Application of Orem's Self-Care

Deficit theory
OBJECTIVES

to assess the patient condition by the various methods explained by

the nursing theory

to identify the needs of the patient

to demonstrate an effective communication and interaction with the

patient.

to select a theory for the application according to the need of the

patient

to apply the theory to solve the identified problems of the patient

to evaluate the extent to which the process was fruitful.

P AT I E N T P R O F I L E

Areas

Patient details

Name
Age
Sex
Education
Occupation
Marital status
Religion
Diagnosis
Theory applied

Mrs. X
56 years
Female
No formal education
House hold
Married
Hindu
Rheumatoid arthritis
Orems theory of self care deficit.

OREMS THEORY OF SELF CARE DEFICIT

The self care deficit theory proposed by Orem is a combination of

three theories, i.e. theory of self care, theory of self care deficit and
the theory of nursing systems.

In the theory of self care, she explains self care as the activities
carried out by the individual to maintain their own health.

The self care agency is the acquired ability to perform the self care
and this will be affected by the basic conditioning factors such as
age, gender, health care system, family system etc.

Therapeutic self-care demand is the totality of the self care

measures required.

The self care is carried out to fulfill the self-care requisites.

There are mainly 3 types of self care requisites such as universal,

developmental and health deviation self care requisites.

Whenever there is an inadequacy of any of these self care

requisite, the person will be in need of self care or will have a deficit
in self care.

The deficit is identified by the nurse through the thorough

assessment of the patient.

Once the need is identified, the nurse has to select required nursing
systems to provide care: wholly compensatory, partly compensatory
or supportive and educative system.

The care will be provided according to the degree of deficit the

patient is presenting with.

Once the care is provided, the nursing activities and the use
of the nursing systems are to be evaluated to get an idea
about whether the mutually planned goals are met or not.

Thus the theory could be successfully applied into the nursing

practice.

For Mrs. X.

She came to the hospital with complaints of pain over all the joints,
stiffness which is more in the morning and reduces by the activities.

She has these complaints since 5 years and has taken treatment
from local hospital.

The symptoms were not reducing and came to --MC, Hospital for
further management.

Patient was able to do the ADL by herself but the way she
performed and the posture she used was making her prone to
develop the complications of the disease.

She also was malnourished and was not having awareness about
the deficiencies and effects.

DATA COLLECTION ACCO RDING TO OREMS

THEORY OF SELF CARE DEFICIT

1. BASIC CONDITIONING FACTORS

Age
56 year

Gender

Female

Health state

Disability due to health condition,

therapeutic self care demand

Development state

Ego integrity vs despair

Sociocultural orientation

No formal education, Indian, Hindu

Health care system

Institutional health care

Family system

Married, husband working

Patterns of living

At home with partner

Environment

Rural area, items for ADL not in easy

reach, no special precautions to
prevent injuries

resources

Husband, daughter, sisters son

2. UNIVERSAL SELF-CARE REQUISITES

Air

Breaths without difficulty, no pallor cyanosis

Water

Fluid intake is sufficient. Edema present

over ankles.
Turgor normal for the age

Food

Hb 9.6gm%, BMI = 14.Food intake is not

adequate or the diet is not nutritious.

Elimination

Voids and eliminates bowel without

difficulty.

Activity/ rest

Frequent rest is required due to pain.

Pain not completely relieved,
Activity level ha s come down.
Deformity of the joint secondary to the
disease process and use of the joints.

Social interaction

Communicates well with neighbors and

calls the daughter by phone Need for
medical care is communicated to the
daughter.

Prevention of hazards

Need instruction on care of joints and

prevention of falls. Need instruction on
improvement of nutritional status. Prefer to
walk bare foot.

Promotion of normalcy

Has good relation with daughter

3. DEVELOPMENTAL SELF-CARE REQUISITES

Maintenance of
developmental
environment

Able to feed self , Difficult to perform the

dressing, toileting etc

Prevention/ management Feels that the problems are due to her own
of the conditions
behaviours and discusses the problems with
threatening the normal
husband and daughter.
development

4. HEALTH DEVIATION SELF CARE REQUISITES

Adherence to medical
regimen

Awareness of potential
problem associated with
the regimen

Reports the problems to the physician when

in the hospital. Cooperates with the
medication, Not much aware about the use
and side effects of medicines

Not aware about the actual disease process.

Not compliant with the diet and prevention of
hazards. Not aware about the side effects of
the medications

Modification of self image Has adapted to limitation in mobility.

to incorporates changes in
health status

The adoption of new ways for activities leads

to deformities and progression of the
disease.

Adjustment of lifestyle to Adjusted with the deformities.

accommodate changes in Pain tolerance not achieved
the health status and
medical regimen.

5. MEDICAL PROBLEM AND PLAN

Physicians perspective of the condition: Diagnosed with rheumatoid
arthritis and is on the following medications:

T. Valus SR OD

T. Pan 40 mg OD

T. Tramazac 50 mg OD

T. Recofix Forte BD

T. Shelcal BD

Syp. Heamup 2tsp TID

Medical Diagnosis: Rheumatoid arthritis

Medical Treatment: Medication and physical therapy.
AREAS AND PRIORITY ACCORDING TO OREMS THEORY OF SELFCARE DEFICIT: IMPORTANT FOR PRIORITIZING THE NURSING
DIAGNOSIS.

Air

Water

Food

Elimination

Activity/ Rest

Solitude/ Interaction

Prevention of hazards

Promotion of normalcy

Maintain a developmental environment.

Prevent or manage the developmental threats

Maintenance of health status

Awareness and management of the disease process.

Adherence to the medical regimen

Awareness of potential problem.

modify self image

Adjust life style to accommodate health status changes and MR

NURSING CARE PLAN ACCORDING TO OREMS

THEORY OF SELF CARE DEFICIT
Nursing
diagnosis
(diagnostic
operations)

Based on self
care deficits

Outcome and plan

(Prescriptive
operations)

Implementation
(control
operations)

Evaluation
(regulatory
operations)

Outcome
Nursing goal and
objectives
Design of nursing
system
Appropriate method of
helping

Nurse- patient
actions to
- Promote patient
as self care agent
- Meet self care
needs
- Decrease the self
care deficit.

1. Effectiveness of
the nurse patient
action to
-Promote patient
as self care agent
- Meet self care
needs
- Decrease the
self care deficit.
2. Effectiveness of
the selected
nursing system to
meet the needs.

Thus in the patient Mrs. X the areas that need assistance were

Air

Water

Food

Elimination

Activity/ Rest(2)

Solitude/ Interaction

Prevention of hazards(2)

Promotion of normalcy

Maintain a developmental environment.

Prevent or manage the developmental threats

Maintenance of health status

Awareness and management of the disease process.

Adherence to the medical regimen

Awareness of potential problem.

modify self image

Adjust life style to accommodate health status changes and

medical regimen

APPLYING THE OREMS THEORY OF SELFC ARE DEFICIT, A NURSING CARE PL AN FOR
MRS. X COULD BE PREPARED AS FOLLOWS
A. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: FOOD
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS

Inability to maintain the ideal nutrition related to inadequate intake

and knowledge deficit

OUTCOMES AND PLAN

a. Outcome:

Improved nutrition

Maintenance of a balanced diet with adequate iron

supplementation.

b. Nursing Goals and objectives

Goal: to achieve optimal levels of nutrition.
Objectives: Mrs. X will:

state the importance of maintaining a balanced diet.

List the food items rich in iron , that are available in the locality.

c. Design of the nursing system:

supportive educative

d. Method of helping:

guidance

support

Teaching

Providing developmental environment

IMPLEMENTATION

Mutually planned and identified the objectives and the patient were
made to understand about the required changes in the behaviour to
have the requisites met.

EVALUATION

Mrs. X understood the importance of maintaining an optimum

nutrition.

She told that she will select the iron rich diet for her food.

She listed the foods that are rich in iron and that are locally
available.

The self care deficit in terms of food will be decreased with the
initiation of the nutritional intake.

The supportive educative system was useful for Mrs. X

----------------------------------------------------------------------

B. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: ACTIVITY

ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS

Self-care deficit: dressing, toileting related to restricted joint

movement, secondary to the inflammatory process in the joints.

OUTCOMES AND PLAN

a. Outcome:

improved self-care

maintain the ability to perform the toileting and dressing with

modification as required.

b. Nursing Goals and objectives

Goal: to achieve optimal levels of ability for self care.
Objectives: Mrs. X will:

perform the dressing activities within limitations

utilize the alternative measures available for improving the toileting

perform the other activities of daily living with minimal assistance.

c. Design of the nursing system: Partly compensatory

d. Method of helping:
1. Guidance:

Assess the various hindering factors for self care and how to tackle
them.

2. Support:

Provide all the articles needed for self care, near to the patient and
ask the family members also to give the articles near to her.

Provide passive exercises and make to perform active exercises so

as to promote the mobility of the joint.

Make the patient use commodes or stools to perform toileting and

insist on avoidance of squatting position

Provide assistance whenever needed for the self care activities

Provide encouragement and positive reinforcement for minor

improvement in the activity level.

Initiate the pain relieving measures always before the patient go for
any of the activities of daily living

Make the patient to use loose fitting clothes which will be easy to
wear and remove.

3. Teaching:

Teach the family members the limitation in the activity level the
patient has and the cooperation required

4. Promoting a developmental environment:

Teach the family and help them to practice how to help the patient
according to her needs

IMPLEMENTATION

Mutually planned and identified the objectives and the patient was
made to understand about the required changes in the behaviour to
have the requisites met.

EVALUATION

Patient was performing some of the activities and she practiced

toileting using a commode in the hospital.

She verbalized an improved comfort and self care ability.

She performed the dressing activities with minimal assistance

Patient verbalized that she will perform the activities as instructed

to get her ADL done.

The partly compensatory system was useful for Mrs. X

----------------------------------------------------------------------

C. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA: PAIN

CONTROL

ADEQUACY OF SELF CARE AGENCY: INADEQUATE

NURSING DIAGNOSIS

Ineffective pain control related to lack of utilization of pain relief

measures

OUTCOMES AND PLAN

a. Outcome:

improved pain self control

achieve and maintain a reduction in the pain.

b. Nursing Goals and objectives

Goal: to achieve reduction in the pain.
Objectives: Mrs. X will:

describe the total plan of pharmacological and non

pharmacological pain relief

demonstrate a reduction in the pain behaviours

verbalize a reduction in the pain scale score from 7 4

c. Design of the nursing system: supportive educative

d. method of helping:
Guidance:

Explore the past experience of pain and methods used to manage

them.

Ask the client to report the intensity, location, severity, associated

and aggravating factors.

Support:

Provide rest to the joints and avoid excessive manipulations

provide hot and cold application to have better mobility.

Encourage exercises to the joints by immersing in the warm water.

Administer T. Ultracet and Tab Diclofecac as prescribed.

Provide diversion and psychological support to the patient

Teaching:

Teach the non pharmacological method to the patient once the

pain is a little reduced.

Providing the developmental environment:

Discuss with the patient the necessity to maintain a pain diary with
all information regarding episodes of pain and refer to that
periodically

Enquire from the health team, the need for opioid analgesics or
other analgesics and get a prescription for the patient.

IMPLEMENTATION
----------------------------------------------------------------------------EVALUATION

Patient still has pain over the joints and she agreed that she will
use the measures for pain relief that is told to her.

The pain scale score was 6 after the measures were provided to
the patient.

She demonstrated slight reduction in the pain behaviours.

The supportive educative system was useful for Mrs. X

--------------------------------------------------------------

D. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA:

PREVENTION OF HAZARDS.
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS

Potential for fall and fractures related to rheumatoid arthritis.

OUTCOMES AND PLAN

a. Outcome:

Absence of falls and injury to the patient

b. Nursing Goals and objectives

Goal: prevent the falls and injury and to maintain a good body mechanics.
Objectives: Mrs. X will:

remain free from injury as evidenced by:

absence of signs and symptoms of fall or injury

Explaining the methods to prevent the injury.

c. Design of the nursing system: supportive educative

d. method of helping:
Support

Never leave the client alone in the unit

Assess the patients gait, activities and the mental status for any
confusion or disorientation

Encourage the patient to use supportive devices as required.

Provide a safe environment in the hospital by avoiding sharp

objects or wooden objects on the way and slippery floor.

Involve the family members in providing and maintaining a safe

environment in the home

Involve the family members to provide support to the patient

whenever necessary

Plan a balanced diet for the patient with a mutual interaction

IMPLEMENTATION
-----------------------------------------------------------------EVALUATION

Patient remained free from injury as evidenced by absence of signs

and symptoms.

Patient explained the various measures that they will take to

prevent the injury.

The supportive educative system was useful for Mrs. X

-----------------------------------------------------------------E. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA:

PREVENTION OF HAZARDS.
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS:

Potential for impaired skin integrity related to edema secondary to

renal cysts.

OUTCOMES AND PLAN:

a. Outcome:

Maintenance of normal skin integrity.

b. nursing Goals and objectives

Goal: Maintain the skin integrity and take measures to prevent skin
impairment.
Objectives: Mrs. X will:

maintain a normal skin integrity

list the measures to prevent the loss of skin integrity

identify the measures to relieve edema.

c. Design of the nursing system: supportive educative

d. method of helping:
Support:

Assess the skin regularly for any excoriation or loss of integrity or

colour changes. Keep the skin clean always

Avoid stress or pressure over the area of edema by providing extra

cushions or padding

Monitor the lab values as well as the patient for any signs and
symptoms of renal failure.

Encourage the patient to use slippers while walking and that should
not be tight fitting.

Assess the edema for its degree, pitting or non pitting and continue
the assessment daily.

Provide a leg end elevated position or elevation of the leg on a

pillow if no cardiac abnormalities are identified.

Explain the patient the need for taking care of the edematous parts

Explain the patient to report the symptoms like decreased urine

output, palpitations, increased edema etc. to the health team

IMPLEMENTATION
------------------------------------------------------------------EVALUATION

Patient remained free from impaired skin integrity

She listed the measures to prevent the loss of skin integrity

She identified the measures to relieve edema.

The supportive educative system was useful for Mrs. x

----------------------------------------------------------------F. THERAPEUTIC SELF CARE DEMAND: DEFICIENT AREA:

AWARENESS OF THE DISEASE PROCESS AND MANAGEMENT
ADEQUACY OF SELF CARE AGENCY: INADEQUATE
NURSING DIAGNOSIS

Potential for complications related to rheumatoid arthritis secondary

to knowledge deficit.

OUTCOMES AND PLAN

a. Outcome:

Absence of complications and improved awareness about the

disease process.
b. nursing Goals and objectives
Goal: Improve the knowledge of the patient about the disease process and
the complications.
Objectives: Mrs. X will:

verbalize the various complication and their preventions

verbalize the changes occurring with the disease process and the
treatment available

describe the actions and side effects of the medications which she
is using

c. Design of the nursing system:

supportive educative

d. Methods of helping:

Guidance

Teaching

Promoting a developmental environment

IMPLEMENTATION

------------------------------------------------------------EVALUATION

Patient got adequate information regarding the disease

She verbalized what she understood about the disease and its
management.

Patient has cleared her doubts regarding the medication actions

and the side effect

The supportive educative system was useful for Mrs. X

E VALU ATI ON OF THE AP P LI C ATI ON OF SE LF

CARE DEFICIT THEORY
The theory of self-care deficit when applied could identify the self care
requisites of Mrs. X from various aspects. This was helpful to provide care in
a comprehensive manner. Patient was very cooperative. the application of
this theory revealed how well the supportive and educative and partly
compensatory system could be used for solving the problems in a patient
with rheumatoid arthritis.
REFERENCES
1.

Alligood M R, Tomey A M. Nursing Theory: Utilization &Application .

3rd ed. Missouri: Elsevier Mosby Publications; 2002.

2.

Tomey AM, Alligood. MR. Nursing theorists and their work. (5th
ed.). Mosby, Philadelphia, 2002

3.

George JB .Nursing Theories: The Base for Professional Nursing

Practice .5th ed. New Jersey :Prentice Hall;2002.