The Use of Orem’s Theory of Self-Care Deficiency in the Patient with Delirium: A Case Study

Abstract

Delirium is a common and costly problem in intensive care unit patients. For this reason, it is very important for the nurses who care for the patient who develops delirium to recognize, evaluate and plan the care of delirium. This case; The patient who applied to the emergency room with the complaint of shortness of breath and was taken to the intensive care unit and developed delirium; It is planned to provide care according to Orems “Self-Care Insufficiency Theory”. Patient data were collected according to all the steps included in the theory. Three main factors affected the patients self-care needs: COPD diagnosis, delirium, and agitation. Nursing interventions were planned and implemented based on these data.

Keywords: Delirium; Psychiatric nursing; Orems self-care theory

Introduction

Delirium is one of the complications frequently encountered in intensive care units and has a high cost [4]. delirium; It is a condition characterized by an acute change and fluctuation in consciousness and a decrease in thought and attention. It is a medical emergency that prolongs the length of stay in the intensive care unit, increases mortality, prolongs the time of connecting the patient to mechanical ventilator, and leads to significant functional impairments (APA, 2013). The Canadian Society for Cardiovascular Critical Care (CANCARE) Researcher Group (2017) interviewed patients in the intensive care unit who entered delirium and were treated and whose symptoms improved. In these talks; patients' fear, anxiety, loneliness, hallucinations, changes in the environment and nurses' approach to patients; It has been shown to have great implications for patients. The best intervention for delirium in intensive care units is prevention. Nurses, who are care professionals who spend the most time with the patient, have great duties to know the approaches to prevent delirium among the team members working in the intensive care unit. For this reason, one of the roles of nurses in recognizing delirium in the early period is to communicate with patients and their relatives. Nursing as a professional profession; While the theories and models they use in the fields of education, management, practice and research form the conceptual framework of the profession, they also provide convenience in terms of the service to be provided. The most important purpose of benefiting from theory and models is to increase the quality of care to be given to the patient and to contribute to the development and maintenance of health.

In intensive care units, patients should be routinely evaluated for delirium using a standard method/tool. Among the tools that nurses frequently use and recommended in clinical practice guidelines for delirium are the Delirium Control Scale and the Confusion Rating Scale. The nurse should plan their practices according to the type of delirium while giving care. Although patients with hyperactive delirium are noticed and handled more frequently due to behavioral and emotional disorders; Since the diagnosis of hypoactive delirium requires a high level of clinical knowledge and skill, this picture cannot be managed appropriately. However, since hypoactive delirium has a worse prognosis, early diagnosis and treatment is extremely important. Patients in hypoactive delirium are at risk for long-term mechanical ventilation and complications related to aspiration, nosocomial pneumonia, pressure ulcers, and venous thromboembolism. In addition, since hypoactive delirium is often confused with depression in intensive care units, nurses should also evaluate delirium in patients diagnosed with depression.

It was first updated by Dorethea Elizabeth Orem as “Self-Care Theory” in 1956 and as “Self-Care Deficit Nursing Theory” in the following years [12]. The nursing theory of lack of self-care is frequently used. The theory is a combination of three separate combinations (Self-care theory, self-deficiency theory, nursing systems) and six core concepts (self-care, therapeutic self-care needs, self-care power, self-care deficiency, nursing power, and nursing system). environmental concept (main situational factors) [6]. intensive care nurses; In addition to the care and treatment of patients, they are responsible for establishing a therapeutic relationship with the patient and for preventive and rehabilitative interventions. The aim of this study is to explain the use of Orem's Self-Care Deficit Theory in a patient who is hospitalized in the intensive care unit and develops delirium. Care was carried out with the nursing process system on the basis of Orem's Self-Care Deficit Theory.

Case

Medical Diagnosis

He was referred to the emergency department of our hospital by 112 ambulance on 05.06.2021 with the complaints of shortness of breath and blurred consciousness. The patient evaluated in the emergency service due to the low oxygen saturation, 35/min respiratory rate and 70 carbon dioxide value in the blood gas, due to the need for intensive care, anesthesia. admitted to the intensive care unit.

Patient Selection and Ethical Dimension

Patient; It was chosen randomly because delirium developed after being admitted to the intensive care unit with chronic obstructive pulmonary disease. Written and verbal consent was obtained from the relatives of the patient. Confidentiality of personal information is assured. In addition, the relatives of the patients were informed that their participation in this study was on a voluntary basis and would not affect the patient's treatment in the intensive care unit.

Nursing Process Based on Orem's Self-Care Theory

Basic Situational Factors

Patient's Name and Surname: B.A.

Age: 64

Gender: Male

Health Status: He was admitted to the hospital due to shortness of breath and blurred consciousness.

Developmental Status:

Patient's height: 1.68

Patient's weight: 55

Socio-Cultural Characteristics: The patient lives in Yenisu neighborhood of Çumra district of Konya province. Income is not good.

Health Care System: Social Security Institution

Family System: Nuclear family

Lifestyle: The patient, who lives at home with his wife, continues his life by receiving oxygen therapy with an oxygen concentrator for a long time.

Environmental Situation: According to the information received from the relatives of the patient, it was stated that in addition to his wife, the patient's children and neighbors frequently visit him.

Availability and adequacy of resources: The patient leads a life dependent on his partner with increased dyspnea in physical activity.

Self Care

It is defined as the behaviors that a person does to protect, develop and maintain his health. Age, developmental style, socio-cultural status, lifestyle, availability of available resources and adequacy affect a person's self-care adequacy [10,11,15]. She has a limited ability to continue her life due to the fact that she has blurred consciousness.

Self Care Power

According to Orem's theory, a person is defined as having the power to take care of herself or someone else and be aware of her needs, and this power differs according to personality traits. People acquire their self-care power from the environment they live in [10,18]. Self-care power could not be evaluated using the “Self-care power scale” since the patient's perceptual, cognitive and emotional competence was weak [17]. The variables that reveal the self-care power of the patient were observed by the nurse and evaluated.

Self-confidence and respect: While speaking with the patient, eye communication and meaningful verbal communication could not be established.

Ability to control and initiate his/her energy: The patient is constantly in motion in the bed. Only the upper extremities of the patient were restrained by filling out the constraint form used in the intensive care unit so that she would not pull the intrachetosis in her arm and remove the oxygen mask.

Adequacy of understanding: While the patient has a person orientation, there is no place and time orientation. In the communication established with the patient, the patient gives meaningless answers to the questions asked and cannot continue the cooperation.

Motivation: The patient taps the edge of the bed to express his needs and the nurse goes to meet his needs. The patient is motivated by the nurse and the caregiver staff working in the intensive care unit.

Making a decision about self-care: Since the patient cannot fulfill his own self-care, only the nurse makes the decision about self-care.

Ability to obtain and apply technical knowledge: Since the patient has blurred consciousness, the ability to obtain and apply technical knowledge is weak.

Perceptual, cognitive status and communication skills: Since the cognitive status of the patient is very weak, communication skills are also weak. While partially obeying the given commands, it gives meaningless answers to some questions.

The ability to regulate self-care behaviors and integrate self-care behaviors into individual and social life to achieve their goals: There is no ability to regulate self-care behavior.

Therapeutic Self-Care Requirements

The person's self-care needs; Orem examines self-care needs in three sub-classes.

Universal Self-Care Requirements: Meeting the person's life activities such as air, water, nutritional needs, ensuring the normal continuity of excretion and defecation, providing activity and rest, solitude and social interaction [12].

Air: The patient's oxygen saturation is 78 without oxygen, and the respiratory rate is 35/min.

Environment: Adjusting the lights, ventilation and heating of the intensive care unit is necessary to create a safe environment.

Hygiene: Applications such as hand-face care, oral care, daily body care, perineum care, cleanness and smoothness of bed sheets and pillows.

Nutrition: It was observed that the patient, whose dyspnea continued with physical activity, had nutritional deficiency and oral intake was low.

Excretion and Defecation: The patient has urine and stool control. He urinates to a duck, and his stool is to the patient's diaper.

Activity: The patient was very active in the bed. He constantly tried to get out of the bed, and his upper extremities were restrained so that he would not hurt himself.

Sleep: The patient does not distinguish between day and night. He sleeps intermittently for a total of 4 hours in a 24-hour period. For this, xanax 0.5 mg was started upon the doctor's request.

Protection from dangers: There is a risk of accident and trauma due to the patient's agitation.

Social activity: The information that he likes to spend time with the family was obtained from his relatives.

Developmental Self-Care Needs: It is defined as the needs that occur during the developmental periods of the individual [12]. The patient is in the young group according to the World Health Organization age classification. His height is 1.68 cm and his weight is 55 kg. While the patient behaved appropriately for her age before she was admitted to the intensive care unit, her agitation increased with the development of delirium in the intensive care unit, and it was observed that she could not meet the individual hygiene requirements.

Health Deviation Self-Care Requirements: Universal and developmental self-care needs that cannot be met due to the needs or limitations that arise in case of illness or disability [12]. The individual needs nursing care [10]. The patient's shortness of breath and confusion affect the quality of life. They need to be supported in increasing their knowledge and skills related to self-care.

Lack of Self Care

A person's self-care power emerges when she cannot meet her needs [13]. Our patient, who is in the intensive care unit, whose shortness of breath increases with physical activity, and who is under restraint due to agitation, is completely dependent on the nurse. The duty of the nurse; It is necessary for the individual to minimize the practices that he can do, to be supported where he needs to be supported, and to be informed about the limitations of the care his family will give to the patient.

Nursing Power

Orem defines nursing as “action or series of actions performed for a purpose” [12]. Nursing power includes three interrelated systems. These; social system, interpersonal system and professional-technological system [12,14,16]. In addition to following critical patients, nurses working in the intensive care unit need to be informed about the ability to move, to perform care behaviors that patients can do, to activate support systems, to maintain communication skills, and to care for family members.

Nursing System

Three basic nursing systems are defined in the interventions to meet the needs of the patient. These; the patient has no active activity in self-care and the nurse is at the forefront of "Completely correcting the deficiency", the nurse and the patient's care needs and other interventions together "partially correcting the deficiency" and the patient has the ability to learn to realize the necessary self-care needs and learn It is the “Supportive educational” nursing system that is required but cannot do this without assistance [11]. Nursing diagnoses in line with patient data; “Insufficient Airway Openness, Pain, Deficiency in Individual Care, Insomnia, Nutritional Disorder, Restricted Physical Activity, Impairment in Verbal Communication, and Death Anxiety”. It has been found that nurses working in intensive care have difficulties in recognizing and meeting psychiatric care needs while giving care to patients [1]. For this reason, only "Insomnia, Impaired Verbal Communication, and Death Anxiety" among nursing diagnoses have been discussed.

Results

Nursing Diagnosis 1. “Sleep Pattern Disruption” due to the observation that the patient sleeps for 4 hours intermittently in a 24-hour shift.

Nursing Assistance Method: Completely deficient

Purpose: It is to tell the patient that he is getting enough sleep.

Nursing Interventions

- Continuous communication was made with the patient in order to reduce the patient's fear and anxiety.

- In order to distinguish between day and night, the lights of the intensive care unit were reduced at night.

- Noise has been reduced to a minimum.

Evaluation: Despite nursing care, the patient resisted not sleeping. Breath Continuation of the complaint of stenosis developed death anxiety in the patient. At the doctor's request, xanax 0.5 mg was started.

Nursing Diagnosis 2. “Death Anxiety” due to the patient's constant saying "I'm going to die, don't leave me alone, they came to get me"

Nursing Assistance Method: Completely deficient

Purpose: To relieve the death anxiety of the individual.

Nursing Interventions:

- Anxiety symptoms (insomnia, agitation, tachypnea) were evaluated.

- Communication with the patient in plain language was established and maintained.

- Information was given about the reason why the patient was in the intensive care unit.

- Factors increasing anxiety in intensive care unit were reduced.

- The patient was able to communicate with his relatives.

- Information about the coping methods of the patient and his family was given.

Evaluation: The patient's anxiety was partially reduced. Whether he used effective coping methods or not could not be evaluated because he was discharged.

Nursing Diagnosis 3. “Impairment in Verbal Communication” due to the decrease in the understanding ability of the patient

Nursing Assistance Method: Completely deficient

Purpose: To ensure the continuity of therapeutic communication skills with the individual

Nursing Interventions:

- The patient's attention was focused on a single point.

- Spoken openly and clearly by looking at the face of the individual.

- The noise in the intensive care environment has been minimized.

- Touching, hand and arm movements were frequently used to maintain communication with the individual.

- The individual was encouraged to speak slowly and to say each word clearly.

Evaluation: The problem has been partially fixed.

Discussion and Conclusion

Patients hospitalized in the intensive care unit are one of the patient groups in which a lack of self-care is detected by the nurses and care is given for this. In this study; Nursing care based on Orem's Self-Care Deficit Theory was planned and evaluated for the diagnosis of delirium in a patient under treatment in the intensive care unit. In the care of the case under consideration, although the theory provided a versatile evaluation opportunity in determining the self-care needs, different guides were needed while applying nursing interventions.

A theoretical framework was needed to sustain psychiatric care. For this reason, the use of Orem's Self-Care Deficit Theory is very important in psychiatric nursing. From this point of view, Orem's Self-Care Deficit Theory is used in individuals with a diagnosis of physical illness; It has also been used in many studies on individuals with a diagnosis of psychiatric illness with a diagnosis of depression, schizophrenia, and obsessive disorder [3].

Psychiatric diseases, which may be caused by different problems, may occur in intensive care patients. Physiological abnormalities and their treatment can cause delirium. However, rapid recognition, diagnosis and treatment of delirium can reduce morbidity, mortality and hospital stay [2]. It is important for intensive care nurses to recognize psychiatric disorders that may develop in order to provide holistic care, instead of focusing only on physiological needs. In the literature review, no study was found in accordance with Orem's Self-Care Deficit Theory of the patient who was hospitalized in the intensive care unit and developed delirium. For this reason, it is thought that this case report will guide consultation liaison psychiatry nurses.

Nurses have important roles in integrative patient care. According to the theory of Orem; The nurse is to determine the self-care needs of the patient, to meet these needs, to support the patient to be self-sufficient, to make the patient independent by providing education and counseling services to the patient and his family. The ability of patients who are hospitalized in the intensive care unit and who develop delirium at the same time to perform self-care behaviors is limited and inadequate. For this reason, considering "Orem's Self-Care Theory", it is one of the easy theories to be applied for many patients in intensivecare. According to the theorist's theory; It has become easier to determine and implement the nursing needs determined in the case. It is thought that providing care by nurses by making use of theorists for professional development will lead to an increase in scientific knowledge in this field, the development of the profession, and nurses to take practical and easier decisions.

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