Case Study 1: Conservation Model. (Week 7)

  

· Yolanda is a 55-year-old married African American mother of two adult children who has a history of breast cancer. She was diagnosed with fibromyalgia 2 years ago, after years of unexplained muscle aches and what she thought was arthritis. The diagnosis was a relief for her; she was able to read about it and learn how to care for herself. Over the past 2 months, Yolanda stopped taking all of her medicine, because she was seeing a new primary care provider and wanted to start her care at “ground zero.” In addition to her family responsibilities, she is completing her degree as an English major. At the time of her clinic appointment, she told the nurse practitioner that she was having the worst pain possible.

Using Levine’s conservation model, the nurse practitioner completes a comprehensive assessment in preparation for developing a plan of care. A thorough assessment of characteristics of the internal and external environments is performed, with assessment of the adequacy of the adaptive fit that Yolanda has achieved in response to the changing environmental conditions produced by this health challenge. Nursing care is planned using the conservation principles. Yolanda’s diagnosis of fibromyalgia was based on the cluster of presenting symptoms (pain, fatigue, and sleeplessness) and the exclusion of other illnesses.

The assessment of the internal environment (physiological and pathophysiological processes) was performed by a thorough physical examination and various laboratory and diagnostic tests. Yolanda’s tests results were within normal limits.

The external environment includes perceptual, operational, and conceptual factors. Perceptual factors are perceived through sensory input. Yolanda reported a history of unexplained fatigue and sensations of pain for years. She recently stopped her medications “to clean my body out.” However, she reported that the pain became unbearable and was making it difficult for her to sleep. She noted that when she sleeps at least 6 hours a night, her pain is less intense. With the current insomnia, her pain is very intense.

Operational factors are threats within the environment that the patient cannot perceive through the senses. Yolanda reported severe pain in response to both the cold weather and changes in barometric pressure.

The conceptual environment includes cultural and personal values about health care, the meaning of health and illness, knowledge about health care, education, language use, and spiritual beliefs. In response to breast cancer, Yolanda developed her spirituality through prayer and reading the Bible. She believes this is how she is getting through the painful moments of her current illness.

Conservation of energy focuses on the balance of energy input and output to prevent excessive fatigue. Yolanda complains of a fatigue that just “comes over me.” She has difficulty doing housework. A day of work usually means 1 day in bed because of extreme fatigue. Her hemoglobin level and hematocrit are normal; her oxygen saturation is also within normal limits. These normal physiological assessments are typical in patients with fibromyalgia.

Conservation of structural integrity involves maintaining the structure of the body to promote normal functioning. Fibromyalgia treatment focuses on reducing symptoms. Yolanda’s symptoms could not be traced to any physical or structural alteration, yet she reports severe pain and fatigue. It is important to acknowledge the reality of the symptoms and work with the patient to determine whether activities of daily living result in changes in the pattern of illness. In addition, Yolanda thinks she is going through menopause (a normal physiological change in body structure), and she is having trouble determining whether her symptoms are menopause or fibromyalgia.

With continued questioning, Yolanda revealed that she was diagnosed with irritable bowel syndrome several years earlier. This condition presents further risks to structural integrity. She is not worried about constipation but is concerned about sudden diarrhea. She is afraid to go to school, fearing embarrassment because she might have an “accident.” Interventions to conserve structural integrity include interventions to promote normal bowel function and optimize Yolanda’s nutritional status.

Personal integrity involves the maintenance of one’s sense of personal worth and self-esteem. Yolanda reported that she “lost control” when she was diagnosed with breast cancer. A dear friend convinced her to go to church and encouraged her to use prayer. When feeling sorry for herself, she would go into her bedroom and read her Bible, cry by herself, and pray. She believes that prayer and Bible reading helped her heal. She continues to pray and read her Bible to gain the strength she needs to live with her illness. She also believes that she needs to be able to laugh at aspects of her situation; humor helps her feel better. She actively seeks health information, as indicated by her quest to learn about her diagnosis of fibromyalgia. She is most upset about not being able to walk as she used to walk. One of her favorite pastimes was shopping for shoes at the mall, which now is difficult for her.

Social integrity acknowledges that the patient is a social being. Yolanda is a married mother of two grown children. She conceals many of her feelings from her children but does share with her husband, who is supportive. Among the ways that he cares for her are to take her places she needs to go (such as grocery shopping) and to make sure she gets to her health care appointments on time.

An initial plan of care for Yolanda includes interventions based on the four conservation principles:

• Conservation of energy: (1) Discuss strategies to balance rest and activity; (2) discuss strategies to help her achieve restful sleep; (3) discuss both nonpharmacological and pharmacological approaches to manage pain; and (4) assess her nutritional intake to ensure adequate energy stores.

• Conservation of structural integrity: (1) Discuss any needed modifications of activities to prevent injury; (2) assess diet to identify whether any foods exacerbate gastrointestinal symptoms; (3) discuss the normal physiological process of menopause, including associated symptoms; and (4) consider additional laboratory work or referrals to evaluate hormone levels and assess whether additional treatment is indicated to relieve menopause symptoms.

• Conservation of personal integrity: (1) Validate the illness experience; (2) encourage continued use of prayer, Bible reading, and humor to help her feel better; and (3) discuss strategies to help her manage her anxiety related to the irritable bowel syndrome, including both nonpharmacological and pharmacological approaches.

• Conservation of social integrity: (1) Praise Yolanda for the strong family relationships that she has built and encourage her to continue to work together with her family to optimize her health; (2) with Yolanda’s permission, talk with her husband to answer his questions about her condition and discuss how they can continue to work together to improve her health; and (3) praise Yolanda for continuing to seek achievement of her goal of completing her English degree and discuss strategies to manage the irritable bowel syndrome and manage problems to help her feel more confident about going to school.

In Yolanda’s follow-up care, these outcomes suggest effective adaptation that is conserving wholeness and integrity:

• Feels rested, with 6 hours of uninterrupted sleep

• Reduction in pain and fatigue

Distinguishes symptoms of menopause from symptoms of fibromyalgia

Collaborates with health care providers to manage symptoms of menopause

Reports comfort as a result of prayer, Bible reading, and humor

Minimal adverse bowel symptoms and adequate nutritional intake

Healthy relationships with family and friends.

Attends school and participates in other social activities with minimal limitations.

This case study was developed from a fibromyalgia study (Schaefer, 2005). A fictitious name was used to protect privacy and anonymity.

Critical thinking activities

1. Are there any aspects of Yolanda’s care that you would add to the plan as you consider nursing care with the conservation principles?

2. Keep a reflective journal about a personal health or illness experience and apply the conservation model to that experience.

3. As you consider application of the conservation principles in question 2, what aspects of care are assessed that previously were not included in your plans of care?

5. Use the perspective of the conservation model to identify what may be missed in simulation experiences of nursing practice. What does it capture that other perspectives miss?

6. Suggest how you might begin to develop your style of nursing practice using the conservation model.