FAYE GLENN ABDELLAH'S THEORY TWENTY ONE NURSING PROBLEMS INTRODUCTION

Faye Glenn Abdellah, pioneer nursing researcher, helped transform nursing theory, nursing care and nursing education Birth:1919 Dr Abdellah worked as Deputy Surgeon General Former Chief Nurse Officer for the US Public Health Service , Department of Health and human services, Washington, D.C. She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research. In 1960, influenced by the desire to promote client-centred comprehensive nursing care, Abdellah described nursing as a service to individuals, to families, and, therefore to, to society. According to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs. As a comprehensive service ,nursing includes;
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Recognizing the nursing problems of the patient Deciding the appropriate course of action to take in terms of relevant nursing principles Providing continuous care of the individuals total needs Providing continuous care to relieve pain and discomfort and provide immediate security for the individual Adjusting the total nursing care plan to meet the patients individual needs Helping the individual to become more self directing in attaining or maintaining a healthy state of mind & body Instructing nursing personnel and family to help the individual do for himself that which he can within his limitations 8)Helping the individual to adjust to his limitations and emotional problems 9) Working with allied health professions in planning for optimum health on local, state, national and international levels 10) Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet the health needs of people These original premises have undergone an evolutionary process. As result, in 1973, the item 3, - providing continuous care of the individuals total health needs was eliminated. From these premises, Abdellahs theory was derived.

PHILOSOPHICAL UNDERPINNINGS OF THE THEORY

Abdellahs patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory. The theory was created to assist with nursing education and is most applicable to the education of nurses. Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings. The language of Abdellahs framework is readable and clear. Consistent with the decade in which she was writing, she uses the term she for nurses, he for doctors and patients, and refers to the object of nursing as patient rather than client or consumer. She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses prerogative. Assumptions were related to
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MAJOR ASSUMPTIONS, CONCEPTS & RELATIONSHIPS

change and anticipated changes that affect nursing; The need to appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery; changing nursing education continuing education for professional nurses development of nursing leaders from under reserved groups

Abdellah and colleagues developed a list of 21 nursing problems. They also identified 10 steps to identify the clients problems 11 nursing skills to be used in developing a treatment typology 1. Learn to know the patient 2. Sort out relevant and significant data 3. Make generalizations about available data in relation to similar nursing problems presented by other patients 4. Identify the therapeutic plan 5. Test generalizations with the patient and make additional generalizations 6. Validate the patients conclusions about his nursing problems 7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior

10 steps to identify the clients problems

8. Explore the patients and familys reaction to the therapeutic plan and involve them in the plan 9. Identify how the nurses feels about the patients nursing problems 10. Discuss and develop a comprehensive nursing care plan 11 nursing skills 1. Observation of health status 2. Skills of communication 3. Application of knowledge 4. Teaching of patients and families 5. Planning and organization of work 6. Use of resource materials 7. Use of personnel resources 8. Problem-solving 9. Direction of work of others 10. Therapeutic use of the self 11. Nursing procedures The twenty one nursing problems Three major categories 1. Physical, sociological, and emotional needs of clients 2. Types of interpersonal relationships between the nurse and patient 3. Common elements of client care 21 NURSING PROBLEMS BASIC TO ALL PATIENTS

To maintain good hygiene and physical comfort To promote optimal activity: exercise, rest and sleep To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection To maintain good body mechanics and prevent and correct deformities To facilitate the maintenance of a supply of oxygen to all body cells To facilitate the maintenance of nutrition of all body cells To facilitate the maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiological responses of the body to disease conditions To facilitate the maintenance of regulatory mechanisms and functions

SUSTENAL CARE NEEDS

To facilitate the maintenance of sensory function REMEDIAL CARE NEEDS To identify and accept positive and negative expressions, feelings, and reactions To identify and accept the interrelatedness of emotions and organic illness To facilitate the maintenance of effective verbal and non verbal communication To promote the development of productive interpersonal relationships To facilitate progress toward achievement of personal spiritual goals To create and / or maintain a therapeutic environment To facilitate awareness of self as an individual with varying physical , emotional, and developmental needs RESTORATIVE CARE NEEDS To accept the optimum possible goals in the light of limitations, physical and emotional To use community resources as an aid in resolving problems arising from illness To understand the role of social problems as influencing factors in the case of illness Abdellah's 21 problems are actually a model describing the "arenas" or concerns of nursing, rather than a theory describing relationships among phenomena. In this way, the theory distinguished the practice of nursing, with a focus on the 21 nursing problems, from the practice of medicine, with a focus on disease and cure.

ABDELLAHS THEORY AND NURSING

Although Abdellahs writings are not specific as to a theoretical statement, such a statement can be derived by using her three major concepts of health, nursing problems, and problem solving. Abdellahs theory would state that nursing is the use of the problem solving approach with key nursing problems related to health needs of people. Such a statement maintains problem solving as the vehicle for the nursing problems as the client is moved toward health the outcome Acc to her, nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs. Health is a dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimum use of necessary resources that serve to minimize vulnerabilities Nursing problem presented by a client is a condition faced by the client or clients family that the nurse through the performance of professional functions can assist them to meet . The problem can be either an overt or covert nursing problem.

NURSING

HEALTH

NURSING PROBLEMS

An overt nursing problem is an apparent condition faced by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions. The covert nursing problem is a concealed or hidden condition faced, by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions In her attempt to bring nursing practice into its proper relationship with restorative and preventive measures for meeting total client needs, she seems to swing the pendulum to the opposite pole, from the disease orientation to nursing orientation, while leaving the client somewhere in the middle. The problem solving process involves identifying the problem, selecting pertinent data, formulating hypothesis, testing hypothesis through the collection of data, and revising hypothesis where necessary on the basis of conclusions obtained from the data. HENDERSON 1. Breathe normally 2. Eat and drink adequately 3. Eliminate by all avenues of elimination 4. Move & maintain desirable posture 5. Sleep & rest 6. Select suitable clothing 7. Maintain body temperature 8. Keep body clean and well groomed & protect the integument ABDELLAH 1. To facilitate the maintenance of a supply of oxygen to all body cells 2. To facilitate the maintenance of nutrition of all body cells 3. To facilitate the maintenance of fluid and electrolyte balance 4. To facilitate the maintenance of elimination 5. To maintain good body mechanics and prevent and correct deformities 6. To promote optimal activity: exercise , rest and sleep 7. To facilitate the maintenance of regulatory mechanisms and functions 8. To maintain good hygiene and physical comfort

PROBLEM SOLVING

COMPARISON WITH OTHER THEORIES MASLOW

Physiological needs

Safety needs

9. Avoid environmental dangers & avoid injuring others

9. To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 10. To facilitate the maintenance of sensory function

Belongingness & love needs

10. Communicate with others 11. Worship according to faith

11.To facilitate the maintenance of effective verbal and non verbal communication 12. To promote the development of productive interpersonal relationships 13. To facilitate progress toward achievement of personal spiritual goals

Esteem needs

12. Work at something providing a sense of accomplishment 13. Play or participate in various forms of recreation 14. Learn, discover, or satisfy curiosity

14. To accept the optimum possible goals in the light of limitations, physical and emotional 15. To recognize the physiological responses of the body to disease conditions 16. To identify and accept positive and negative expressions, feelings, and reactions 17. To identify and accept the interrelatedness of emotions and organic illness 18. To create and / or maintain a therapeutic environment 19. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs 20. To use community resources as an aid in resolving problems arising from illness 21. To understand the role of social problems as influencing factors in the case of illness

Self actualization needs

ABDELLAHS THEORY AND THE FOUR MAJOR CONCEPTS Nursing

Nursing is a helping profession. In Abdellahs model, nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment. Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment. She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope with their health needs. Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largely physical needs, or covert, such as emotional and social needs. Patient is described as the only justification for the existence of nursing. Individuals (and families) are the recipients of nursing Health, or achieving of it, is the purpose of nursing services. In Patient Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness. Although Abdellah does not give a definition of health, she speaks to total health needs and a healthy state of mind and body in her description of nursing as a comprehensive service. Society is included in planning for optimum health on local, state, national, and international levels. However, as she further delineated her ideas, the focus of nursing service is clearly the individual. The environment is the home or community from which patient comes.

Person

Health

Society/Environment

ABDELLAHS WORK AND CHARACTERISTICS OF A THEORY Characteristic1

Abdellahs theory has interrelated the concepts of health, nursing problems, and problem solving as she attempts to create a different way of viewing nursing phenomenon The result was the statement that nursing is the use of problem solving approach with key nursing problems related to health needs of people. Problem solving is an activity that is inherently logical in nature Framework seems to focus quite heavily on nursing practice and individuals. This somewhat limit the ability to generalize although the problem solving approach is

Characteristic2

Characteristic 3

readily generalizable to clients with specific health needs and specific nursing problems Characteristic4

One of the most important questions that arise when considering her work is the role of client within the framework. This question could generate hypothesis for testing and thus demonstrates the ability of Abdellahs work to generate hypothesis for testing The results of testing such hypothesis would contribute to the general body of nursing knowledge Abdellahs problem solving approach can easily be used by practitioners to guide various activities within their practice. This is true when considering nursing practice that deals with clients who have specific needs and specific nursing problems Although consistency with other theories exist, many questions remain unanswered ASSESSMENT PHASE

Characteristic5

Characteristic6

Characteristic7

USE OF 21 PROBLEMS IN THE NURSING PROCESS Nursing problems provide guidelines for the collection of data. A principle underlying the problem solving approach is that for each identified problem, pertinent data are collected. The overt or covert nature of the problems necessitates a direct or indirect approach, respectively. The results of data collection would determine the clients specific overt or covert problems. These specific problems would be grouped under one or more of the broader nursing problems. This step is consistent with that involved in nursing diagnosis The statements of nursing problems most closely resemble goal statements. Therefore, once the problem has been diagnosed, the goals have been established. Given that these problems are called nursing problems, then it becomes reasonable to conclude that these goals are basically nursing goals. Using the goals as the framework, a plan is developed and appropriate nursing interventions are determined.

NURSING DIAGNOSIS

PLANNING PHASE

IMPLEMENTATION

EVALUATION

According to the American Nurses Association Standards of Nursing Practice, the plan is evaluated in terms of the clients progress or lack of progress toward the achievement of the stated goals. This would be extremely difficult if not impossible to do for Abdellahs nursing problem approach since it has been determined that the goals are nursing goals, not the client goals. Thus, the most appropriate evaluation would be the nurse progress or lack of progress toward the achievement of the stated goals.

AN illustration of the implementation of Abdellahs framework in Ryans care Consider a case of Ryan who experienced severe crushing chest pain shortness of breath, tachycardia and profuse diaphoresis

Stage of illness is basic to care Selected Abdellah nursing problem To maintain good hygiene and personal comfort Classification and approach Overt problem of pain; Direct and indirect method Selected Nursing Interventions

administer oxygen elevate headrest reposition client administer prescribed analgesic remain with client

Criterion measure- Amount of pain

CONCEPT OF PROGRESSIVE PATIENT CARE PPC is defined as better patient care through the organization of hospital facilities, services and staff around the changing medical and nursing needs of the patient PPC is tailoring of hospital services to meet patients needs PPC is caring for the right patient in the right bed with the right services at the right time PPC is systematic classification of patients based on their medical needs

Elements of PPC 1. Intensive care

Critically and seriously ill patients requiring highly skilled nursing care, close and frequent if not constant, nursing observation are assigned to the ICU. One patient in an ICU requires at least three nurses to observe him in 24 hrs

2. Intermediate care

Patients assigned to this unit are both the moderately ill and those for whom the treatment can only be palliative Ambulatory patients who are convalescencing or require diagnosis or therapy may be cared for in this unit This unit will provide services to certain patients now cared for in the general hospital, in nursing homes, or in their own homes and who would benefit by care in a hospital environment to achieve its maximum potential This programme makes it possible to extend needed services to the patient after he leaves the hospital and returns to his home in the community

3. Self care

4. Long term care unit

5. Home care

Benefits of PPC PATIENT

better attention better adjustment minimized problems life saving care constant medical and nursing care assuring best nursing care drugs and equipments at hand orders carried out effectively better clinical an team service effective and efficient use of staff improved public image individual skills can be used more time with patient helping pt. and family to solve problems job satisfaction in-service education continuity with hospital services minimize the need of hospitalization

PHYSICIAN

HOSPITAL

NURSING PERSONNEL

COMMUNITY

Implications of PPC for nursing education

Many nurse educators feel that the PPC hospital where all five phases of care are available can provide clinical experience in which the nurse can learn to solve basic nursing problems in meeting patients needs. The three month assignment of professional nurses may no longer be realistic in such a setting. In the intensive care unit, the critically ill patients are concentrated regardless of diagnosis. These patients are under the constant audio-visual observation of the nurse, with life saving techniques and equipment immediately available In the intermediate care unit are concentrated patients requiring a moderate amount of nursing care, not of an emergency nature, who are ambulatory for short periods, and who are beginning to participate in he planning of their own care The self-care unit provides for patients who are physically self-sufficient and require diagnostic and convalescent care in hotel-type accommodations. This unit serves as a link between the hospital and the home. In the long-term care unit are concentrated patients requiring prolonged care. The grouping of such patients will permit staffing patterns that are less costly Home care, the fifth element of progressive patient care, extends hospital services into the home to assist the physician in the care of his patients The patient centered approach was constructed to be useful to nursing practice, with impetus for it being nursing education. Abdellahs publications on nursing education began with her dissertation; her interest in education for nurses continues into the present. Cont Abdellah has also published on nursing, nursing research, and public policy related to nursing in several international publications. She has been a strong advocate for improving nursing practice through nursing research It helped to bring structure and organization to what was often a disorganized collection of lectures and experiences. She categorized nursing problems based on the individuals needs and developed developed a typology of nursing treatment and nursing skills.. She has been a leader in nursing research and has over one hundred publications related to nursing care, education for advanced practice in nursing and nursing research.

Organization of hospital and community services based on patients needs

USEFULNESS

VALUE IN EXTENDING NURSING SCIENCE

NURSING RESEARCH

LIMITATIONS

Very strong nursing centered

orientation

Little emphasis on what the client is to achieve Her framework is inconsistent with the concept of holism Potential problems might be overlooked Using Abdellahs concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived is the use of the problem solving approach with key nursing problems related to health needs of people. From this framework, 21 nursing problems were developed Abdellahs theory provides a basis for determining and organizing nursing care. The problems also provide a basis for organizing appropriate nursing strategies. It is anticipated that by solving the nursing problems, the client would be moved toward health. The nurses philosophical frame of reference would determine whether this theory and the 21 nursing problems could be implemented in practice.

SUMMARY

CONCLUSIONS

REFERENCES 1. George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990. 2. Abdellah, F.G. The federal role in nursing education. Nursing outlook. 1987, 35(5),224-225. 3. Abdellah, F.G. Public policy impacting on nursing care of older adults .In E.M. Baines (Ed.), perspectives on gerontological nursing. Newbury, CA: Sage publications. 1991. 4. Abdellah, F.G., & Levine, E. Preparing nursing research for the 21st century. New York: Springer. 1994. 5. Abdellah, F.G., Beland, I.L., Martin, A., & Matheney, R.V. Patient-centered approaches to nursing (2nd ed.). New York: Mac Millan. 1968. 6. Abdellah, F.G. Evolution of nursing as a profession: perspective on manpower development. International Nursing Review, 1972); 19, 3.. 7. Abdellah, F.G.). The nature of nursing science. In L.H. Nicholl (Ed.), perspectives on nursing theory. Boston: Little, Brown, 1986.