The Neuman Systems Model applies a comprehensive and holistic approach to the care of patients based on the five variables. According to Parker and Smith (2010), the Neuman System Model is described as, “wellness orientation, client perception and motivation, and a dynamic systems perspective of energy and variable interaction with the environment to mitigate possible harm from internal and external stressors” (p. 183). The patient/ family are the client system and interrelate with the five variables namely; the physiological, psychological, sociocultural, developmental, and spiritual beliefs. The Neuman System Model has been used in diverse settings such as, in critical nursing, psychiatric nursing, gerontological nursing, and for teaching purposes. In the United States, “the model is used to guide practice with clients with acute and chronic health problems” (Parker &ump; Smith, 2010, p. 192).
As further explained by Parker and Smith (2010), the client system is the core: a person, individual, or community and the core interact with the flexible lines of defense, the normal lines of defense, and the lines of resistance. The client system is constantly affected by internal and external stressors. The goal of nurses in applying the Neuman System Model is, “to maximizing the quality of life lived, maintaining the highest level of independence possible, and preventing exacerbations of the on-going illness” (Ebersole, Hess, Touhy, Jett, and Luggen, 2008, p. 258).
Mrs. J is a 79-year-old African-American female client, who lives with her husband in a wheelchair accessible home. She has always been a home maker, enjoys cooking the family meals, and raising the grandchildren. Mrs. J is a mother of three children with great family support and loves the outdoors. She has multiple medical conditions: adult onset diabetes, moderate obesity, indigestion, hypertension, chronic heart failure, depression, and currently, still smoking. She uses the wheelchair frequently due to painful swollen knee. She also has a walker to aid with ambulation. She has lost about 20 pounds in the last three months. Her husband’s health is declining, but her children and family members are very supportive. She takes a lot of medication and uses inhalers. She has the government medical health insurance and social security income. She used to go to church, and was an active member until her worsening respiratory status. Some church members do visit occasionally.
She was able to accomplish most of her tasks and activities of daily living until she was admitted to the Medical Intensive Care Unit with Chronic Obstructive Pulmonary Disease (COPD) exacerbation. During the course of this admission, she has developed new onset of confusion, oxygen dependency, and fatigue. Mrs. J has recovered significantly; her vital signs are within normal ranges; her mental status and respiratory has improved, and overall assessment indicates that Mrs. J is ready for discharge home. The chronic (COPD) exacerbation has resulted to shortness of breath, fatigue, loss of appetite, loss of weight, and decline in food intake. Pending discharge, a nurse case manager was consulted to facilitate Mrs. J’s discharge home procedure and disease management. According to Mullahy (as cited in Finkelman (2011), “case management is a multidisciplinary area of practice with representation from the fields of nursing, social work, rehabilitation, counseling, and occupational and physical therapy” (p. 192). Nurses, based on clinical experience and knowledge of disease process and outcomes, practice as case managers. Mrs. J needs home oxygen, nutritional support, medications, and rehabilitation to enable her return to her baseline health status.
A nurse case manager coordinates the different resources and ensures that the required services and resources are available to the patient at discharge as illustrated, “it involves systematic collaboration with the patients, their significant others, and their health care providers to coordinate high quality health care services in a cost effective manner with positive patient outcomes” (Chitty &ump; Black, 2011, p. 17). The case manager serves as the patient’s advocate and focuses on the most important needs of the patient and family. Many facilities have adopted a clinical pathway for nurse case managers to enhance the continuity and standard of care.
The nurse care manager starts by obtaining Mrs. J’s medical history, the family support system, and present medical history. The case manager then conducted an assessment and physical examination of Mrs. J. Her vital signs showed Mrs. J to be afebrile, tachypnea with a rate of 26-30 at rest. She requires oxygen to maintain the oxygen saturation at 88%. Her blood pressure is within normal range for her medical condition. She requires more inhalers and breathing treatment at home according to the physician’s orders. She is alert and oriented to name, place, and person. She appears depressed and answers question reluctantly. She is very concerned about her husband’s failing health and the burden on her children. Mrs. J’s children have visited her regularly and will be available for the discharge home teaching. She has developed some problems chewing, and can tolerate soft foods and nutritional supplements. Her appetite is still very poor. Her laboratory values; kidney profile, arterial blood gas, pulmonary function test, and complete blood count levels are within acceptable limit.
Considerable research has proven that a “comprehensive geriatric evaluation with older patients reveals reduced hospital use, reduced mortality rates, improved mental status, lower health cost, improved functional ability, and lower hospital readmission rates” (Tabloski, 2010, p. 58). Based on these findings, the case manager identified Mrs. J’s stressors. Ebersole et al., (2008) explains that, “stress is any event or situation that brings about bodily or mental tension” (p. 24). Mrs. J’s stressors are: shortness of breath related to the COPD, the husband’s failing health, the burden on the children, and declining physical condition. Due to these stressors, Mrs. J has developed coping mechanism as the normal line of defense. Coping skills allow the client to adapt and return to the baseline. Mrs. J’s normal lines of defense are: still married, enjoys smoking and eating, visitation by church members, spiritual beliefs, and family relationship.
The flexible lines of defense are the strength and weakness that the client possesses to maintain a normal state of health. According to Erikson developmental stage, Mrs. J is dealing with “ego integrity versus despair” (Harder, 2009, p. 1). She is depressed, not just for her chronic illness but her husband’s failing health. She is lacking a sense of fulfillment and achievement. The identified flexible lines of defense are: getting enough sleep and hydration, balanced diet, routine vitamins to boost energy and increase vitality, and rekindling the strong spiritual supports and beliefs.
The lines of resistance are the treatments, life style changes, services, and resources available to enable Mrs. J achieve the optimal state of wellness. The lines of resistance are made up of internal and external factors. The identified lines of resistance for Mrs. J are: medical management of multiple conditions, oxygen for hypoxia, diabetic teaching for blood glucose controlled, smoking cessation, physical and occupation therapy for mobility, antibiotics for infection, antidepressant and analgesic, health education, and continued family supports.
The case manager identified Mrs. J’s five variables: physiological, psychological developmental, sociocultural, and spiritual beliefs based on the intrapersonal, interpersonal, and extra personal relationship. The physiological variables are: shortness of breath, hypertension, and all medical conditions. The psychological variables are: feelings of being a burden to the children, feels sad and lonely, afraid of the future, and feels of hopelessness. The developmental variables are: a mother of children, still married, grandmother, and applying Erikson’s late adult developmental stage, “integrity vs. despair” (Harder, 2009, p. 1). The sociocultural variable are: as an African-American mother, the children should serve as care givers and support her. Mrs. J is still smoking and wants to go back home. The spiritual belief variables are: Mrs. J still believes in God, prays for her family and church members and pastors still visit.
After completing the history data, assessment, and physical examination: the case manager was able to identify Mrs. J stressors and variables. The case manager in collaboration with the family, nursing staff, and other multidisciplinary staff implemented a discharge plan of care for the client. Melesis (2007) noted that, “the nurse’s work begins with a careful assessment of the client and plans for the appropriate intervention by focusing on the needs, resources, the problems, or the response” (p. 319). The nurse case manager using the Neuman System Model apply this knowledge to ensure a wholistic approach in meeting the physiological, spiritual, developmental, psychological, and the sociocultural needs of Mrs. J. The client system was in agreement with the plan of care.
The case manager communicates with the different discipline such as, the social worker, dietician, pastoral care, and oxygen supply companies to ensure that all the needed services and resources are available and delivered to Mrs. J’s home. The length of time a service will be provided is coordinated and appropriate referrals are made to the physical and occupational therapist, oxygen delivery, meals on wheels, and visitation by home health nurses. Information about services and resources for reimbursement and payment to the different agencies and insurances companies are coordinated by the case manager for Mrs. J. As illustrated, “the nurse case manager realizes this goal by organizing rehabilitation and other necessary healthcare services to promote outcomes for the individual that will encourage the highest possible level of independence and quality of life” (Rehabilitation Nursing Foundation, 2010, p. 1).