Application of Roy's Adaptation Model in Nursing Practice

==
INTRODUCTION
Born at Los Angeles on October 14, 1939 as the 2nd child
of Mr. and Mrs. Fabien Roy.
At age 14 she began working at a large general hospital,
first as a pantry girl, then as a maid, and finally as a nurse's
aid.
She entered the Sisters of Saint Joseph of Carondelet.
she earned a Bachelor of Arts with a major in nursing from
Mount St. Mary's College, Los Angeles in 1963.
a master's degree program in pediatric nursing at the
University of California ,Los Angeles in 1966.
She also earned a masters & PhD in Sociology in 1973 &
1977 ,respectively
Sr. Callista had the significant opportunity of working with
Dorothy E. Johnson
Johnson's work with focusing knowledge for the discipline
of nursing convinced Sr. Callista of the importance of
describing the nature of nursing as a service to society and
prompted her to begin developing her model with the goal

of nursing being to promote adaptation.

Sister Callista Roy (1984), Introduction to Nursing: An

Adaptation Model (2nd ed)
ASSUMPTIONS OF ROYS ADAPTATION MODEL
Scientific
Systems of matter and energy progress to higher levels of
complex self-organization
Consciousness and meaning are constitutive of person and
environment integration
Awareness of self and environment is rooted in thinking and
feeling
Humans by their decisions are accountable for the
integration of creative processes
Thinking and feeling mediate human action
System relationships include acceptance, protection, and

fostering of interdependence
Persons and the earth have common patterns and integral
relationships
Persons and environment transformations are crated in
human consciousness
Integration of human and environment meanings results in
adaptation
Philosophical
Persons have mutual relationships with the world and God
Human meaning is rooted in an omega point convergence of
the universe
God is intimately revealed in the diversity of creation and is
the common destiny of creation
Persons use human creative abilities of awareness,
enlightenment, and faith
Persons are accountable for the processes of deriving,
sustaining, and transforming the universe
PERSONS AND RELATING PERSONS
An adaptive system with coping processes
Described as a whole comprised of parts

Functions as a unity for some purpose

Includes people as individuals or in groups (families,
organizations, communities, nations, and society as a
whole)
An adaptive system with cognator and regulator subsystems
acting to maintain adaptation in the four adaptive modes:
physiologic-physical, self-concept-group identity, role
function, and interdependence.
ENVIRONMENT
All conditions, circumstances, and influences surrounding
and affecting the development and behavior of persons and
groups with particular consideration of mutuality of person
and earth resources
Three kinds of stimuli: focal, contextual, and residual
Significant stimuli in all human adaptation include stage of
development, family, and culture
HEALTH AND ADAPTATION
Health: a state and process of being and becoming
integrated and whole that reflects person and environmental
mutuality

Adaptation: the process and outcome whereby thinking and

feeling persons, as individuals and in groups, use conscious
awareness and choice to create human and environmental
integration
Adaptive Responses: responses that promotes integrity in
terms of the goals of the human system, that is, survival,
growth, reproduction, mastery, and personal and
environmental transformation
Ineffective Responses: responses that do not contribute to
integrity in terms of the goals of the human system
Adaptation levels represent the condition of the life
processes described on three different levels: integrated,
compensatory, and compromised
NURSING
Nursing is the science and practice that expands adaptive
abilities and enhances person and environment
transformation
Nursing goals are to promote adaptation for individuals and
groups in the four adaptive modes, thus contributing to
health, quality of life, and dying with dignity

This is done by assessing behavior and factors that

influence adaptive abilities and by intervening to expand
those abilities and to enhance environmental interactions
ROY ADAPTATION MODEL (RAM) TERMS
System-a set of parts connected to function as a whole for
some purpose.
Stimulus-something that provokes a response, point of
interaction for the human system and the environment
Focal Stimuli-internal or external stimulus immediately
affecting the system
Contextual Stimulus-all other stimulus present in the
situation.
Residual Stimulus-environmental factor, that effects on the
situation that are unclear.
Regulator Subsystem-automatic response to stimulus
(neural, chemical, and endocrine)
Cognator Subsystem-responds through four cognitive
responds through four cognitive-emotive channels
(perceptual and information processing, learning, judgment,
and emotion)

Behavior -internal or external actions and reactions under

specific circumstances
Physiologic-Physical Mode
Behavior pertaining to the physical aspect of the human
system
Physical and chemical processes
Nurse must be knowledgeable about normal processes
5 needs (Oxygenation, Nutrition, Elimination, Activity &
Rest, and Protection)
Self Concept-Group Identity Mode
The composite of beliefs and feelings held about oneself at
a given time. Focus on the psychological and spiritual
aspects of the human system.
Need to know who one is, so that one can exist with a state
of unity, meaning, and purposefulness of 2 modes (physical
self, and personal self)
Role function Mode
Set of expectations about how a person occupying one
position behaves toward a occupying another position.
Basic need-social integrity, the need to know who one is in

relation to others
Interdependence Mode
Behavior pertaining to interdependent relationships of
individuals and groups. Focus on the close relationships of
people and their purpose.
Each relationship exists for some reason. Involves the
willingness and ability to give to others and accept from
others.
Balance results in feelings of being valued and supported by
others. Basic need - feeling of security in relationships
Adaptive Responses-promote the integrity of the human
system.
Ineffective Responses-neither promote not contribute to the
integrity of the human system
Copping Process-innate or acquired ways innate or of
interacting with the changing of environment
NURSING PROCESS
A problem solving approach for gathering data, identifying
the capacities and needs of the human adaptive system,
selecting and implementing approaches for nursing care,

and evaluation the outcome of care provided

Assessment of Behavior: the first step of the nursing
process which involves gathering data about the behavior of
the person as an adaptive system in each of the adaptive
modes.
Assessment of Stimuli: the second step of the nursing
process which involves the identification of internal and
external stimuli that are influencing the persons adaptive
behaviors.
Stimuli are classified as:
1) Focal- those most immediately confronting the person,
2) Contextual-all other stimuli present that are affecting the
situation and
3) Residual- those stimuli whose effect on the situation are
unclear.
Nursing Diagnosis: step three of the nursing process which
involves the formulation of statements that interpret data
about the adaptation status of the person, including the
behavior and most relevant stimuli
Goal Setting: the forth step of the nursing process which

involves the establishment of clear statements of the

behavioral outcomes for nursing care.
Intervention: the fifth step of the nursing process which
involves the determination of how best to assist the person
in attaining the established goals
Evaluation: the sixth and final step of the nursing process
which involves judging the effectiveness of the nursing
intervention in relation to the behavior after the nursing
intervention in comparison with the goal established.
DEMOGRAPHIC DATA
Mr. NR
Name

53 years

Age

Male

Sex

-----

IP number

Degree

Education

Bank clerk

Occupation

Married

Marital status

Hindu

Religion

Patient and Wife

Informants

21/01/08

Date of admission
FIRST LEVEL ASSESSMENT
PHYSIOLOGIC-PHYSICAL MODE
Oxygenation:
Stable process of ventilation and stable process of gas
exchange. RR= 18Bpm.
Chest normal in shape. Chest expansion normal on either
side.
Apex beat felt on left 5th inter-costal space mid-clavicular
line.
Air entry equal bilaterally. No ronchi or crepitus. NVBS.
S1& S2 heard.
No abnormal heart sounds.
Delayed capillary refill+. JVP0.
Apex beat felt- normal rhythm, depth and rate.
Dorsalis pedis pulsation of affected limp is not palpable.
All other pulsations are normal in rate, depth, tension with
regular rhythm.
Cardiac dull ness heard over 3rd ICS near to sternum to left
5ht ICS mid clavicular line.

S1& S2 heard.
No abnormal heart sounds. BP- Normotensive. .
Peripheral pulses felt-Normal rate and rhythm, no clubbing
or cyanosis.
Nutrition
He is on diabetic diet (1500kcal). Non vegetarian.
Recently his Weight reduced markedly (10 kg/ 6 month).
He has stable digestive process.
He has complaints of anorexia and not taking adequate
food.
No abdominal distension. Soft on palpation. No tenderness.
No visible peristaltic movements.
Bowel sounds heard.
Percussion revealed dullness over hepatic area.
Oral mucosa is normal. No difficulty to swallow food
Elimination:
No signs of infections, no pain during micturation or
defecation.
Normal bladder pattern. Using urinal for micturation.
Stool is hard and he complaints of constipation.

Activity and rest:

Taking adequate rest.
Sleep pattern disturbed at night due unfamiliar surrounding.
Not following any peculiar relaxation measure.
Like movies and reading. No regular pattern of exercise.
Walking from home to office during morning and evening.
Now, activity reduced due to amputated wound. Mobility
impaired.
Walking with crutches.
Pain from joints present. No paralysis.
ROM is limited in the left leg due to wound.
No contractures present. No swelling over the joints.
Patient need assistance for doing the activities.
Protection:
Left lower fore foot is amputated.
Black discoloration present over the area.
No redness, discharge or other signs of infection.
Nomothermic.
Wound healing better now.
Walking with the use of left leg is not possible.

Using crutches.
Pain form knee and hip joint present while walking.
Dorsalis pedis pulsation, not present over the left leg. Right
leg is normal in length and size.
Several papules present over the foot.
All peripheral pulses are present with normal rate, rhythm
and depth over right leg.
Senses:
No pain sensation from the wound site. Relatively, reduced
touch and pain sensation in the lower periphery; because of
neuropathy. Using spectacle for reading. Gustatory,
olfaction, and auditory senses are normal.
Fluids and electrolytes:
Drinks approximately 2000ml of water. Stable intake out
put ratio. Serum electrolyte values are with in normal limit.
No signs of acidosis or alkalosis. Blood glucose elevated.
Neurological function:
He is conscious and oriented.
He is anxious about the disease condition.
Like to go home as early as possible.

Showing signs of stress.

Touch and pain sensation decreased in lower extremity.
Thinking and memory is intact.
Endocrine function
He is on insulin. No signs and symptoms of endocrine
disorders, except elevated blood sugar value. No enlarged
glands.
SELF CONCEPT MODE
Physical self:
He is anxious about changes in body image, but accepting
treatment and coping with the situation. He deprived of
sexual activity after amputation.
Belongs to a Nuclear family. 5 members. Stays along with
wife and three children. Good relationship with the
neighbours. Good interaction with the friends. Moderately
active in local social activities
Personal self:
Self esteem disturbed because of financial burden and
hospitalization. He believes in god and worshiping Hindu
culture.

ROLE PERFORMANCE MODE:

He was the earning member in the family. His role shift is
not compensated. His son doesnt have any work. His role
clarity is not achieved.
INTERDEPENDENCE MODE:
He has good relationship with the neighbours. Good
interaction with the friends relatives. But he believes, no
one is capable of helping him at this moment. He says all
are under financial constrains. He was moderately active in
local social activities
SECOND LEVEL ASSESSMENT
FOCAL STIMULUS:
Non-healing wound after amputation of great and second
toe of left leg- 4 week. A wound first found on the junction
between first and second toe-4 month back. The wound was
non-healing and gradually increased in size with pus
collected over the area.
He first showed in a local (---) hospital. From there, they
referred to ---- medical college; where he was admitted for 1
month and 4 days. During hospital stay great and second toe

amputated. But surgical wound turned to non- healing with

pus and black colour. So the physician suggested for below
knee amputation. That made them to come to ---Hospital,
---. He underwent a plastic surgery 3 week before.
CONTEXTUAL STIMULI:
Known case DM for past 10 years. Was on oral
hypoglycemic agent for initial 2 years, but switched to
insulin and using it for 8 years now. Not wearing foot wear
in house and premises.
RESIDUAL STIMULI:
He had TB attack 10 year back, and took complete course of
treatment. Previously, he admitted in ---Hospital for leg pain
about 4 year back. . Mothers brother had DM. Mother had
history of PTB. He is a graduate in humanities, no special
knowledge on health matters.
CONCLUSION
Mr.NR who was suffering with diabetes mellitus for past 10
years. Diabetic foot ulcer and recent amputation made his
life more stressful. Nursing care of this patient based on
Roy's adaptation model provided had a dramatic change in

his condition. Wound started healing and he planned to

discharge on 25th april. He studied how to use crutches and
mobilized at least twice in a day. Patients anxiety reduced
to a great extends by proper explanation and reassurance.
He gained good knowledge on various aspect of diabetic
foot ulcer for the future self care activities.
NURSING CARE PLAN
ASSESS
ASSES

NURSI
MENT

S. OF

NG
OF

BEHAV

INTERVE EVALU
GOAL

DIAG

NTION

ATION

STIMU
IOUR

NOSIS
LI

Ineffecti Focal
ve

1.

Long-term -

Short

stimuli: Impaire objective: Maintain term

protecti Non-

d skin 1.

the wound goal:

on and healing integrit amputated area clean Met: size

sense in wound

physical after

related completely contamina wound

amputati to

physiol on of

area will be as

healed by

fragilit 20/5/08

tion

of

decrease

affects the d to less

ogical

great

y of the 2.Skin will healing

than 1x1

mode

and

skin

cms.

(No

second

second intact with - Follow WBC

pain

toe of

ary to

remain

process.

no ongoing sterile

values

sensatio left leg- vascula ulcerations. technique became

n from 4 week

while

the

insuffic Short-

providing on

wound

iency

cares to

site.)

Term

Objective: prevent

normal

24/4/08
Long

i. Size

infection term

of wound

and delay goal:

decreases

in

Partially

to 1x1 cm healing.

Met:

within

skin

24/4/08.

Perform

partially

wound

intact

signs of

dressing

with no

infection

with

ulceratio

over the

Betadine ns.

wound

which

ii. No

Continue

within 1-

promote

plan

wk

healing

Reassess

and

goal and

iii.
Normal

growth of intervent

WBC

new

ions

values

tissue.

Unmet:

within 1-

- Do not not

wk

move the achieved

iv.

affected

Presence of area

complete
healing

healthy

frequently of

granular

as it

tissues in

affects the d area.

amputate

the wound granulatio Continue

site within n tissue
1-wk

plan

formation. Reassess
goal and
-

intervent

Monitor

ions

for signs

and
symptoms
of
infection
or delay
in
healing.
Administe
r the
antibiotics
and
vitamin C
suppleme
ntation
which
will
promote
the
healing

process.

Impaire Focal
d

Long term - Assess Short

stimuli: Impaire Objective: the level

activity During
in

2.

Patient

of

term
goal:

hospital physica will attain restriction Met:

physical stay

mobilit possible

movemen crutches

physiol and

ogical

second

related mobility

- Provide on

mode

toe

to

active and 22/4/08.

great

maximum of

physical

with in 6

amputat amputa months.

passive

used

correctly

he is self

ed. But tion of Short term exercises motivate

surgical the left objective: to all the d in
wound

forefoo i.

turned to t and
non-

extremitie doing

Correct use s to

presenc of crutches improve

healing e of

excesses

the

Partially

with pus unheale 22/4/08

muscle

Met:

and

tone and

walking

with in

minor

ii.

black
colour.

wound walking

strength. with

with

- Make

minimum

the patient m

support-

to

support.

22/4/08

perform

Long

iii.

the ROM term

He

minimu

will be self exercises goal:

motivated to lower
in

Unmet:

extremitie not

activities- s which

attained

20/4/08.

maximu

will

strengthen m
the

possible

muscle.

physical

mobility-

Massage Continue
the upper plan
and lower Reassess
extremitie goal and
s which

intervent

help to
improve
the
circulatio
n.
- Provide
articles
near to
the patient
and
encourage
performin
g
activities
within
limits
which
promote a
feeling of
well

ions

being.
- Provide
positive
reinforce
ment for
even a
small
improvem
ent to
increase
the
frequency
of the
desired
activity.
Measures
for pain
relief
should be

taken
before the
activities
are
initiated
as pain
can hinder
with the
activity.

Alterati Context 3.
on in

ual

Long term - Allow Short

Anxiet Objective: and

Physical stimuli: y

term

The client encourage goal:

self in

Known related will remain the client Met:

Self-

case DM to

free from

concept for past hospital anxiety

and

family to ated

mode

10 years admissi Short term ask

(He is

and on

t with

appropri

on and objective: questions. ate range

anxious treatmen unkno i.

about

demonstr

wn

Bring up effective

demonstrat common coping

changes insulin

Outco ing

concerns. with

in body for 8

me of

appropriate - Allow treatment

image) years.

the

range

the client

Change Residual disease effective

and

in Role stimuli: and

family to able to

coping in

He is

perform no

financi the

verbalize rest

ance

special

al

anxiety.

mode.

knowled constrai ii.

(He was ge in

quietly.

Being - Stress Long

able to rest that

term

and

frequent

goal:

earning matters

iii.

assessmen Unmet:

member

Asking

t are

client not

in the

fewer

routine

complete

family.

questions

and do

ly

His role

not

remained

shift is

necessaril free from

not

y imply a anxiety

compen

deteriorati due to

sate)

ng

the

health

ns.

treatment

financial

condition. constrain

s- Repeat Continue
informati plan
on as

Reassess

necessary goal and

because

intervent

of the

ions

reduced
attention
span of
the client
and
family
Provide
comfortab
le quiet
environm
ent for the
client and

family

Context 4.
ual

deficie Objective: Explain

stimuli: nt

------

Long term -

Patient will the

Short
term
goal:

Known knowle acquire

treatment Met:

case DM dge

measures Verbaliza

adequate

for past regardi knowledge to the

tion and

10 years ng the regarding

patient

demonstr

and on

the t foot

and their ation of

care,

benefits in foot

foot

treatmen care,
t with

wound wound

a simple

insulin

care,

understan Strictly

for 8

diabetic diabetic

dable

years.

diet,

diet, and

language. g

need of

diabetic

stimuli: need of follow up

Explain

diet plan

no

follow care and

about the Unmet:

special

up care. practice in home

Demonst

their day to care.

ration of

Residual and

knowled

care,

care.

followin

ge in

day life.

Include

health

Short term the points care.

matters

objective: like care

Long

i.

term

of

Verbalizati wounds,
on and

wound

goal:

nutrition, Unmet:

demonstrat activity

not

ion of foot etc.

complete

care.

Clear the ly

ii. Strictly doubts of acquired

following

the patient and

diabetic

as the

practiced

diet plan

patient

the

iii.

may

required

Demonstrat present

knowled

ion of

with some ge.

wound

matters of Continue

care.

importanc plan
e.

Reassess

- Repeat goal and

the

intervent

informati ions
on
whenever
necessary
to
reinforce
learning.
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