Lydia Hall’s Care, Core, and Cure Theory in Patient with Thromboangiitis Obleterans (Buerger’s Disease)

Rationale of the Study

Buerger’s disease also known as Thromboangiitis Obliterans is a rare arterial vascular disease characterized by acute inflammatory lesions and occlusis thrombosis of the small and medium arteries and veins. The legs, feet, upper limbs. (Canobbio, 2006; Black and Hawks, 2005). The distal tips of hands and feet are pale, but as the disease progresses, the hands and feet become reddened when held in a dependent position (White, 2000; White and Duncan, 2002).

This disorder occurs in 6 of every 10,000 people. Incidence is highest among males aged 20 to 40 who have history of smoking or chewing tobacco. Recently has been increasing in prevalence in women. Although the classic patient is a heavy smoker, there may be association with passive exposure to smoke. More recent have revealed a notable increase in the number of women affected, with 8 to 23%. Because there has been a significant increase in the use of tobacco by women over the past several decade (Rajagopalan et. al., 2004; Beers, 2003). It is associated with a 30% of major amputation rate over 5-20 years (Cuschiere, 2003).

Tobacco is a slow, insidious, but most malignant poison. In whatever form it is used, it tells upon the constitution; it is all the more dangerous because its effects are slow and at first hardly perceptible. It excites and the paralyzes the nerves. Among children and youth the use of tobacco is working untold harm. The unhealthful practices of past generations affect the children and youth of today (White, 2001).

A growing number of young Filipinos are picking up smoking despite new restrictions on tobacco advertising, according to a nationwide study. Based on health report in 2005, there are 20 million of Filipinos who are smoking. Four million youth, aged between 11 and 19, are smokers, said the 2007 survey commissioned by the World Health Organization and the health department. The youth group made up 23 percent of all Filipino smokers, compared to about 18 percent in 2005. “This 23 percent could further increase in a matter of three years,” said Maricar Limpin, a doctor who leads an anti-smoking lobby, Framework on Tobacco Control of the Philippines Alliance (Varona, 2009).

Government data shows smoking is linked to five of the top 10 leading causes of deaths in the Philippines, where up to 35 percent of the country’s 89 million people are tobacco users (www.yehey.com). It is interesting to know the leading disease and health condition that kill Filipinos everyday. Based from the Department of Health’s Health Statistics and was updated last January 2007 that the second Philippines’ top killer is the Vascular System Disease. It is closely related to the number one top killer which is the Heart Disease. The disease that affect the circulatory system or the blood vessels may include periphery artery disease, all types of aneurysms and dissections, atherosclerosis, Buerger’s Disease, Raynaud’s phenomenon, and arterial embolism and thrombosis (www.emeritus.blogspot.com)

Considering the figures that were stated, it is evident that Buerger’s disease is indeed rising in the Philippines that needs to be addressed early, especially since the disease is highly preventable through proper health teaching, education and by living a healthy lifestyle. With proper handling and adherence to the management program of the disease, complication and debilitating conditions can also be prevented in order to promote a quality of life that could be beneficial not only to the patient, but also to the community.

As a result of this study, a holistic care management can be proposed which would be used in managing a patient with Buerger’s disease and preventing such complication.

The researcher is a registered nurse, a volunteer public health nurse at Rural Health Unit II in Lipata, Minglanilla, Cebu, and was trained as an orthopedic nurse at Vicente Sotto Memorial Medical Center in Ward VIII for three (3) months. Qualified by his experience and educational background, the researcher is highly competent in conducting a case study that would benefit not only the client but the family and the community as a whole.

During the researcher’s exposures and experiences, the researcher saw the suffering of the client so as the family or significant others in giving care. The researcher saw the struggle and regret of the client, which can be prevented by stopping the cigarette smoking. Acknowledging the fact that the disease is increasing statistically, still the people are unaware of the disease.

Lydia Hall’s Nursing Model is believed to be applicable to the patient suffering from Buerger’s disease. By making this study, buerger’s disease will be minimal or under control case in the country, and the nurse will be guided on how to handle and deliver a holistic quality nursing care to the client.
Theoretical Background

This study is anchored on Lydia Hall’s Care, Core, and Cure Model. Care alludes to the hands on intimate bodily care of the client implies a comforting, nurturing relationship. Core involves the therapeutic use of self in communicating with the patient. The nurse reflects questions appropriately and helps the client clarify motives and goals facilitating the process of increasing the client’s awareness. Cure is the aspect of nursing involved with administration of medication and treatments. The nurse functions in this role as an investigator. The major outcome of nursing care is rehabilitation and feelings of self-actualization by the patient (Taylor, Lillis, and LeMone, 2005; Basavanthappa, 2007).

According to Tomey and Alligood (2002) Hall sees that nursing can and should be professional, that patients should be cared for only by a professional registered nurse who can take total responsibility for the care and teaching of the clients. The professional nurse functions most therapeutically when patients have entered the second stage of their hospital stay. The second stage is the recuperating, or non acute, phase of illness. The first stage of illness is a time of biological crisis, with nursing being ancillary to medicine. After the crisis period, the patient is more able to benefit and learn from the teaching that nurses can offer.

Potter (2004) pointed that Teaching presents correct principles, procedures and techniques of the health care to clients and informs clients about their health status. As nursing responsibility, teaching is implemented in all health care settings. The nurse is responsible for assessing the learning needs of clients and is accountable for the quality of education delivered.

Nursing is complex. The patient is complex. Not only is the patient a human being, bringing the influences of his or her culture and environment, but the patient may be suffering from an illness that medicine is still struggling to understand and treat. The nurse giving the care is also a unique human being, interacting with the patient in a complex process of teaching and learning. Nursing expertise centers around the body, because Hall viewed the patient as composed of Body, Pathology, and Personality. The uniqueness of nursing lies not only in knowing bodily care, but also in knowing how to modify these process and treatment and amend them in line with the personality of the patient (Tomey and Alligood, 2002).

Client achieves their maximal potential through a learning process, therefore the chief therapy they need is teaching. Rehabilitation is a process of learning to live within limitations. Physical and mental skills must be learned, but a prerequisite is learning about oneself as a person, becoming aware of feelings and behaviors, and clarifying motivations. Hall believed that the professional nurse, educated in communication skills, could best facilitate the teaching-learning process (Tomey and Alligood, 2002).

Hall was not pleased with the concept of team nursing. She said, “Any career that is defined around the work that has to be done, is a trade.” She vehemently opposed the idea of anyone other than educated, professional nurses taking direct care of patients and she decried the fact that nursing has trained non-professionals to function as practical nurses so professional nurses function as practical doctors (Tomey and Alligood, 2002).
Llyod (2007) pointed that it is an organizational system in which nurses carry out individual assessments of the clients’ needs and is basic on the relationship between specific nurse and specific client. It encourages professionalism in nursing practice. It also improves the quality of care and increases satisfaction of clients and nurses.

There are two phases of medical care practiced in medical centers: (1) biological crises and (2) evaluative medicine. The biological crises phase involves intensive medical and diagnostic treatment of the patient. The evaluative medicine phase follows and generally, it is the time when the patient is observed to appraise whether he or she is meeting the doctor’s goals (Tomey and Alligood, 2002).

Hall proposed that the nursing functions differ, using the three interlocking circles to represent aspects of the patient. She labeled the circles as the body (the care), the disease (the cure), and the person (the core). Nurses function in all three circles but to different degrees. They also share the circles with other providers. Hall believed that professional nursing care hastened recovery and that as less medical care was needed, more professional nursing care and teaching were necessary.

Hall viewed illness and rehabilitation experiences in which the nurse’s role was to guide and teach the client through personal care giving (Ellis and Hartley, 2004).

Care. The care circle represents the nurturing component of nursing and is exclusive to nursing. Nurturing involves using the factors that make up the concept of mothering (care and comfort of the person) and provide for teaching-learning activities (George, 2001).

The professional nurse provides care to the body of the client and will help the client to his activities of daily living such as eating, bathing, eliminating, and dressing. In providing the care, the main goal of the nurse is to provide comfort to the patient.

In providing care for a patient at the basic need level presents the nurse and patient with opportunity for closeness. As closeness develops, the patient can share and explore feelings with the nurse. The opportunity to explore feelings represents the teaching-learning aspect of nurturing.

George (2001) said that when functioning in the care circle, the nurse applies knowledge of the natural and biological sciences to provide a strong theoretical base for nursing implementations. In interactions with the patient the nurse’s role needs to be clearly define. A strong theory base allows the nurse to maintain a professional status rather than a mothering status, while at the same time incorporating closeness and nurturance in giving care. The patient views the nurse as a potential comforter, one who provides care and comfort through the laying on of hands.

Core. The core circle of the client care based in the social sciences, involves the therapeutic use of self, and is shared with other members of the health team. The professional nurse, by developing an interpersonal relationship with the client, is able to help the patient verbally express feelings regarding the disease process and its effects. Through such expression the patient is able to gain self-identity and further develop maturity. Hall (1965) says to look at an listen to self is often too difficult without the help of a significant figure (nurturer) who has learned how to hold up a mirror and sounding board to invite the behaver to look and listen to himself. If he accepts the invitation, he will explore the concerns in his acts and as he listen to his exploration through reflection of the nurse, he may uncover in sequence his difficulties, the problem area, his problem, and eventually the threat which is dictating his out-of-control behavior.

The professional nurse, by use of the reflective technique (acting as a mirror for the client), helps the patient look at and explore feelings regarding his or her current health status and related potential changes in lifestyle. The nurse uses a freely offered closeness to help the patient bring into awareness the verbal and nonverbal messages being into sent to others. Motivations are discovered through the process of bringing into awareness the feelings being experienced. With this awareness the patient is now able to make conscious decisions based on understood and accepted feelings and motivations. The motivation and energy necessary for healing exist within the patient, rather than in the health care team (George, 2001).

Cure. The cure circle of client care is based in the pathological and therapeutic sciences and is shared with other members of the health team. The professional nurse helps the client and family through the medical, surgical, and rehabilitative prescriptions made by the physician. During this aspect of nursing care, the nurse is an active advocate of the patient.

George (2001) The nurse’s role during the cure aspect is different from the care circle because many of the nurse’s actions take on a negative quality of avoidance of pain rather than a positive quality of comforting. This is negative in the sense that the client views the nurse as a potential cause of pain, one who is involved in such actions as administering injections, versus the potential comforter who provides care and comfort.
Hall places the motivation and energy needed for healing within the client. This aspect of her theory influences the nurse’s total approach to the five phases of the nursing process; assessment, diagnosis, planning, implementation, and evaluation.

George (2001) said that he assessment phase involves the collections of date about the health status of the individual. According to hall, the process of data collection is directed for the benefit of the patient rather than for the benefit of the nurse. Data collection should be directed toward increasing the patient’s self-awareness. Through use of observation and reflection, the nurse is able to assist the client t in becoming aware of both verbal and nonverbal behaviors. In the individual, increased awareness of feelings and needs in relation to health status increases the ability for self-healing.

The assessment phase also pertains to guiding the patient through the cure aspect of nursing. The health team collects biological data (physical and laboratory) to help the client and family understand and progress through the medical regimen.

During this phase the nurse determines the client’s learning need and readiness to learn. The nurse then interpret the data to formulate nursing diagnoses reflecting the identified needs.

The second phase is the nursing diagnosis, or statement of the patient’s need or problem area. How a nurse envisions the nursing role influences the interpretation of assessment data and conclusions reached. Viewing the patient as the power of self-healing directs conclusions differently than if the healing power rests in the physician or nurse. The patient is the one in control, the one who identifies the need (George, 2001).
Planning involves setting priorities and mutually establishing patient—centered goals. The client decides what is of highest priority and also what goals are desirable.

The core is involved in planning. The role of the nurse is to use reflection to help the client become aware of and understand needs, feelings, and motivations. Once motivations are clarified, Hall indicates that the client is the best person to set goals and arrange priorities. The nurse seeks to increase patient awareness and to support decision making based on the client’s new level of awareness. The nurse works with the client to help keep the goals consistent with the medical prescription. The nurse needs to draw on a knowledge base in the social and scientific areas to present the client with creative alternatives from which to choose (George, 2001; Basavanthappa, 2007).

Implementation involves the actual institution of the plan of care. This phase is the actual giving of nursing care. In the care and core circles, the nurse works with the patient, helping with bathing, dressing eating, and other care and comfort needs. The professional nurse uses a “permissive nondirective teaching-learning approach” to implement nursing care, thus helping the patient reach the established goals. This include “helping the patient with his feelings, providing requested information and supporting patient-made decisions” the nurse also helps the patient and family to help them understand and implement the medical plan (George, 2001; Basavanthappa, 2007).

Evaluation is the process in which the nurse will check if the goals are met or not. It is phase that the nurse will decide if the things that are done to the client is effective and successful. Timby (2009) and Smith (2007) although this is considered the last step, the entire process is ongoing. During this phase, nurse compares the actual to the expected outcomes or selected alternative plans of action when expected outcomes are not met.
Lydia Hall’s nursing theory has a limitation of its application to the patient care. The first of these areas is the stage of illness. Hall applies her ideas of nursing to a patient who has passed the acute stage of biological stress- that is, the patient who is experiencing the acute stage of illness is not included in Hall’s approach to nursing care. However, it is possible to apply the care, core, and cure ideas to the care of those who are acutely ill. The acutely ill individual often needs care in relation to basic needs, as well as core awareness of what is going on and, in cure understanding of the plan of medical care (George, 2001).

Another limitation of the theory is the age of the client. Hall refers the adult client in the second stage of their illness, thus limiting all younger clients. However, it would be possible to apply Hall’s theory with younger individuals. Certainly adolescents younger than age 16 are capable of seeking self-identity.

A third limiting factor is the description of how to help a person toward self-awareness. The only tool to be used is “reflection” in therapeutic communication; the emphasis of reflection arises from the belief that both the problem and the solution lie in the individual and that the nurse’s function is to help the individual find them. There are some techniques can also be use like active listening and nonverbal support, may also be used to facilitate the development of self-identity.

Fourth, the family is mentioned only in the cure circle. This means that the nursing contact with the families is used only in regard to the patient’s own medication care. It does not allow for helping a family increase awareness of family’s self.

Lastly, Hall’s theory relates only to those who are ill. This w9ould indicate no nursing contact with the healthy individuals, family, or communities, and it negated the concept of health maintenance and health care to prevent illness (George, 2001).

Although the study is anchored mainly on Lydia Hall’s Care, Core, and Cure model, but other theories were also used in support to support the study.

Undan (2004) further points out that from the theory of Faye Glenn Abdellah, defined nursing as service to individual and families. She conceptualized nursing as an art and a science that mold 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.
Jean Watson’s theory of human caring in nursing proposes human caring as the moral ideal of nursing. In her definition for nursing consists of transpersonal human-to-human attempts to protect, enhance and preserve humanity by helping a person find meaning in illness, suffering, pain, and existence. Nurses participate in human caring to protect, enhance, and preserve humanity by assisting individuals to find meaning in illness, pain, and existence and to help others gain self knowledge, self-control, and self-healing. Watson’s conceptualizations of caring embody the essence of professional nursing practice. The nurses assist patients to find meaning in their existence, patient’s gain self-knowledge, self-control, self-love, choice, and self-determination in health decisions and lifestyle management. She articulates a holistic viewpoint of patient care (Rice, 2006; Hood, 2006).

Virginia Henderson’s theory, believed that the unique function of the nurse is to assist the individual, sick and well, in the performance of those activities contributing to health or its recovery the nurse would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. Henderson defined the patient as someone who needs nursing care (McEwen and Wills, 2007).

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