teaching Support Guiding Monitor and document vital signs especially blood pressure and heart rate as necessary, assess skin turgor and mucous membranes for signs of dehydration, encourage intake of oral rehydration salts, administer intravenous fluids, monitor input and output chart, administer prescribed medication Changes in vital signs may indicate hypotension, skin elasticity and dry mucous membrane can be used to determine dehydration, intake of oral rehydration salts and intravenous fluids for fluid replacement, input and output monitoring determines quantity of fluid retained Vital signs especially blood pressure and heart rate monitored as necessary and documented, skin turgor and mucous membranes assessed for signs of dehydration, 50mls of oral rehydration salts served after each vomit and client encouraged to drink, Intravenous fluids administered, input and output chart monitored, prescribed medication served. Goal fully met as patient maintained normal fluid volume during hospitalisati on Supportive educative Teaching support Observe oral hygiene, feed in Oral hygiene has a Positive effect on Oral hygiene observed, food Goal fully met as Maintain sufficient food intake Elimination At present no problem Adequate nutrition less than body requirements related to vomiting optimal levels of nutritional status Potential for inadequate urine production related to fluid loss through vomiting Patient maintains balanced input and output with clear odour free urine Supportive educative guiding bits frequently, monitor input and output chart, maintain pleasant environment, serve varied non spicy foods. Guiding Teaching Support Monitor vital signs, assess severity of vomiting, encourage adequate fluid intake, monitor input and output chart especially fluid intake and urine output, observe urine for concentration and consistency, serve prescribed medication appetite, feeding in bits lessens feeling of fullness and urge to vomit, input and output chart measures quantity of food and water retained, pleasant environment and non-spicy foods reduces stimulus to vomit Change in vital signs may suggest decreased fluid volume, assessing severity of vomit determines quantity of fluid loss, encouraging fluid intake replaces lost fluid, input and output chart determines amount of fluid retained, observe urine concentration for low production of urine by the kidneys served attractively in bits frequently, input and output monitored, pleasant environment maintained, varied non spicy foods served client maintained optimal levels of nutrition throughout hospitalisati on Vital signs monitored and documented, severity of vomiting assessed, adequate fluid intake encouraged, input and output chart monitored especially fluid intake and urine output, concentration of urine observed and documented, prescribed Goal fully met as patient did not develop urine elimination problems during hospitalisati on Activity and Inadequate rest Maintain balance Disturbed sleep pattern related to excessive cough and anxiety Client will attain optimal amounts of sleep as evidenced by statements of feeling well rested. Supportive educative Support guidance Determine the clients usual sleep habits, elevate head end of bed, maintain quiet environment, use minimal lightening, address restrictive clothing, address anxiety, serve prescribed medication Determine usual sleep pattern to make baseline comparisons, elevate head end of bed to promote breathing, maintain quiet environment to minimise distractions, minimal lightening to promote sleep, address restrictive clothing to increase comfort, address anxiety to reduce fear and prescribed medication to reduce cough and other symptoms medication served. Clients usual sleep pattern determined, Head end of bed elevated, quiet environment maintained, minimal lightening used, restrictive clothing removed, anxiety addressed and prescribed medication served Goal fully met as client maintained normal sleep patterns during hospitalisati on Solitude/ social interaction At present no problem adequate Potential for impaired social interaction related to chronic illness and over protection from parents Prevention of hazards Keep patient safe Inadequate Potential for personal injury related to irritability client and family will understand need for adequate socialization by time of discharge as evidenced by verbalisatio n of strategies( adherence to treatment and support group attendance) to adopt to maintain socialization client will remain free of injuries during hospitalizati on as evidenced Supportive educative Guidance teaching support Assess client and family’s feelings relative to social isolation, discuss condition with client and family and encourage questions, clarify misconceptions, provide support group therapy, give education on medical regimen and need to comply To obtain data to work with, discuss condition to impact knowledge, encourage questions to clarify misconception, support group to identify new ways to promote socialisation educate on adherence to medical regimen to promote health Family engaged in discussion on condition and encouraged to ask questions. Teaching with aids done and all misconceptions clarified, support group therapy provided, education given on medical regimen and need to comply Goal fully met as client and family demonstrat ed an understandi ng for the need for socialisation and verbalised strategies to adopt to maintain socialisation Supportive educative Support Teaching guidance Assess general status of client, Increase observation, keep bed side rails in place, eliminate all hazards, attend to Assess to determine extent of irritability, increase observation and attending to calls to intervene promptly if need be, keep bed side rails up to prevent patient Assessment of general status done, client closely observed at all times, bed side rails put in place, hazards eliminated, Goal fully met as client remained free of injuries on discharge by absence of injuries client’s calls promptly Promotion Inadequate of normalcy Improve health status through life style changes that avoid triggers Deficient knowledge related to long term medical management and triggering factors for asthma. Patient and family will verbalise knowledge of chronicity of condition, triggering factors, manageme nt and community resource available to help client cope. Supportive educative Teaching Support guidance Assess knowledge on triggers, and management during attacks, educate on warning signs and importance of early treatment, identify precipitating factors for attacks, and provide support group therapy. Maintain developme ntal environme nt Support increased Potential for delay in normal development related to isolation Client will verbalise the need to avoid isolation by adhering to treatment Supportive Educative Teaching guidance Counsel on condition and clarify misconceptions, provide support group therapy Adequate from falling, eliminate hazards to protect patient from harm Knowledge will make client know how to control them and how to correctly use metred dose inhalers, early warning signs and early treatment prevents exacerbation of symptoms, support groups offers opportunities to learn new ways of adapting to the condition client’s calls attended to promptly. Counsel to equip them with knowledge on the condition and clarify misconception for better cooperation, support group Counselling on condition done and misconceptions clarified, support group therapy provided Patient knowledge on triggers and care during attacks assessed, education on early warning signs and early treatment done, precipitating factors for attacks identified and support group therapy provided. Goal fully met as patient and family demonstrat ed an understandi ng of chronicity of the condition, triggers and its manageme nt and resources available to help in coping Goal fully met as client and family verbalised need to promote normalcy in environmen t Prevent/ manage developme ntal threats Manage threats to developme nt by receiving appropriate therapy. secondary to chronic illness Inadequate Maintenanc Inadequate e of health status to maintain a normal developme ntal environmen t Potential for Client and Supportive developmental family will Educative deficit related verbalise an to frequent understandi attacks and ng of the hospitalisation impact of frequent attacks and hospitalisati on on developme nt and state strategies to avoid it. Potential for continued alterations in health status Client and family will express increased Supportive educative therapy to identify new ways to cope Teaching guidance Teaching guiding Assess for indications that client may be unable to adhere to therapeutic regimen, Provide support group therapy, educate on condition in terms he and family can understand and stress need to adhere to treatment, clarify all misconceptions, reinforce behaviours that ensure future compliance Assess patient and family knowledge on condition, educate on health Assess to identify gaps to fill, support group to identify new ways to cope, educate to foster understanding of the condition, stress adherence to treatment promote health and normal development, reinforce positive behaviour to reduce risk taking behaviour Assess to know how much information to give, educate to equip them with developme nt and identified resources to achieve this Client assessed for indications of non-compliance to therapeutic regimen, support group therapy provided, education on condition done using terms they understand and adherence to treatment stressed, misconceptions clarified, behaviour that ensure future compliance reinforced. Patient and family knowledge on condition assessed, Goal fully met as client and family Promote health related to inadequate health seeking behaviours. interest in adhering to medical recommend ations to promote health Awareness Inadequate and manageme nt of disease process Gain understandi ng of chronicity and complicatio ns of condition and its manageme nt Potential for developing complications (status asthmaticus )related to poor management of condition Client and family will demonstrat e an increased willingness to avoid complicatio ns as evidenced by stating signs and symptoms, complicatio ns and manageme nt of condition seeking behaviours, educate on, management and preventing attacks Supportive educative teaching Provide conducive environment for teaching and learning, use teaching aids to give education on condition, educate on what to do during attacks, educate when to report to the hospital, allow questions and answer appropriately, clarify all misconceptions knowledge on health seeking behaviours, educate on management and prevention of attacks to minimise the severity and frequency of attacks and hospital visits education on health seeking behaviour, management and prevention of attacks done expressed increased interest in adopting health seeking behaviours that promote health Conducive Conducive Goal fully environment to environment for met as facilitate learning, teaching and client and teaching aids to learning family boost understanding, provided, demonstrat educate on what to teaching aids ed do during attacks used to promote understandi and to report to the effective learning, ng and an hospital immediately education on increased to prevent what to do during willingness complications, allow attacks and when to avoid questions and to report to the complicatio answers to address hospital done, ns. concerns, clarify client and family misconception to allowed to ask reduce questions and misinformation answers provided appropriately, all misconceptions clarified Adherence to medical regimen Ensure adherence Inadequate Risk for nonadherence to medical regimen related to knowledge deficit on complications of condition Client and family will demonstrat e an increased willingness to adhere to medical treatment as evidence by stating risk associated with defaulting Supportive educative Teaching guidance Awareness of potential problems Understand chronicity of condition inadequate Knowledge deficit related to side effects of medical regimen Client and Supportive family will educative gain an understandi ng of side effects teaching Provide conducive environment for teaching and learning, assess clients knowledge on asthma, assess past and current treatment and response to them, teach how to correctly use metered dose inhaler(spacer) and the use of peak flow meters, teach how to administer nebulizer treatments, reinforce what to do in an attack (action plan), allow questions and give appropriate answers Assess knowledge on side effects of medication, educate dosage and timing of medication, Conducive environment to facilitate learning, Assess to know how much information to give, assess past and present mediation to determine efficacy of the medication, teach how to use the spacer , peak flow meter and nebulizer to ensure effective use, reinforce action plan in attack to reduce symptoms and prevent complications, allow questions to address concerns Conducive environment provided for teaching and learning, clients knowledge on asthma assessed, response to past and current treatment assessed, teaching on correct use of the metred dose inhaler and peak flow metre done, teaching on nebulizer treatment done and emphasis placed on what to do in an attack. Concerns clarified Goal fully met as client and family demonstrat ed an increased willingness to adhere to medical regimen To know how much information is required, educate on dosage and timing to avoid overdose, educate on side Education on condition, what to do in attacks and long term management of Goal fully met as client and family expressed understandi associated with treatment regimen Modify self- inadequate image to incorporate changed health status Actual threats to self-image related to disease and long term treatment Adjust lifestyle to accommod ate health status changes and Impaired adjustment related to health status requiring change in lifestyle. inadequate Client and family will express increased interest in self-image modificatio n that integrates a treatment plan for health promotion Client and family will express an increased interest in lifestyle changes that avoid educate on side effects of medication and when to report to the hospital, educate on need to adhere to treatment. Supportive educative Teaching guidance Provide support group therapy, allow expression of concerns, offer suggestions on effective ways on interacting with peers, encourage discussion of condition with peers and other family members Supportive educative Teaching guidance Assess obstacles to life style changes, Involve client and family in discussions on condition (asthma) placing emphasis on need to effects to equip client and family with what to expect, educate on when to report to avoid complications, educate on adherence to improve health Group therapy to learn new ways to cope with condition, allow expression of fears to address them, offer suggestions to aid coping, encourage discussion to facilitate acceptance, the condition done ng of the side effects associated with the treatment regimen Support group therapy provided, client allowed to express concerns, suggestions offered on effective ways of interacting with peers, discussion of condition with peers encouraged Goal fully met as client and family expressed increased interest in self-image medication for health promotion Promote trust, cooperation and encourage adherence, avoid triggers especially those mentioned because they have been associated with Discussions involving client and family on need for lifestyle changes carried out, emphasis placed on avoiding triggers. Goal fully met as client and family expressed increased interest in lifestyle medical regimen triggers and promote health + minimise attack by avoiding triggers especially physical exertion, cold weather, pets and dust, emphasise medication adherence and need to always carry them along, assist client to identify ways treatments can be incorporated in to lifestyle, reinforce need to always have emergency numbers and an identification tag, allow questions. client, medications to reduce incidence, to avoid complications, for easy identification and to clarify misconception Medication changes adherence and that avoid need to carry triggers them on him emphasised, emphasis placed on need to always carry emergency phone numbers and an identification tag, questions allowed and misconceptions clarified. A CRITIQUE OF OREM’S SELF CARE DEFICIT NURSING THEORY INTRODUCTION The knowledge base of a profession is normally expressed in the form of concepts, propositions and theories. Nursing has currently reached this level of theoretical evolution. (Hugh Mckenna). Nursing theories and models, integrated with evidence based practice aims to improve on care rendered to the patient. One of the modern day theorist, Dorothea Orem’s self-care deficit nursing theory is one theory that has widely been used in practice with positive results. It is in view of this that the self care deficit theory was employed in the care of a sixteen year old that presented with an asthmatic attack to the emergency ward. OVERVIEW OF THE SELF CARE DEFICIT THEORY Nursing practice oriented by the self care deficit nursing theory represents a caring approach that uses experiential and specialized knowledge (science) to design and produce nursing care (art). The body of knowledge that guides the art and science incorporates empirical and antecedent knowledge (Orem, 1995). The theory is based on three central theories of self care deficit, theory of self-care and theory of nursing systems. Its central philosophy is that individuals wish to care for themselves and should be aided to care for themselves if they cannot do so on their own. It also encourages that they be allowed to perform their self care to the best of their abilities as they recover more quickly and holistically. COMPONENTS AND DEFINITIONS OF MAJOR CONCEPTS Self care This is said to be the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and well-being. (GCNM lecture notes 2016) Self care agency This is the human’s ability or power to engage in self-care and is affected by basic conditioning factors. (GCNM lecture notes 2016) Self care deficit This is when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in the provision of continuous effective self-care. Basic conditioning factors These are stated as the age, gender, developmental state, health state, sociocultural orientation, patterns of living, health care system, family system factors, environmental factors and resource adequacy and availability. Therapeutic self care demand Defined as the summation of activities or self care actions needed to be performed to alleviate an existing disease or correct an existing health deviation. Self care requisates These are requirements a person must meet and perform in order to achieve wellbeing. According to Orem these are three as listed; Universal self care requisates which include all physiological needs such as water, air etc. Developmental self care requisates which include actions that are undertaken to provide for the developmental growth of the patient Health deviation self care requisates which are required in conditions of illness, injury, or disease or may result from medical measures required to diagnose and correct the condition. Nursing system These include functions that the nurse must perform in order to meet client’s needs. This system is activated when the client’s therapeutic self-care demand exceeds available self-care agency, leading to the need for nursing. Nursing agency For nursing design to be met the nurse must possess established capabilities known as the nursing agency. These capabilities include knowledge, attitude and skills to be effective Theory of self care Orem’s theory of self care is based on the following concepts: Self care, Self care agency, Therapeutic self care demand and Self care requisites. Theory of self care deficit According to Orem, nursing is required when an adult is incapable or limited in the provision of continuous, effective self-care. In providing care the nurse employs methods of helping which include; Acting for and doing for others, guiding others, supporting another, teaching another and providing an environment promoting personal development. Theory of nursing systems This describes how the patient's self-care needs will be met by the nurse, the patient, or by both. Orem identifies three classifications of nursing system to meet the self-care requisites of the patient: wholly compensatory system, partly compensatory system and supportive-educative system. Assumptions of the theory Orem makes the following assumptions in her theory; People should be self-reliant, and responsible for their care, as well as others in their family who need care. People are distinct individuals. Nursing is an action or interaction between two or more people. Meeting universal and development self-care requisites is an important component of primary health care and illness prevention. A person's knowledge of potential health problems is needed for promoting self-care behaviours. Self-care and dependent care are behaviours learned within a socio-cultural context. (GCNM, lecture notes 2016) DEFINITION OF NURSING METAPARADIGMS IN THE SELF CARE DEFICIT THEORY Environment Made up of physical, chemical and biological features. It includes the family, culture and community. Human Comprise of men, women, and children. They are cared for either singly or as social units. They are the focus of nursing care. (GCNM lecture notes 2016) Nursing The art through which the nurse gives specialized assistance to persons who are unable to meet their self care needs all by themselves. The nurse also intelligently participates in the medical care the individual receives from the physician. (GCNM lecture notes 2016) Health Being structurally and functionally whole or sound. It also encompasses both the health of individuals and of groups. It also includes the ability to reflect on one’s self, to symbolize experience and to communicate with others. (GCNM lecture notes 2016) CRITIQUE Orem’s self care deficit theory is comprehensive in nature and widely accepted. Its application in practical settings has received both positive and negative reviews. I hope to in this critique highlight both the strengths and weaknesses of the theory. Clarity In the theory definitions are clear, organised and well defined with no excessive narrative. However there is repetition of words and terms that can be confusing. This observation is supported by Mendoza, et al (2004) who stated that students studying Orem’s theory are often perplexed on the different terminologies with similar meanings. Concepts are used consistently throughout and are not disjointed. However, they appear to be redundant as they become more detailed. Definitions given to some of them separately seems to be a deliberate attempt to make the theory broader. For example, Orem defines self care deficit separately from the theory of self care deficit. The two could have been merged without necessarily distorting the idea behind the theory. A lot more of such examples can be highlighted if we implore further. This view is supported by Abdul (2002) that Orem’s theory is redundant in some way. Simplicity Orem’s theory is easy to understand in the sense that it explains what an individual must do to maintain health and also defines exactly when the nurse must step in the event that the individual is unable to do so on his own. The relationship between concepts are complex but applicable practically to achieve results. However, though terms used are easily understood, the theory is still complex in the sense that it is composed of three theories put together and broken down into even more layers. (Theory of self care, theory of self care deficit and theory of nursing systems). Abdul 2002 supports this view by stating that Orem’s theory is simple with limited number of concepts but complex in terms of number of theories put together. Generality The theory is not only applicable in clinical practice, but also in nursing education, nursing administration and research. Also, both novice nurses and experts can apply Orem’s theory without difficulty. The theory however is more inclined to physiological and sociological wellbeing of the individual whilst neglecting the emotional and mental wellbeing of the individual. Orem suggest that an individual must willingly express a lack of the ability to maintain self care to receive same. This is however not the case in all instances. For example an individual with mental health issues might not willingly admit to needing help with self care and going by Orem’s concepts it will be difficult to nurse such a patient. This is supported by Moustafa (1999) who greatly stressed that the lack of mental health on this theory could possibly cause problems when applied in a health care setting. George 2010, however states that Orem in a later discussion emphasises the importance of a positive mental health. Accessibility It is a readily applicable theory with entities well defined and measureable. concepts can be operationalized and empirically tested in research studies. The theory has been used in several researches that has yielded significant result regarding scope, complexity and clinical usefulness. A number of theories were conducted which were derived from her theory and its implication served as a guide in the development of tools for patients self care assessment. An example is the development of the community care deficit nursing models from Orem’s self care deficit nursing theory. (Serey, S et al, 2005) Importance The theories impact on the clinical setting is significant. It defines need for nursing care and when to act. It also delineates the various interactions between nurse and patient. It is tied to nursing goals, clinical practice and research. Nursing based on the theory is driven by the nurse’s relationship with patients self-care needs. Some research articles also use Orem’s theory as a theoretical frameworks and hypothesis derived from concepts. This is supported by George, 2006. Strengths Major strengths include the fact that it can be used by all categories of nurses, from the beginner to the expert. It also specifically defines when nursing is needed or when the nurse should step in to help maintain self care necessary to sustain life and health. Three identifiable nursing systems were clearly described and easily understood. The portrayal of nursing care as that which provides assistance to people was apparent in every concept and helps to keep the nurse focused on her role. Another major strength of Orem’s theory is the inclusion of the nursing process whilst also specifying and identifying the steps in the process. The use of the self care requisites of the person in data collection helps to individualise care as these are unique to each person. She also mentioned that the nursing process involves intellectual and practical phases. Orem’s theory also not only focuses on individual self care but also multi person units. Limitations A major limitation is it appears the theory is illness oriented. WHO defines health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. By this definition, everyone should be given health care services regardless of whether they are physically ill or not. Orem however implies in her theory that health care should only be rendered to those with health deviation self care requisates. The theory also neglects the dynamic nature of health. Orem’s presentation of three fixed nursing systems to employ in restoring health connotes rigidity. Provision is not made for the dynamic state of health and the exploration of all possible avenues to maintain or restore health. The theory can be said to be simple yet complex because of the embedment of three sub theories (theory of self care, theory of self care deficit and theory of nursing systems). The use of self-care in multitude of terms also makes it confusing. She also does not acknowledge the emotional needs of the individual throughout her work. The role of the environment to the nurse patient relationship and health though mentioned was not discussed. Also self care as defined by Orem in her theory cannot be applied to the aged and infants. MY REFLECTION ON THE THEORY AS APPLIED TO CLIENT (SUMMARY) Orem’s theory of self care deficit is not only practical but applicable as well. It is also not only concerned with nursing the client in the phase of active illness but can be used effectively in teaching for rehabilitative and self-care transition purposes. However, although the theory has been widely acclaimed and received positive reviews with its application in practical settings I found a number of flaws in relation to my client. It lacked in dealing with the emotional needs of my client which would have impacted positively with his anxiety. His spiritual needs were not also taken care of in the application of the theory. Orem sought to suggest that an individual’s self care needs depended on him and the use of nursing systems to assist if need be. However the role of his parents in the self care needs of this adolescent was just as important. Although the theory acknowledges the family, community and environment in self care action, its primary focus is on the individual. Nursing with specific consideration to the background or cultural orientation of the client was also not aptly dealt with in the theory. In conclusion, Orem’s theory continues to be useful in practice despite the flaws highlighted. I would recommend its use in the future in nursing clients for its comprehensive nature. References Alligood, M. R. (2014). Nursing theorists and their work. Elsevier Health Sciences. Abdul, H. (2002). The academic implications of the grand nursing theories. International journal of nursing, Vol 12, no. 10 Biggs, A. (2008). Orem's self-care deficit nursing theory: Update on the state of the art and science. Nursing Science Quarterly, 21(3), 200-206. Dean, A. J., Walters, J., & Hall, A. (2010). A systematic review of interventions to enhance medication adherence in children and adolescents with chronic illness. Archives of disease in childhood, 95(9), 717-723. Fawcett, J., & Desanto-Madeya, S. (2012). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories. FA Davis. George, J. B. (2011). Nursing Theories: The Base for Professional Nursing Practice, 6/e. Pearson Education India. Ghana college of nurses and midwives, (2016). Lecture notes Mendoza, A., et al, (1998). The students perspective on the foreign and local nursing theories. Murphy, F., Williams, A., & Pridmore, J. A. (2010). Nursing models and contemporary nursing 1: their development, uses and limitations. Nursing times, 106(23), 18. Moustafa, E. (1999). The modern nursing theories and their deficiencies. The scientific society of Arab nursing faculties, Vol 1 no. 12 North American Nursing Diagnosis Association. (2007). NANDA nursing diagnoses. North American Nursing Diagnosis Association. Shum, S., McGonigal, R., & Biehler, B. (2005). Development and application of the Community Care Deficit Nursing Model (CCDNM) in two populations. Self-Care Dependent-Care, 13(1), 22. Tomey, A. M., & Alligood, M. R. (2006). Nursing Theory Utilization and Application. St. Louis. World Health Organization. (2013). Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. World Health Organization.