2. •Nursing is establishing itself as a scientific
discipline.
•Its thrust toward scientifically sound social
usefulness including the development of
conceptual models.
•The nursing models provide the basis for
selecting knowledge to be transmitted in
nursing education.
INTRODUCTION
3. CONTD…
It is the framework for nursing
practice and the direction for
nursing research.
Sister callista Roy’s adaptation
theory (Roy and Obloy
1979,Roy 1980,1984,1989)
views the client as an adaptive
system.
4. BIOGRAPHICAL SKETCH OF
THE NURSE THEORIST
Sister callista Roy was born
on oct, 14,1939.
She did her bachelors of arts
in nursing from mount st.
Mary’s college, losAngeles in
1963 and masters of science
in nursing from ,University of
California,Los Angeles1966.
5. CONTD….
She also received her masters of arts(M.A) in
sociology from the same university in 1975 and
Ph.D in sociology .
Roy was an associate professor and chairperson of
the department of nursing at mount Saint Mary’s
college until 1982.
6. CONTD….
From 1983 to 1985; she was Post Doctoral fellow at
Robert Wood Johnson at University of California,
as a clinical nurse scholar in neuroscience.
In 1988 Roy began the newly created position of
graduate faculty at, Boston school of nursing.
7. CONTD….
According to Roy’s model, the goal of nursing is
to help the person’s adaptive system.
According to Roy’s model, the goal of nursing is
to help the person adapt to change in
physiological needs, self-concepts, role function
and interdependent relations during health and
illness .
8. CONTD….
All individual must adapt to
the following demands:
1. Meeting basic physiological
needs.
2. Developing a positive self-
concept.
3. Performing social roles.
4. Achieving a balance
between dependence and
interdependence.
9. CONTD….
It is role of nurse:
To find out demands which
are causing problems for a
client.
To assess how well the
client is adapting to them.
Nursing care is then
directed at helping the
client to adopt.
10. ORIGIN OF THE MODEL:
While a student of M.sc. nursing, at the university
of California sister C. Roy was challenged in a
seminar by another nurse theorist Dorothy
E.JOHNSON to develop a theory of nursing ,
subsequently in 1970 the ‘ROY ADAPTATION
MODEL’ was born as a derivation of Bertalanfty
(1968) general system theory and Harry Helson’s
Adaptation level theory (1964).
12. CONTD….
1. The person is a bio-psycho-social
being includes biologic components
(Anatomy and Physiology),
psychological and social
components.
2.The person is in constant
interaction with a changing
environment (interaction with
physical, social & psychological
environment changes)
13. CONTD…
3.To cope with a changing world,
the person uses both innate and
acquired mechanisms which are
biologic,psychological and social
in origin.
4.Health and illness are an
inevitable dimension of the
person’s life.
5.To respond positively to
environmental changes, the
person must adapt (changing
environment demands positive
response)
14. CONTD….
6.The person’s adaptation is a
function of the stimulus, he is
exposed to and his adaptation level,
which is determined by the
combined effect of three classes of
stimuli:
*focal stimuli
*contextual stimuli
*Residual stimuli
15. CONTD….
*Focal stimuli or stimuli demanding prompt
attention.
*Contextual stimuli or stimuli present in a
surrounding and situation.
*Residual stimuli such as belief, attitude and
habits, which have an indeterminate on the present
situation.
16. CONTD….
7. The person’s adaptation level is such that it
comprises a zone indicating the range of stimulation
that will lead to a positive response. (if the stimulus
is within the zone the person responds positively,
however if the stimulus outside the zone ,the person
cannot make a positive response)
17. CONTD….
8. The person is conceptualized as
having four modes of adaptation:
psychological needs
self-concept,
role function, and
interdependence relations.
18. Four philosophical assumptions based
on the humanist principles are as
follows.
a. The individual shares in creative
power.
b. Behaves purposefully, not in
sequence of cause and effect.
c. Possesses intrinsic holism and
d. Strives to maintain integrity & to
realize the need for relationship.
19. CONTD….
VERTIVITY
The term vertivity derived
from the Latin ‘veritas’
meaning the trust, was
coined by Roy. It’s a
principle of human nature
that affirms a “common
purposefulness of human
existence”.
20. The four principles
are :
The individual is
viewed in the context of
the purposefulness of
human existence.
Unity of purpose of
human kind
Activity & creativity for
the common goods
Value of meaning of life.
21. 5. CONCEPTS OF MODEL
Roy’s model is a system model that focuses on
outcomes. the major features of the system models
are the:
-System and its environment
• A system is a set of parts connects to function as a
whole for some purposes and are interdependence
of its parts.
22. CONTD….
Keys elements in the Roy
adaptation model are-
1. The person who is recipient of
nursing care
2. The goal of nursing.
3. The concept of health
4. The direction of nursing
activities.
23. CONTD…
Person: Roy uses person in her model as a concept
to identify the recipient of nursing care. critical to
the model is the description of recipient of nsg care
as holistic adaptive systems.
Persons as living systems are in constant
interactions with their environments between the
system and the environment occurs on exchange of
information, matter and energy.
24. Goal-the goal of nsg. as the
promotion of adaptive responses
in relation to the four adaptive
modes (physiological, self
concept, role function and
interdependence)and contribute
to health.
25. Nsg activities-The nursing activities
are delineated by the model as those that
promotes adaptive responses in
situation of health and illness. The nsg
activities are identified as actions taken
by nurses to manipulate the focal,
contextual residual stimuli impringing
on person.
26. CONTD….
The nsg process acc. to Roy’s
model consists of six steps-
(1)Acceptance of behavior
(2)Acceptance of stimuli
(3)Nsg diagnosis
(4)Goal setting
(5)Intervention
(6)Evaluation
27. Health-health has been defined as a “state and
process of being and becoming an integrate
and whole person’’ Health is a process where by
individuals are striving to achieve their maximum
potentials.
28. Environment-stimuli from within the person and
stimuli from around the person represents the
element of environment acc. to Roy.
Environment is specifically defined by Roy as “all
conditions, circumstances influences surrounding
and affecting the development and behavior of
persons and groups.
29. 6. THE PERSON AS AN
ADAPTIVE SYSTEM
In addition to the concept of person,goal of
nsg,health and environment and nsg activities in
the model ,the theory of person as an adaptive
system employs additional concepts.
32. CONTD….
(1)Input-input coming from external environment
as well as internally from the person as a
stimuli(a stimulus is a unit of
information,matter,or energy from the
environment or a person who elicits a
response).The stimuli immediately confronting
the person are focal stimuli greatest degree of
change impact on person.
33. CONTD…
Contextual stimuli-observable, measureable and
reported by the person.
Residual stimuli-those make up characteristics of
the person that are present and relevant to
situation.
34. CONTD…….
Example: Mr. smith experiencing the chest
pain, the stimulus immediately confronting
Mr. smith,the focal stimulus ,is the deficit of
oxygen supply to his heart muscles.The
contextual stimuli include the 90 degree of
temperature ,the sensation of pain ,Mr.
smith’s age ,weight,blood sugar level,and
degree of coronary artery patency.The
residual stimuli include his history of
cigarette smoking and work relate stress.
35. Adaptation level is a constantly changing
point that represents the person’s ability to
cope with the changing environment in a
positive manner.
Adaptation level sets up a zone or a range
within which stimulation will lead to adaptive
responses.
Stimuli falling outside their adaptive zone lead
to ineffective responses.
Suicide due to inability to cope up with the
child is an extreme example of an ineffective
response.
36. Coping mechanisms
some coping mechanisms are
inherited or genetic such as
white blood defense system
against bacteria seeking to
invade the body.
some are learned as use of
antiseptics
37. CONTD….
Mechanisms are of 2 types:
(1)Regulator is used primarily as a mechanism
to cope with physiological stimuli.
(2)Cognator used mainly as mechanism to cope
with psychological stimuli dealing primarily in
area of cognition, judgment and emotion.
-Regulator and cognator mechanisms are linked
through the process of perception.
38. CONTD….
It is important to recognize that it is the
manifestation of the coping mechanism that can be
observed and measured within the adaptive modes.
Thus adaptive modes are often referred as
effectors.
39. CONTD….
Effectors: Roy has identified four adaptive modes;
Physiological
self concept
role function
interdependence.
40. CONTD….
Adaptive responses output-
The behaviors that contribute to the general goals
of the person(i.e survival,growth,reproduction and
mastery)are considered adaptive response.
Behaviors not contributing to general goals are
considered ineffective responses.
Adaptive responses being about a state of
adaptation.
41. 7. THEORY OF ADAPTIVE
MODES:
The theory of adaptive modes was developed in 1981,
consist of four parts:
physiological,
self concept,
role function &
interdependence.
42. CONTD…
Each adaptive mode represents a grouping of
behaviors that promote the individuals movements
towards the general goals (survival, growth,
reproduction, mastery).
43. CONTD…..
(1)PHYSIOLOGICAL MODE
Physiological wholeness is achieved
by adapting to changes in
physiological needs.
The regulator coping mechanism is
primarily responsible for attaining
and maintaining this integrity.
other complex process that
influences regulator
activities are the senses, fluids and
electrolytes, neurological function &
endocrine function.
44. Five primary needs have been identified as
necessary for physiological integrity:
oxygen,
nutrition,
activity rest,
protection,
elimination
45. CONTD…
(2)SELF CONCEPT MODE
Self concept is one of the 3 psychosocial modes, the
basic human need within modes in psychic
integrity,which means people need to know who
they are so that can exist with a sense of unity.
46. CONTD…..
Physical self: is an appraisal of one’s physical,
attributes, appearance, functioning,
sensation(feeling about self) sexually and
wellness illness status.
Personal self: is an appraisal of one’s own
characteristics, expectations, values & worth.
Personal self has been divided into the moral
ethical spiritual self ,self consistency & self
ideal, self expectancy e.g. I believe God will
help me through this surgery.
47. CONTD…..
(3)ROLE FUNCTION MODE:
The basic need in the role function adaptive model
is for social integrity. This means that people need
to know who they are in relation to others so that
they can act. All people have role in society. With
each role there are expected behavior .Role have
been divided into primary, secondary and tertiary.
48. CONTD….
(4)INTERDEPENDENCE MODE
Interdependence is a social adaptive
mode,needs affection adequacy or the feeling of
security in nurturing relationships.
Interdependence means the close relationship
of people that involves willingness & ability to
love, respect & value others and to accept &
responds to love, respect and value given by
others.
Loneliness as a common adaptation problem
resulting from a disruption in the modes.
49. Those currently identified
needs are listed below:
(a) Basic physiological needs-
Exercise and rest
Nutrition
Elimination
Fluid and electrolyte
Oxygen
Circulations
Regulations
52. CONTD….
Nature of planning and goal setting process
The focus of nsg interventions during the
implementation of the nsg care plan
The nature of the process of evaluating the quality
of effects of the care given.
53. NURSING PROCESS ACCORDING TO
RAM
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.
o 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.
54. CONTD….
Assessment of Stimuli: the second step of the
nursing process which involves the identification
of internal and external stimuli that are
influencing the person’s 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
3) Residual- those stimuli whose effect on the
situation are unclear.
55. 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
56. GOAL SETTING
the fourth step of the nursing process which
involves the establishment of clear statements of
the behavioral outcomes for nursing care.
57. Intervention: the
fifth step of the
nursing process which
involves the
determination of how
best to assist the
person in attaining
the established goals
58. 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.
59. DEMOGRAPHIC DATA
Name
Mr. NR
Age 53years
Sex Male
IP number ------
Education Degree
Occupation Bank clerk
Marital status Married
Religion Hindu
Informants Patient and Wife
Date of admission 21/01/08
60. 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.
No abnormal heart sounds.
S1& S2 heard.
BP- Normotensive. .
61. CONTD….
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. No tenderness.
Bowel sounds heard.
Percussion revealed dullness over
hepatic area.
62. CONTD….
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.
63. CONTD…
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.
64. CONTD….
o 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.
65. CONTD….
Protection:
Left lower fore foot is amputated.
Black discoloration present over the area.
No redness, discharge or other signs of infection.
Wound healing better now.
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.
All peripheral pulses are present with normal rate, rhythm
and depth over right leg.
66. CONTD….
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.
67. CONTD….
Neurological function:
He is conscious and oriented.
He is anxious about the disease
conditon
Touch and pain sensation
decreased in lower extrimity.
Endocrine function
He is on insulin. No signs and
symptoms of endocrine
disorders, except elevated blood
sugar value. No enlarged
glands.
68. CONTD….
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 doesn’t 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
69. 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,referred to
medical college; 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.
70. CONTD….
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. . Mother’s brother had DM. Mother had
history of PTB. He is a graduate in humanities,
no special knowledge on health matters.
71. 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. He studied how to use crutches
and mobilized at least twice in a day.
Patient’s 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.
72. NURSING CARE PLAN
ASSESS. OF
BEHAVIOUR
ASSESSMENT
OF
STIMULI
NURSING
DIAGNOSIS
GOAL INTERVEN
TION
EVALUA
TION
Ineffective
protection
and sense
in physical-
physiologic
al mode
(No pain
sensation
from the
wound
site.)
Focal
stimuli:
Non-
healing
wound
after
amputation
of great
and second
toe of left
leg- 4 week
1. Impaired
skin
integrity
related to
fragility of
the skin
secondary
to vascular
insufficie
ncy
Long-term
objective:
1.
amputated
area will be
completely
healed by
20/5/08
2.Skin will
remain
intact with
no ongoing
ulcerations.
- Maintain the
wound area
clean as
contamination
affects the
healing process.
- Follow sterile
technique while
providing cares
to prevent
infection and
delay in healing.
- Perform
wound dressing
with Betadine
which promote
healing and
growth of new
tissue.
Short term
goal:
Met: size of
wound
decreased to
less than 1x1
cms.
WBC values
became
normal on
24/4/08
73. ASSESS. OF
BEHAVIOUR
ASSESSMENT
OF STIMULI
NSG
DIAGNO
SIS
GOAL INTERVEN
TION
EVALUA
TION
Short-Term
Objective:
i. Size of
wound
decreases to
1x1 cm within
24/4/08.
ii. No signs
of infection
over the
wound within
1-wk
iii. Normal
WBC values
within 1-wk
iv. Presence
of healthy
granular
tissues in the
wound site
within 1-wk
-Do not move
the affected
area
frequently as it
affects the
granulation
tissue
formation.
- Monitor for
signs and
symptoms of
infection or
delay in
healing.
- Administer
the antibiotics
and vitamin C
supplementati
on which will
promote the
healing
process.
Long term
goal:
Partially
Met: skin
partially
intact with
no Continue
ulcerations.
Plan,Reasse
ss goal and
intervention
Unmet: not
achieved
complete
healing of
amputated
area.
Continue
plan
Reassess
goal and
74. ASSESS. OF
BEHAVIOUR
ASSESSMENT
OF
STIMULI
NURSING
DIAGNOSIS
GOAL INTERVEN
TION
EVALUA
TION
Impaired
activity in
physical-
physiological
mode
Focal stimuli:
During
hospital stay
great and
second toe
amputated.
But surgical
wound turned
to non- healing
with pus and
black colour.
2. Impaired
physical
mobility
related to
amputation of
the left
forefoot and
presence of
unhealed
wound
Long term
Objective:
Patient will
attain
maximum
possible
physical
mobility with
in 6 months.
- Assess the
level of
restriction of
movement
- Provide active
and passive
exercises to all
the extremities
to improve the
muscle tone and
strength.
- Make the
patient to
perform the
ROM exercises
to lower
extremities
which will
strengthen the
muscle.
Short term
goal:
Met: used
crutches
correctly on
22/4/08.
he is self
motivated in
doing minor
excesses
Partially
Met: walking
with
minimum
support.
75. ASSESS. OF
BEHAVIOUR
ASSESSMENT
OF
STIMULI
NURSING
DIAGNOSIS
GOAL INTERVEN
TION
EVALUA
TION
Short term
objective:
i.Correct
use of
crutches
with in
22/4/08
ii. walking
with
minimum
support-
22/4/08
iii.He will
be self
motivated
in
activities-
20/4/08.
-Massage
upper and
lower
extremities
which help
to improve
circulation.
- Provide
articles
near to
patient,
encourage
performing
activities
within
limits
which
promote a
feeling of
Long term
goal:
Unmet: not
attained
maximum
possible
physical
mobility-
Continue
plan
Reassess
goal and
interventio
ns
77. CONTD…
Clarity
Clarification of assumption needed , especially
philosophical assumptions.
Clarification of role , interdepence & self
concepts.
Ambiguity regarding concepts of cognator
regulator subsystems, effector mode/focal stimuli,
adaptive modes/ mechanism,env./internal
stimuli.
Language is clear & easy to read &understand.
78. CONT…
Consistency & congruency
Physiologic mode not connected to other 3 modes.
Unclear boundaries , abstract , lack of
operational definition.
Systemic assessment potential limked to nursing
process.
Level of theory development
Exemplary theory on development (melius,2007)
Grand theory used as conceptual framework for
middle range and micro theories.
Used as a framework for addressing adaptive
needs in individual , families & groups.
79. EXTERNAL CRITICISM
Complexity/ simplicity /discrimination
/pragmatism.
Simplicity is based on the language & terms.
Grand theories are inherently complex.
Complexity doesn’t bend into operationalizability
for research .
Studies based on the model moved from face
validity to construct validity studies and
relational research studies.
80. CONTD….
Reality convergence
Nutrsing interfaces between the individual &
health care system providing holistic care.
Nurses need to continue to learn and adapt to
avoid outsourcing.
Roy belives nurses can avoid extinction of the
profession by not allowing themselves to nurse
solely in the physiologi mode.
81. CONTD….
Scope
Grand theory RAM
Middle range theory evolved RAM:-
Caregivers’s effectiveness & well being.
Coping with pain & chronicity.
Coping with diabetes.
Gentle touch in preterm infants.
82. CONTD…
Significance
1987 – over 100,000 nurses have
graduated from program based on
RAM
Used by global scholars
Models used in research , curriculum
development, social issues , chronic
illness & development of research
instruments.
83. CONTD….
Utility
Research tool development
Describes responses to health illness.
Evaluates intervention
Measures perception of adaptation levels.
Measures perception of powerlessness & decision
making.
Measures health care outcomes of cancer patients.
Regaining functional abilities after delivery.
Used to identify adaptive and maladaptive
behavior to stimuli.
Lack of motivation to quit smoking.
Assessing & planning care of surgical patients.
Care of geriatric patients.
85. 9. APPLICATION OF R.A.M IN
NURSING
(1) Nsg practice- R.A.M is a very useful method in
nursing practice specially in those setting where
there are convert psychological needs which are as
essential as physical one. Roy’s models are very
effective in pediatrics as well as community and
rehabilatory nsg.
86. CONTD….
(2)Nursing Research-
R.A.M provide a conceptual model for
nursing process and this has been a
basis for number of research being
done.for e.g measuring functional
status after child birth,functional status
during pregnancy.
If research is to affect practitioners’
behavior, it must be directed at testing
and retesting conceptual models for
nursing practice. Roy has stated that
theory development and the testing of
developed theories are nursing’s
highest priorities. The model must be
able to regenerate testable hypotheses
for it to be researchable.
87. CONTD….
(3)Education-
RAM useful in educational setting. Roy states that the model defines
for students the distinct purpose of nursing which is to promote man’s
adaptation in each of the adaptive modes in situations of health and
illness.
