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TO BE OF SERVICE: Team E Utilizing

The Three C’s of Lydia Hall

(Introduction by Rose de Leon)

It was the 1st week of July 2008 when we had the chance to introduce ourselves in the group. It amazes me that we will have this actual grouping to be able to work together interactively, though a little bit hesitant at first, if this could really work for us and if we can really hang-on with each other. Thus, I grab this opportunity with a delightful heart to introduce my team members for our Group Blog, FMA 1 for N207. Most of my team mates are located in our beloved native land. Truly, one of the best countries where an excellent foundation for Nursing Education could exists nowadays. And also highly diversified in experience with each of us coming from different fields yet we shared one common vision…to come-up with a substantive output and to fulfill our nursing dream. The team, although far from ideal, showed their best efforts in putting the blog together, not minding the hindrances such as work schedules, family and personal lives. These are the talented and hardworking people of Team E:
ROSE: An offshore student who works as a Nursing Service Director, coordinates all group activities, and yes, even posting forums in MOODLE, just to keep everyone updated.
SHANDZ: Working as a CI in one of the nursing schools in Rizal, she took the challenge to become the group’s first Team Manager and formulated a questionnaire to help us ponder deeply into our assigned theory.
JOY: also an offshore student taking up graduate studies in London, through communication by far hinders, she made he way to make it up with the team through technical layout support and collaborative idea of its final picture that comes to reality.
ANNA: A bank executive from the South, she took the challenge of being the secretary, buzzing everyone in time for the conferences; and she does it even while working overtime!
CAYE: Despite working 2 shifts in the Neonatal Intensive Care unit of one of the country’s top hospital, took the challenge of being the team editor (in between naps).
DOC LOREL: A physician and a nurse, shared very clear and interesting point of view about the CURE model. Truly, she’s heaven-sent.
ELOISE: Shares with Rose the same operating room experiences, putting the theory to use in their perioperative patients.
JAN: A dialysis nurse on training, inspired the team to come up with the best that it can do, challenging the limitations to be able to present a blog that is short, concise and unique.
RANDULF: Together with Jan, he injected some masculinity in the predominantly woman team and encouraged everyone to come up with a personalized insight on the applicability and relevance of Lydia Hall’s theory in our practice.

These are the team members, and this is our TEAM BLOG.


ON LYDIA HALL AND HER THEORY: BY ANNA ESTOY and NHINA DE ROSAS

Lydia Hall was born in New York City on September 21, 1906 and grew up in Pennsylvania. She was an innovator, motivator, and mentor to nurses in all phases of their careers, and advocate for the chronically ill patient. She promoted involvement of the community in health-care issues. She derived from her knowledge of psychiatry and nursing experiences in the Loeb Center the framework she used in formulating her theory of nursing. These experiences might have given her insight in on the distinct roles of nurses in providing care for the patients and how the nurses can be of utmost importance in caring for these patients.
The theory of all, as they say, contains of three independent but interconnected circles—the core, the care and the cure. But what do these terms mean? According to the theory, the core is the person or patient to whom nursing care is directed and needed. The module has mentioned that the core has goals set by himself and not by any other person, and that these goals need to be achieved. The core, in addition, behaved according to his feelings, and value system. The cure, on the other hand is the attention given to patients by the medical professionals. The module has been explicit in stating that the cure circle is shared by the nurse with other health professionals. These are the interventions or actions geared on treating or “curing” the patient from whatever illness or disease he may be suffering from. Some interventions I can think of in relation to this are the surgeries performed to treat a tumors or other malignancies, prescribing pharmacologic therapies and performing diagnostic tests. The highlight, however is the care model. This is the part of the model reserved for nurses, and focused on performing that noble task of nurturing the patients, meaning the component of this model is the “motherly” care provided by nurses, which may include, but is not limited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed.
That means that if all three circles exhibit harmony and balance, the patient will be the one to benefit from it all since his needs are being put into priority but the meeting of it depends on which circle of the model is responsible for meeting such activities. It was hard not to see that in all of the circles of the model, the nurse is always presents, but the bigger role she takes belongs to the care circle where she acts a professional in helping the patient meet his needs and attain a sense of balance.


THE THEORY AT WORK: APPLICATION TO OUR INDIVIDUAL PRACTICE

ELOISE ENCARNACION AND ROSE DE LEON, Operating Room Nurses:
The theory can be applied in all the phases of the operative experience. The CARE can be utilized when providing patient care and teaching at each phase of the surgery, providing comfort both physiologically and psychosocially. The CORE model can be realized when he patient is able to express his feelings about the procedure and participates in exploring these feelings, helping him towards a faster recovery. The CURE model is used when we provided medication therapy to the patient, nurses assuming our roles as either scrub or circulating nurse.

CAYE ELLIMA, Critical Care/NICU Nurse: The patient with congestive heart failure usually has health problems related to the ineffective pumping mechanism of the blood, pooling of the blood in the lower extremities and a vast array of systemic symptoms. The cure model can be applicable in this case when the nurse would perform assessment and formulate care plans based on the patient’s needs and against limitations set by the physicians. The cure model will also require the nurse to closely monitor the patient’s response to the treatments and any untoward symptoms and relay these with the other members of the health team. In the care model, the nurse can help the patient or the family in accepting and adapting to the emotional and other stresses the condition may bring. It will be the nurse’s task to open channels of communication to allow expression of feelings and help the patient/family work out through it. It is also in this model that health teachings are imparted. The core model dominates when the patient and/or family are able to address the emotional concerns and issues related to the perception of the effects of the disease process such as activity restrictions. It will be, therefore, the sole role of the nurse to help the patient/family maintain or achieve his sense of balance.

NHINA SANDEEP DE ROSAS, Nursing Education/Clinical Instructor: The core, care and cure model can be applied into nursing education by utilizing its concepts in the mode of instruction given to students. The care model can be materialized in education by having clinical instructors provide “real-world” learning experiences to students. This would provide the students more opportunities for learning and encourages feedbacks about learning topics. Doing this would institute measures to further explore learning needs and help students develop confidence in assuming their roles as nurses. The cure model can be used by nursing educators when they plan for learning activities for their students. This can be done through implementation of diagnostic examinations to ascertain the students’ learning needs not only on nursing practice but also on other fields of science affecting the practice of nursing. The core model can be fully realized only when the clinical instructors are successful in helping the student meet his learning needs and thus providing him with an increased sense of accomplishment in terms of knowledge.

RANDULF ERGUIZA, Community Health Nursing/Clinical Instructor: Care becomes effective when we show sincerity and genuineness in out approach not only towards students but also to patients. We listen, we communicate and we make them feel a part helping the patients. Core is strengthened when we make them (students and patients) realize their potentials as individuals by reflecting not only on things that they can do but also on things that they were not able to do, and what things they still can do. Cure is provided when measures such as encouraging people in the community to utilize the services offered by the health centers and; and teaching them compliance to treatment regimens.

JAN STANLEY DIARESCO, Dialysis Nurse: Lydia Hall’s Care, Core and Cure theory can also be seen and identified in this kind of setting. Patients undergoing hemodialysis experiences problems such as physical vulnerability, feeling of being a burden to the family and being hopeless. Being a nurse one should use therapeutic communication when dealing with the patient, and family, provide proper care to the client as he or she undergoes dialysis and create an environment that would promote holism as the procedure is being done.

As soon as the patient arrives in our unit we explain the treatment and how would it benefit her and the risks involve so that he/she would be ready once the consent is being explained to her the physician. The therapeutic use of self of a nurse is shown here. As a practitioner in the Kidney Unit, we perform dual responsibility, one as nurse and the other as a technician. Being a nurse technician, we provide care to our clients by understanding the concept of dialysis with the use of the machine, how to troubleshoot technical problems, understanding water treatment, cannulation and priming the machine When priming the machine we wash out the renalin and residues present in the dialyzer to protect the client from its harmful effects that could lead to anaphylactic shock. Injecting innohep and heparinizing the tubings makes it safer for the client since clotting will be prevented, which could cause blood loss or wastage. Monitoring vital signs of the client 15 min for the first hour and 30 min thereafter to check for hypotension or hypertension (common complications during HD) would easily alert the nurse to provide initial interventions such as positioning, flushing and notifying the physician for medications to be given or any procedure to be carried out. Upon removal of the cannula’s from the patient site, the nurse should properly apply pressure dressing on the site so as to prevent blood loss and promote healing of the site. Educating the client not to scratch the site, exercise her are so that the fistula site would be bigger and prevent any injury to the site would be ways of preventing future complications to the site.

References:
Anonuevo, et al., Theoretical Foundations of Nursing; UP Open University Press; 2005
Potter and Perry; Fundamentals of Nursing, Fifth Edition; Mosby Publishers; 2001
George, J.B.; Nursing Theories: The Base for Professional Nursing Practice; 2000
http://www.napnes.org/practice/news/clinical_articles/care_of_the%20_congestive_heart_failure_patient.html

AND THIS IS OUR TEAM…

Shandz, Anna, Caye, Rhose, Eloise, Doc Lorel, Joy, Jan, & Randulf

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"Health is a condition in which all parts and subparts are in harmony
with the whole of the client.”

BIOGRAPHY

1924 - Born in Lowell, a village in Washington County, Ohio, United States, along the Muskingum River

1947 - Obtained her Registered Nurse Diploma from the Peoples Hospital School of Nursing, in Akron Ohio. After that, she went to California where she worked in a hospital as a staff nurse, and eventually became the head nurse. She also explored other fields, and experienced being a school nurse, industrial nurse, and clinical instructor.

1957 - She went to the University of California at Los Angeles (UCLA) and took a double major in psychology and public health. She received her BS Nursing from this institution.

1966 - She completed her Masters degree in Mental Health, Public Health Consultation, also at UCLA. She became recognized as a pioneer in the field of nursing involvement in community mental health.

1970 - Started developing The Systems Model as a way to teach an introductory nursing course to nursing students. The goal was to provide a Holistic overview of the physiological, psychological, sociocultural, and developmental aspects of human beings.

1972 - After a two-year evaluation of her model, it was eventually published in Nursing Research.

1985 - She completed her doctorate in Clinical Psychology from Pacific Western University.

1988 - She founded the Neuman Systems Model Trustee Group, Inc. They are dedicated to the support, promotion and integrity of the Neuman Systems Model to guide nursing education, practice and research.

1992 - She was given an Honorary Doctorate of Letters, at the Neumann College, Aston, Pennsylvania.

1993 - Because of her important contributions to the field on Nursing, Dr. Neuman was named Honorary Member of the Fellowship of the American Academy of Nursing.

1998 - Received an Honorary Doctorate of Science from the Grand Valley State University in Michigan. For the past years, Dr. Betty Neuman has continuously developed and made famous the Neuman systems model through her work as an educator, author, health consultant, and speaker. Her model has been very widely accepted, and though it was originally designed to be used in nursing and is now being used by other health professions as well.

As keynote speaker at the University of Maine (2004)

INFLUENCES

Betty Neuman took inspiration in developing her theory from the following theories/ philosophers:

1. Pierre Tielhard deChardin : a philosopher-priest that believed human beings are continually evolving towards a state of perfection – an Omega Point

2. Gestalt Theory : A theory of German origin which proposes that the dynamic interaction of the individual and the situation determines experience and behavior.

3. General Adaptation Syndrome mainly talks about an individual’s reaction to stress on the 3 levels a) alarm b) resistance c) exhaustion

4. General Systems Theory postulates that the world is made up of systems that are interconnected and are influenced by each other.

The Neuman System Model

KEY CONCEPTS

• Viewed the client as an open system consisting of a basic structure or central core of energy resources which represent concentric circles

• Each concentric circle or layer is made up of the five variable areas which are considered and occur simultaneously in each client concentric circles. These are:

1. Physiological - refers of bodily structure and function.
2. Psychological - refers to mental processes, functioning and emotions.
3. Sociocultural - refers to relationships; and social/cultural functions and activities.
4. Spiritual - refers to the influence of spiritual beliefs.
5. Developmental - refers to life’s developmental processes.

Basic Structure Energy Resources

This is otherwise known as the central core, which is made up of the basic survival factors common to all organisms. These include the following:

1. Normal temperature range – body temperature regulation ability
2. Genetic structure – Hair color and bodily features
3. Response pattern – functioning of body systems homeostatically
4. Organ strength or weakness
5. Ego structure
6. Knowns or commonalities – value system

• The person's system is an open system - dynamic and constantly changing and evolving

• Stability, or homeostasis, occurs when the amount of energy that is available exceeds that being used by the system.

• A homeostatic body system is constantly in a dynamic process of input, output, feedback, and compensation, which leads to a state of balance
  

Flexible Lines of Defense

• Is the outer boundary to the normal line of defense, the line of resistance, and the core structure.

• Keeps the system free from stressors and is dependent on the amount of sleep, nutritional status, as well as the quality and quantity of stress an individual experiences.

• If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated.
  

Normal Line of Defense

• Represents client’s usual wellness level.

• Can change over time in response to coping or responding to the environment, which includes intelligence, attitudes, problem solving and coping abilities. Example is skin which is constantly smooth and fair will eventually form callous over times.

Lines of Resistance

• the last boundary that protects the basic structure

• Protect the basic structure and become activated when environmental stressors invade the normal line of defense. An example would is that when a certain bacteria enters our system, there is an increase in leukocyte count to combat infection.

• If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death.

Stressors

• Are capable of producing either a positive or negative effect on the client system.

• Is any environmental force which can potentially affect the stability of the system:

1. Intrapersonal - occur within person, example is infection, thoughts and feelings
2. Interpersonal - occur between individuals, e.g. role expectations
3. Extrapersonal - occur outside the individual, e.g. job or finance concerns

• A person’s reaction to stressors depends on the strength of the lines of defense.

• When the lines of defense fails, the resulting reaction depends on the strength of the lines of resistance.

• As part of the reaction, a person’s system can adapt to a stressor, an effect known as reconstitution.
  

Reconstitution

• Is the increase in energy that occurs in relation to the degree of reaction to the stressor which starts after initiation of treatment for invasion of stressors.
• May expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness.
• Nursing interventions focus on retaining or maintaining system stability.
• By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system.
  

Prevention

• Is the primary nursing intervention.

• Focuses on keeping stressors and the stress response from having a detrimental effect on the body.

1. Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. This occur before the system reacts to a stressor and strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors and also manipulates the environment to reduce or weaken stressors. Includes health promotion and maintenance of wellness.
   
2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction of the stressor and increasing resistance factors in order to prevent damage to the central core. This occurs after the system reacts to a stressor. This includes appropriate treatment of symptoms to attain optimal client system stability and energy conservation.
   
3. Tertiary prevention focuses on readaptation and stability, and protects reconstitution or return to wellness after treatment. This occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

Betty Neuman's System Model

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APPLICATION

The main use of the Neuman Model in practice and in research is that its concentric layers allow for a simple classification of how severe a problem is. For example, since the line of normal defense represents dynamic balance, it represents homeostasis, and thus a lack of stress. If a stress response is perceived by the patient or assessed by the nurse, then there has been an invasion of the normal line of defense and a major contraction of the flexible line of defense. Infection or other invasion of the lines of resistance indicates failure of both lines of defense. Thus, the level of insult can be quantified allowing for graduated interventions. Furthermore each person variable can be operationalized and the relationship to the normal line of defense or stress response can be analyzed. The drawback of this is that there is no way to know whether our operationalization of the person variables is a good representation of the underlying theoretical structures.

For example, Eileen Gigliotti published a research article in 1999 based on the Neuman Systems Model. The study investigated the relationship of multiple role stress to the psychological and sociocultural variables of the flexible line of defense. If multiple role stress had occurred, then the normal line of defense had been invaded. Questionnaire instruments were used to operationalize the psychological component with perceived role as a student and as a mother; the sociocultural component with social support, the normal line of defense as perceived multiple role stress.

Upon analysis, no conclusions could be made about the normal line of defense simply on the basis of the psychological component and sociocultural component. By dichotomizing the data by median age, however, a relationship between them could be described. Thus the relationship between the normal line of defense and the psychological and sociocultural components could only be described by taking into account the developmental component. It indicates that the components of the flexible line of defense interact in very complex ways and it may be difficult and dangerous to overgeneralize their interaction.

PERSONAL EXPERIENCES

Experience #1

I’m assigned at the service/charity ward of PDMMMC few months ago. As a staff in the ward of a government hospital, I noticed many weaknesses and shortcomings in the medical management and nursing care as well maybe due to the city government’s not prioritizing health care. They say it is maybe due to “lack of budget” but I really don’t believe in that same old music. I know there is, but the question is where is it going? We are badly lacking of resources, instruments and material so we need to improvise. And most of all, we are under staff so proper nursing care is compromised to every patient plus the fact that the environment is not conducive to the nurses and the patients. At that time, a 25 year old female patient was transferred to our ward from the ICU. The case was PTB advanced and heart problem. I was very curious why? They said that the patient is stable but the catch is she was admitted to the isolation room of the charity ward together with other PTB cases and with minimum nursing care because of the overwhelming census. Based on my own assessment, the patient is not yet stable, I think the true reason for transfer is that the patient can no longer withstand the demands for her medication in ICU because she is the one who is availing that, or maybe there is a much priority patient who will be placed in ICU, because it is only two – bed capacity so they need to manage and decide very well on admissions and discharge. And if they want to transfer the patient post ICU, why in service ward that is not so conducive? Of course the patient is financially incapable to be admitted to pay ward.

The client’s flexible line of defense is compromised here; she had a hard time resting because the temperature in the isolation room is very warm and humid even if she has an electric fan. Her nutritional level is also not good and quantity of stress increases. Her normal line of defense is also unstable, she is not well and we can assess she is not. And her line of resistance is severely debilitated; she has PTB infection and dyspnea. Her environment to isolation room further worsens her condition.

Extrapersonal stressors like the isolation room environment where infection is floating around the room and also the nursing care that nurses wasn’t able to render because of the nurse to patient ratio of 1:30 which is not very ideal. She also has interpersonal stressors like the problem of broking up with his husband and for not having the opportunity to see her son because children are restricted to ward premises especially in isolation room. And her intrapersonal stressors like disturbed emotional status, deteriorating physical ability and financial problems.

These factors disrupted the reconstitution of the patient. In this situation, primary prevention is not given priority, because her admission to charity ward, isolation room increases her risk to infection and stress and limited nursing care. In secondary prevention, we succeed in the first part in ICU but wasn’t able to continue in the ward because of many factors as stated above. Even the prescribed medications are not purchased because of financial constraints. In tertiary prevention, sometimes we nurses do our best, but fate will still prevail. Patient died that evening during endorsement before we receive her case. Nursing goal is not met. And lessons are learned.

Neuman system model is a delicate tool to be used in nursing care especially in identifying the stressors, the interventions, and the affectation in the line of defenses of the client that we must protect to maintain quality of life, reconstitution and optimum level of functioning of our clientele and much better in disease prevention. Holistic care should be given to all of our patients at all times in any setting.

Experience #2

About a week ago I had in my care the wife of the captain of the ill-fated Princess of the Stars. In this case, I was able to identify the following stressors:

1. Psychological-Emotional:

• Anxiety which stemmed from the uncertainty about the fate of her husband.
• A sense of guilt because relatives of the passengers are blaming her husband for the tragedy.
• Ambivalence in the sense that she would be happy if her husband survived and at the same time worried too that if he did survive he would be subjected to court litigation.

2. Financial Stress: Her husband is the breadwinner of the family and in a brood of 5 children, only one is employed; the rest are still in school.

3. Physical Stress manifested as:

a. Insomnia

b. Elevated blood pressure unresponsive to maintenance medications

c. Persistent chest pains

Nursing interventions are carried out on three preventive levels:

• Primary Prevention would not be applicable because the accident causing the stressors has already occurred and the patient has already developed the reactions/symptoms of stress.

• Secondary Prevention is applicable in this case. Because of the persistent elevated blood pressure ( above 200/110) accompanied by severe chest pains, the patient was admitted to the hospital for both diagnostic and therapeutic management. Nursing intervention centered initially on the round the clock monitoring of the blood pressure and giving of the ordered anti- hypertensive drugs. Since the EKG showed ischemia, the patient was closely watched for worsening of the pain because of the possibility of a myocardial infarction. Immediate referral of the patient to the resident physician is to be made if chest pain persisted despite giving isosorbide dinitrate for proper evaluation. Aside from giving anxiolytics to decrease the anxiety of the patient, I have to warn visiting relatives to refrain from talking about the tragedy. Sedatives were given before bedtime to prevent insomnia.

• Tertiary Prevention: Upon discharge, I gave the patient and the immediate family members the following advice:

1. If possible to stay in a relative’s house for a few weeks because they were being hounded by media who were camped outside their home.
2. Regular monitoring of the patient’s blood pressure by a daughter who is a student-nurse who should also monitor her intake of medications as prescribed by the physician.
3. Avoid watching TV shows that mention about the tragedy.
4. Avoid answering the phone.
5. She should have a close relative with her aside from the children who will manage their affairs in the meantime.

Experience #3

In the Community...
In one of the rotations of my students in the community, we encountered this very interesting newly married young couple (both are 18 years old). They have been married only for 3 months, but the supposed to be happy pair is already facing a lot of stressors.

One condition that brings extrapersonal stress is the unemployment of the husband. Their financial source is not enough to meet their needs. The woman somzd enough for her son. This relationship poses as an interpersonal stress to her.

The wife is also pregnant at that time, and her poor nutritional (underweight) and emotional status (sadness and anger at her mother-in-law) create intrapersonal stresses.

We know, based on Neuman’s Systems Model, that the reaction to stressors would depend on the strength of the lines of defense. The woman, due to financial constraints, is suffering from poor nutritional status. She usually lacks enough sleep due to the nature of her work. This creates a breach to her flexible line of defense. The normal line of defense also becomes unreliable because of her uncaring attitude toward her pregnancy and sexual behaviors that predispose her to a lot of possible illnesses. Her coping abilities are also affected because she is sometimes preoccupied with her relationship problems with her mother-in-law.

These conditions put not only our client but also her unborn child on the verge of developing various illnesses. Hence, our interventions focused on restoring system stability, by helping the client’s system adapt to the stressors.

Starting with primary prevention, we tried to educate their family on the importance of having good nutrition. We suggested some nutritious but cheap food choices. We also tried to advice her on possible alternative jobs that would not jeopardize her health and that of her unborn baby.

For the secondary prevention, we advised that she seek pre-natal check-up, and make use of the available services of the nearby health center.

After about 1 month of constant visits to these clients, we really observed noticeable improvements in their health conditions. The woman began to show weight gains consistent with her age of gestation. The couple has also learned to plant and eat nutritious food such as fruits and vegetables. The husband started to work as a production operator in a nearby factory, allowing his wife to take a break from her old job.

Before our duty in the community ended, we were able to initiate tertiary prevention by supporting and commending the positive behavioral changes exhibited by the couple. We also dwelt on strengthening the positive attributes of the family, such as their unwavering faith in God, and their strong devotion to each other. We learned from this experience that no problem is unsolvable with the use of consistent and well-contemplated nursing care.

REFERENCES:

Websites:
http://www. google.com

http://www.neumansystemsmodel.org

http://www.neumansystemsmodel.org/NSMdocs/nsm_powerpoint_overview.htm

http://www.patheyman.com/essays/neuman/index.htm

Patrick Heyman and Sandra Wolfe, University of Florida, April 2000 http://www.patheyman.com/essays/neuman/implications.htm


Books

Añonuevo, C. et. Al (2000). N207 Theoretical Foundations of Nursing. Philippines: UP Open University

Balita, Carlito E. (2005). Ultimate Learning Guide to Nursing Review. Ultimate Learning Series

Kozier, B. et. Al (2004). Fundamentals of Nursing: Concepts, Process, and Practice (4^th ed.) New Jersey: Pearson

Marriner-Tomey, A. (1994). Nursing Theorists and Their Work (2nd edition). St. Louis: Mosby

Octaviano, Eufemia F. and Balita, Carlito E. Theoretical Foundations of Nursing: The Philippine Perspective. Ultimate Learning Series, 2008



CONTRIBUTORS

Reyes, Jose Richard III

Ricana, Ryan

Rico, Ron Paulo

Rimas, Ma. Filipina

Rosales, Ava

“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”

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