Health Assessment Lecture: Respiratory System D

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

Thoracic Percussion

Percussion sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. The nurse uses percussion to determine whether underlying tissues are filled with air, fluid, or solid material. Percussion also is used to estimate the size and location of certain structures within the thorax (eg, diaphragm, heart, liver).

Percussion usually begins with the posterior thorax. Ideally, the patient is in a sitting position with the head flexed forward and the arms crossed on the lap. This position separates the scapulae widely and exposes more lung area for assessment. The nurse percusses across each shoulder top, locating the 5-cm width

of resonance overlying the lung apices. Then the nurse proceeds down the posterior thorax, percussing symmetric areas at 5- to 6-cm (2- to 2.5-inch) intervals. The middle finger is positioned parallel to the ribs in the intercostal space; the finger is placed firmly against the chest wall before striking it with the middle finger of the opposite hand. Bony structures (scapulae or ribs) are not percussed.

Percussion over the anterior chest is performed with the patient in an upright position with shoulders arched backward and arms at the side. The nurse begins in the supraclavicular area and proceeds downward, from one intercostal space to the next. In the female patient, it may be necessary to displace the breasts for an adequate examination. Dullness noted to the left of the sternum between the third and fifth intercostal spaces is a normal finding because it is the location of the heart. Similarly, there is a normal span of liver dullness in the right thorax from the fifth intercostal space to the right costal margin at the midclavicular line. The anterior and lateral thorax is examined with the patient in a supine position. If the patient cannot sit up, percussion of the posterior thorax is performed with the patient positioned on the side. Dullness over the lung occurs when air-filled lung tissue is replaced by fluid or solid tissue. 

DIAPHRAGMATIC EXCURSION

The normal resonance of the lung stops at the diaphragm. The position of the diaphragm is different during inspiration than during expiration. To assess the position and motion of the diaphragm, the nurse instructs the patient to take a deep breath and hold it while the maximal descent of the diaphragm is percussed. The point at which the percussion note at the midscapular line changes from resonance to dullness is marked with a pen. The patient is then instructed to exhale fully and hold it while the nurse again percusses downward to the dullness of the diaphragm. This point is also marked. The distance between the two markings indicates

the range of motion of the diaphragm. Maximal excursion of the diaphragm may be as much as 8 to 10 cm (3 to 4 inches) in healthy, tall young men, but for most people it is usually 5 to 7 cm (2 to 2.75 inches). 

Normally, the diaphragm is about 2 cm (0.75 inches) higher on the right because of the position of the heart and the liver above and below the left and right segments of the diaphragm, respectively. Decreased diaphragmatic excursion may occur with pleural effusion and emphysema. An increase in intra-abdominal pressure, as in pregnancy or ascites, may account for a diaphragm that is positioned high in the thorax.

Health Assessment Lecture: Respiratory System C

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

Thoracic Palpation

The nurse palpates the thorax for tenderness, masses, lesions, respiratory excursion, and vocal fremitus. If the patient has reported an area of pain or if lesions are apparent, the nurse performs direct palpation with the fingertips (for skin lesions and subcutaneous masses) or with the ball of the hand (for deeper masses or

generalized flank or rib discomfort).

RESPIRATORY EXCURSION

Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. The nurse assesses the patient for range and symmetry of excursion. The patient is instructed to inhale deeply while the movement of the nurse’s thumbs (placed along the costal margin on the anterior chest wall) during inspiration and expiration is observed. This movement is normally symmetric. 

Posterior assessment is performed by placing the thumbs adjacent to the spinal column at the level of the tenth rib. The hands lightly grasp the lateral rib cage. Sliding the thumbs medially about 2.5 cm (1 inch) raises a small skinfold between the thumbs. The patient is instructed to take a full inspiration and to exhale fully. The nurse observes for normal flattening of the skinfold and feels the symmetric movement of the thorax.

Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction.

TACTILE FREMITUS

Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. This is especially true of consonant sounds. The detection of the resulting vibration on the chest wall by touch is called tactile fremitus.

Normal fremitus is widely varied. It is influenced by the thickness of the chest wall, especially if that thickness is muscular. However, the increase in subcutaneous tissue associated with obesity may also affect fremitus. Lower-pitched sounds travel better through the normal lung and produce greater vibration of the chest wall. Thus, fremitus is more pronounced in men than in women because of the deeper male voice. 

Normally, fremitus is most pronounced where the large bronchi are closest to the chest wall and least palpable over the distant lung fields. Therefore, it is most palpable in the upper thorax, anteriorly and posteriorly. The patient is asked to repeat “ninety-nine” or “one, two, three,” or “eee, eee, eee” as the nurse’s hands move down the patient’s thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared . Bony areas are not tested.

Air does not conduct sound well but a solid substance such as tissue does, provided that it has elasticity and is not compressed. Thus, an increase in solid tissue per unit volume of lung will enhance fremitus; an increase in air per unit volume of lung will impede sound. Patients with emphysema, which results in the rupture of alveoli and trapping of air, exhibit almost no tactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased tactile fremitus over that lobe. Air in the pleural space will not conduct sound.

Health Assessment Lecture: Respiratory System B

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING

Thorax

Inspection of the thorax provides information about the musculoskeletal structure, the patient’s nutritional status, and the respiratory system. The nurse observes the skin over the thorax for color and turgor and for evidence of loss of subcutaneous tissue. It is important to note asymmetry, if present. When findings are

recorded or reported, anatomic landmarks are used as points of reference

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CHEST CONFIGURATION

Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1 2. However, there are four main deformities of the chest associated with respiratory disease that alter this relationship: barrel chest, funnel chest (pectus excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis.

Barrel Chest. Barrel chest occurs as a result of overinflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The appearance of the patient with advanced emphysema is thus quite characteristic and often allows the observer to detect its presence easily, even from a distance.

Funnel Chest (Pectus Excavatum). Funnel chest occurs when there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfan’s syndrome.

Pigeon Chest (Pectus Carinatum). A pigeon chest occurs as a result of displacement of the sternum. There is an increase in the anteroposterior diameter. This may occur with rickets, Marfan’s syndrome, or severe kyphoscoliosis.

Kyphoscoliosis. A kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.

BREATHING PATTERNS AND RESPIRATORY RATES

Observing the rate and depth of respiration is a simple but important aspect of assessment. The normal adult who is resting comfortably takes 12 to 18 breaths per minute. Except for occasional sighs, respirations are regular in depth and rhythm. This normal pattern is described as eupnea. 

Bradypnea, also called slow breathing, is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea, or rapid breathing, is commonly seen in patients with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, and rib fracture.  Shallow, irregular breathing is referred to as hypoventilation. An increase in depth of respirations is called hyperpnea. 

An increase in both rate and depth that results in a lowered arterial PCO2 level is referred to as hyperventilation. With rapid breathing, inspiration and expiration are nearly equal in duration. Hyperventilation that is marked by an increase in rate and depth, associated with severe acidosis of diabetic or renal origin, is called Kussmaul’s respiration.

Apnea describes varying periods of cessation of breathing. If sustained, apnea is life-threatening.

Cheyne-Stokes respiration is characterized by alternating episodes of apnea (cessation of breathing) and periods of deep breathing. Deep respirations become increasingly shallow, followed by apnea that may last approximately 20 seconds. The cycle repeats after each apneic period. The duration of the period of apnea may vary and may progressively lengthen; therefore, it is timed and reported. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced, tumor, trauma).

Biot’s respirations, or cluster breathing, are cycles of breaths that vary in depth and have varying periods of apnea. Biot’s respirations are seen with some central nervous system disorders.

Certain patterns of respiration are characteristic of specific disease states. Respiratory rhythms and their deviation from normal are important observations that the nurse reports and documents. The rate and depth of different patterns of respiration are presented

In thin people, it is quite normal to note a slight retraction of the intercostal spaces during quiet breathing. Bulging during expiration implies obstruction of expiratory airflow, as in emphysema. Marked retraction on inspiration, particularly if asymmetric, implies blockage of a branch of the respiratory tree. Asymmetric bulging of the intercostal spaces, on one side or the other, is created by an increase in pressure within the hemithorax. This may be a result of air trapped under pressure within the pleural cavity where it does not normally appear (pneumothorax) or the pressure of fluid within the pleural space (pleural effusion).

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Nursing Theory Lecture 15: Myra Estrin Levine

Myra Estrin Levine

(1973)

Conservation Model

Conservation Model
• Believes nursing intervention is a conservation activity, with conservation of energy as a primary concern, four conservation principles of nursing: conservation of client energy, conservation of structured integrity, conservation of personal integrity, conservation of social integrity.
• Described the Four Conversation Principles. She advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of the individual. The four conservation principles are as follows:
1. Conservation of energy. The human body functions by utilizing energy. The human body needs energy producing input (food, oxygen, fluids) to allow energy utilization output.
2. Conservation of Structural Integrity. The human body has physical boundaries (skin and mucous membrane) that must be maintained to facilitate health and prevent harmful agents from entering the body.
3. Conservation of Personal Integrity. The nursing interventions are based on the conservation of the individual client’s personality. Every individual has sense of identity, self worth and self esteem, which must be preserved and enhanced by nurses.
4. Conservation of Social integrity. The social integrity of the client reflects the family and the community in which the client functions. Health care institutions may separate individuals from their family. It is important for nurses to consider the individual in the context of the family.

Metaparadigm

Person
• A holistic being

Environment
• Broadly, includes all the individual’s experiences

Health
• The maintenance of the client’s unity and integrity

Nursing
• A discipline rooted in the organic dependency of the individual human being on his or her relationship with others

Nursing Theory Lecture 14: Martha Rogers

Martha Rogers

(1970)

Science of Unitary Man

Science of Unitary Man
• Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is concerned with the nature and direction of human development.
• Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the Individual and redirect human and environmental patterns or organization to achieve maximum health.
• 5 basic assumptions:
1. The human being is a unified whole, possessing individual integrity and manifesting characteristics that are more than and different from the sum of parts.
2. The individual and the environment are continuously exchanging matter and energy with each other.
3. The life processes of human beings evolve irreversibly and unidirectionally along a space-time continuum 4. Patterns identify human being and reflect their innovative wholeness.
5. The individual is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion.

Metaparadigm

Person
• Unitary man, a four-dimensional energy field.

Environment
• Encompasses all that is outside any given human field. Person exchanging matter and energy.

Health
• Not specifically addressed, but emerges out of interaction between human and environment, moves forward, and maximizes human potential.

Nursing
• A learned profession that is both science and art. The professional practice of nursing is creative and imaginative and exists to serve people.

Nursing Theory Lecture 13: Madeleine Leininger

Madeleine Leininger

(1978, 1984)

Transcultural Care Theory and Ethnonursing

Transcultural Care Theory and Ethnonursing
• Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition.
• Nursing is a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death.
• Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness caring practices, beliefs and values with the goal to provide meaningful and efficacious nursing care services to people according to their cultural values and health-illness context.
• Focuses on the fact that different cultures have different caring behaviors and different health and illness values, beliefs, and patterns of behaviors.
• Awareness of the differences allows the nurse to design culture-specific nursing interventions.

Nursing Theory Lecture 12: Lydia Hall

Lydia Hall

(1964)

Core, Care and Cure Model

Core, Care and Cure Model
• The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment (cure) and body (care).
• Introduced the model of Nursing: What Is It? Focusing on the notion that centers around three components of Care, Core and Cure.
• Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing related to the physician’s orders. Core and cure are shared with the other health care providers.
• The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core.

Metaparadigm

Person
• Client is composed of body, pathology, and person. People set their own goals and are capable of learning and growing.

Environment
• Should facilitate achievement of the client’s personal goals.

Health
• Development of a mature self-identity that assists in the conscious selection of actions that facilitate growth.

Nursing
• Caring is the nurse’s primary function. Professional nursing is most important during the recuperative period.

Nursing Theory Lecture 11: Joyce Travelbee

Joyce Travelbee 

(1966, 1971) 

Interpersonal Aspects of Nursing 

 

Interpersonal Aspects of Nursing 

• She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing individual or family in preventing or coping with illness, regaining health finding meaning in illness, or maintaining maximal degree of health.

• She further viewed that interpersonal process is a human-to-human relationship formed during illness and “experience of suffering”

• She believed that a person is a unique, irreplaceable individual who is in a continuous process of becoming, evolving and changing.

Metaparadigm 

Person 

• A unique, irreplaceable individual who is in a continuous process of becoming, evolving, and changing.

Environment 

• Not defined

Health 

• Heath includes the individual’s perceptions of health and the absence of disease.

Nursing 

• An interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary, to find meaning in these experiences.

Nursing Theory 10: Jean Watson

Jean Watson 

(1979) 

The Philosophy and Science of Caring 

 The Philosophy and Science of Caring
• Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health.
• Nursing is a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human care transactions
• She defined caring as a nurturing way or responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the person as what he/she may become in a caring environment

Carative Factors:
1. The formation of a humanistic-altruistic system of values
2. Instillation of faith-hope
3. The cultivation of sensitivity to one’s self and others
4. The development of a helping- trust relationship
5. The promotion and acceptance of the expression of positive and negative feelings.
6. The systemic use of the scientific problem-solving method for decision making
7. The promotion of interpersonal teaching-learning
8. The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritual environment
9. Assistance with the gratification of human needs
10. The allowance for existential phenomenological forces

Metaparadigm

Person
• A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, integrated self

Environment 
• Social environment, caring and the culture of caring affect health

Health 
• Physical, mental, and social wellness

Nursing 
• A human science of people and human health; illness experiences that are mediated by professional, personal, scientific, aesthetic, and ethical human care transactions.

Nursing Theory Lecture 9: Imogene King

Imogene King 

(1971, 1981) 

Goal Attainment Theory 

 

Goal Attainment Theory 

• Nursing process is defined as dynamic interpersonal process between nurse, client and health care system.

• Postulated the Goal Attainment Theory. She described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. If is this not possible, nurses help individuals die with dignity.

• In addition, King viewed nursing as an interaction process between client and nurse whereby during perceiving, setting goals, and acting on them transactions occurred and goals are achieved.

Metaparadigm 

Person 

• Biopsychosocial being

Environment 

• Internal and external environment continually interacts to assist in adjustments to change.

Health 

• A dynamic life experience with continued goal attainment and adjustment to stressors.

Nursing 

• Perceiving, thinking, relating, judging, and acting with an individual who comes to a nursing situations

Nursing Theory Lecture 8: Hildegard Peplau

Hildegard Peplau 

(1951) 

Interpersonal Relations Theory 

Interpersonal Relations Theory 
• Defined Nursing: “An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.
• Nursing is a “maturing force and an educative instrument”
• Identified 4 phases of the Nurse - Patient relationship:

1. Orientation - individual/family has a “felt need” and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase.

2. Identification - where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance.

3. Exploitation - the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services.

4. Resolution - where patient’s needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.


Metaparadigm 

Person 
• An organism striving to reduce tension generated by needs

Environment 
• The interpersonal process is always included, and psychodynamic milieu receives attention, with emphasis on the client’s culture and mores.

Health 
• Ongoing human process that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living.

Nursing 
• Interpersonal therapeutic process that “functions cooperatively with others human processes that make health possible for individuals in communities. Nursing is an educative instrument, a maturing force that aims to promote forward movement of personality.

Nursing Theory Lecture 7: Florence Nightingale

Florence Nightingale 

(1860)

Environmental Theory 

Environmental Theory
• Defined Nursing: “The act of utilizing the environment of the patient to assist him in his recovery.”
• Focuses on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.
• Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and light/direct sunlight.
• Considered a clean, well-ventilated, quiet environment essential for recovery.
• Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body could repair itself.
• Developed the described the first theory of nursing. Notes on Nursing: What It Is What It Is Not. She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.


Metaparadigm 

Person 
• An individual with vital reparative processes to deal with disease.

Environment 
• External conditions that affect life and individuals development.

Health 
• Focus is on the reparative process of getting well

Nursing 
• Goal is to place the individual in the best condition for good healthcare

Nursing Theory Lecture 6: Faye Glenn Abdellah

Faye Glenn Abdellah 

(1960) 

Twenty One Nursing Problems 

Twenty One Nursing Problems 
• Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement.
• Introduced Patient – Centered Approaches to Nursing Model She defined nursing as service to individual and families; therefore the society. Furthermore, she conceptualized nursing as an art and a science that molds the attitudes, intellectual competencies and technical skills of the individual nurse into the desire and ability to help people, sick or well, and cope with their health needs.

21 Nursing Problems 
1. To maintain good hygiene.
2. To promote optimal activity; exercise, rest and sleep.
3. To promote safety.
4. To maintain good body mechanics
5. To facilitate the maintenance of a supply of oxygen
6. To facilitate maintenance of nutrition
7. To facilitate maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic response of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory functions
12. To identify and accept positive and negative expressions, feelings and reactions
13. To identify and accept the interrelatedness of emotions and illness.
14. To facilitate the maintenance of effective verbal and non-verbal communication
15. To promote the development of productive interpersonal relationship
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying needs.
19. To accept the optimum possible goals
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


Metaparadigm 

Person 
• The recipients of nursing care having physical, emotional, and sociologic needs that may be overt or covert.

Environment 
• Not clearly defined. Some discussion indicates that clients interact with their environment, of which nurse is a part.

Health 
• A state when the individual has no unmet needs and no anticipated or actual impairment.

Nursing 
• Broadly grouped in “21 nursing problems,” which center around needs for hygiene, comfort, activity, rest, safety, oxygen, nutrition, elimination, hydration, physical and emotional health promotion, interpersonal relationships, and development of self-awareness. Nursing care is doing something for an individual

Nursing Theory Lecture 5: Ernestine Wiedenbach

Ernestine Wiedenbach 

(1964) 

The Helping Art of Clinical Nursing 

The Helping Art of Clinical Nursing
• Developed the Clinical Nursing – A Helping Art Model.
• She advocated that the nurse’s individual philosophy or central purpose lends credence to nursing care.
• She believed that nurses meet the individual’s need for help through the identification of the needs, administration of help, and validation that actions were helpful. Components of clinical practice: Philosophy, purpose, practice and an art.



Metaparadigm 

Person
• Any individual who is receiving help from a member of the health profession or from a worker in the field of health.

Environment 
• Not specifically addressed

Health 
• Concepts of nursing, client, and need for help and their relationships imply health-related concerns in the nurse—client relationship.

Nursing 
• The nurse is a functional human being who acts, thinks, and feels. All actions, thoughts, and feelings underlie what the nurse does

Nursing Theory Lecture 4: Dorothy Johnson

Dorothy E. Johnson 

(1980) 

Behavioral System Model 

Behavioral System Model 
• Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move more easily through recovery.
• Viewed the patient’s behavior as a system, which is a whole with interacting parts.
• The nursing process is viewed as a major tool.
• To reduce stress so the client can recover as quickly as possible. According to Johnson, each person as a behavioral system is composed of seven subsystems namely:
1.Ingestive. Taking in nourishment in socially and culturally acceptable ways.
2.Eliminated. Riddling the body of waste in socially and culturally acceptable ways.
3.Affiliative. Security seeking behavior.
4.Aggressive. Self – protective behavior.
5.Dependence. Nurturance – seeking behavior.
6.Achievement. Master of oneself and one’s environment according to internalized standards of excellence.
7.Sexual role identity behavior

• In addition, she viewed that each person strives to achieve balance and stability both internally and externally and to function effectively by adjusting and adapting to environmental forces through learned pattern of response. Furthermore, She believed that the patient strives to become a person whose behavior is commensurate with social demands; who is able to modify his behavior in ways that support biologic imperatives; who is able to benefit to the fullest extent during illness from the health care professional’s knowledge and skills; and whose behavior does not give evidence of unnecessary trauma as a consequence of illness.


Metaparadigm

Person 
•A system of interdependent parts with patterned, repetitive, and purposeful ways of behaving.

Environment 
•All forces that affect the person and that influence the behavioral system

Health 
•Focus on person, not illness. Health is a dynamic state influenced by biologic, psychological, and social factors

Nursing 
•Promotion of behavioral system, balance and stability. An art and a science providing external assistance before and during balance disturbances