This case study was conducted on a patient with wrist joint hematoma in Iran since December 27, 2019 to January 4, 2020, on a case referred to Poursina Hospital in Rasht, Guilan Province, Iran. After evaluating the patient, the care program was implemented based on Johnson's behavioral model. To protect patients' privacy, only target data has been reported. There was no material or spiritual pressure on patients and their companions to participate in the study.
- Patient report
Our study participant, a 50-year-old woman named M.M, with a fifth-grade education who is conscious of time, place, and person, due to left-sided hematoma, with symptoms of severe swelling and pain in the area, on 31 December 2019, she went to the Poursina Hospital with her husband. She had a history of hypertension and diabetes for the past 15 years, as well as anemia for the past 5 years. The patient, following lumbar spine surgery due to a fourth vertebral dislocation, noticed a left forearm hematoma that initially had a hazelnut size that had increased in size, swelling, and severe pain in her forearm since about 5 months ago that was taken to the hospital via his wife. The patient scores his pain based on the VAS 7 score. The patient was hospitalized for 5 days. Pain from right-sided hematoma is unaffected, relieved by pain medication and cold compress prescription, and pain intensified with movement. The patient was reluctant to eat and her appetite was reduced. The patient weighs were 62 kg and had lost 3 kg in the past 5 months. She had two children (a 16-year-old girl and an 11-year-old boy), both of whom live with her and her husband. His wife was retired and caring for him. The client had a completely non-standard diet in the past 3 years ago, due to overweight, as a result, the stomach ulcer was treated medically for this problem and now the latest endoscopy Client showed better condition than last year's endoscopy. One of her problems was a loss of appetite and eating less, because of the disorder. Her other problem was suffering from excessive fatigue and numbness due to diabetic neuropathy resulting from constipation and inadequate dietary fiber, such as vegetables and liquids, from a week before admission to the first day of hospitalization. She had been pregnant twice. The patient's period was regular and every 28 days. At the age of 48, he became a menopause. The patient had a normal pregnancy twice. Her vaccination record was complete. The results of her experiments are shown in Table 1. A review of the subsystems is also shown in Table 2.
- Application of Johnson's behavioral model
The nursing process in a middle-aged woman with wrist hematoma, based on Johnson's behavioral model, is as follows:
Nursing Diagnosis 1: Pain related to right forearm hematoma.
Drive: To calm the patient's condition and report their pain based on VAS from 3 to 7.
Actions: 1. Check for pain using the VAS scale (Defend), 2. Deflection (Defend), 3. Priority of the patient's right wrist by placing the pillow (Inhibit), 4. Using cold compresses (Facilities), 5. Give pain relief as prescribed by your doctor (Facilities).
Nursing Diagnosis 2: Eating disorder is less than the body needs related to with anorexia.
Drive: Make the patient interested in food and eat more.
Actions: 1. Check the nutrition status (facilities), 2. Check the status of water and electrolytes (facilities), 3. Checking the client's weight (facilities), 4. Requesting the family to decorate their favorite food (facilities), 5. Consume low volume food frequently (Inhibit), 6. Use of cold compresses (Facilities).
Nursing Diagnosis 3: Constipation related to reduced intake of high fiber foods and liquids.
Drive: The patient should report abdominal flatulence and have a defecation at least once every three days.
Actions: 1. Check defecation (inhibit), 2. Evaluation of activity and type of diet (inhibit), 3. Training on consuming plenty of fluids and fruits and vegetables (inhibit), 4. Recommend to increase activity (inhibit), 5. Not eating foods that cause flatulence (inhibit), 6. consume laxatives as prescribed by your doctor (inhibit).
Nursing Diagnosis 4: Sleep Pattern Disorders related to Pain.
Drive: The patient should sleep at least 7 hours a day easily.
Actions: 1. Investigate the environment, create a quiet and dark environment (facilities), 2. Eat warm milk before bed (inhibit), 3. Training to raise the under head with pillow and use of blinds (inhibit), 4. Lack of thinking about life's problems before bed and distraction (restricted).
Nursing Diagnosis 5: Dysfunction in maternal role, spouse related to decreased libido.
Drive: Adapt family members to lack of client and role changes by meeting client needs and interacting positively with them.
Actions: 1. Encourage expression of emotion and training in coping techniques (inhibit), 2. References to Psychologists (facilities).
Nursing Diagnosis 6: Lack of awareness about low salt diet.
Drive: The patient will name at least two foods that are harmful to hypertension, know the side effects of salty foods, and follow a low-salt diet.
Actions: 1. Teaching Harmful Foods for Hypertension (inhibit), 2. Training on the complications of hypertension due to non-compliance with diet (inhibit).
Nursing Diagnosis 7: Lack of awareness of low sugar diet.
Drive: Have the patient name at least two of the most harmful sugars for diabetes, know the side effects of sweeteners, and follow a low-sugar diet.
Actions: 1. Teaching the patient harmful foods for hyperglycemia (inhibit), 2. Training on the complications of hyperglycemia due to non-compliance with diet (inhibit).
Table 1. The results of client experimental tests
Lab tests
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Normal range
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client reading
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WBC
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5000-10000
|
8000Mill/mm3
|
Hemoglobin
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Woman:12-15.5 gr/dL
|
11 gr/dL
|
MCV
|
80-94 fl
|
78 fl
|
MCH
|
27-31 Pg
|
26.9 Pg
|
Na
|
135-145 mEq/L
|
137 mEq/L
|
K
|
3.5-5.2 mEq/L
|
4.5 mEq/L
|
FBS
|
70-110 mmol/L
|
400 mmol/L
|
CRP
|
Less than 6.0
|
+2
|
Table 2. Investigating subsystems
Subsystems
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Instable behaviors
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Stable behaviors
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Aggressive/Protective
Drive: Protecting the patient and others from potential risk factors, tensions and the notion of possible dangers.
Function: Identify biological, environmental, and potential risk factors for the patient and their surroundings.
|
The client feels severe swelling and pain in her left wrist area, that exposes her to trauma and rupture of the hematoma and exacerbates the pain due to lack of proper care.
|
Normal findings were found in the endocrine, nervous, skin, hair, nail and musculoskeletal systems.
|
Achievement
Drive: Mastery or control of self or the environment.
Function: Establishing appropriate goals, directing behavior toward achieving the desired goal of life balance.
|
Due to movement constraints and hospitalization, she is worried and upset. Therefore, the subsystem is impaired. she has limited mobility and has difficulty sleeping and sleeps 4-5 hours a day. During the day, she feels tired and lethargic due to insufficient sleep and diabetic neuropathy.
|
The musculoskeletal system and the patient's sleep and rest were assessed and normal. To control his diabetes, he was able to control the disease by visiting a doctor and following a diet and medication. Sleep disorders were also resolved by actions such as creating a quiet and dark setting, eating warm milk before bedtime, teaching raising head with pillow and using blinds and distractions.
|
Affiliative
Drive: Making others aware of their existence.
Function: Providing focused attention, nurturing, physical aids, gaining truth and confidence.
|
Due to hand hematoma and limited motor impairment and impaired individual independence, the patient needs a constant companion to assist in restoring individual independence and to assist in some of their personal tasks, such as changing clothes and bathing in bed.
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The psychiatric examination was normal. The constant companion was provided with client request to meet her needs.
|
Dependency
Drive: To relate or belong to someone or something other than oneself and achieving empathy.
Function: Develop and use interpersonal skills to achieve empathy.
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In surveys conducted by the client, she was frustrated by the lack of involvement of the treatment staff in her treatment process and sometimes depressed by her lack of independence.
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The client's psychiatric examination was normal and the treatment staff was asked to participate in their treatment.
|
Eliminative/ Ingressive
Drive: Maintain physiological stability by relieving stress.
Function: Maintain physiological stability by repelling and relieving stress, expressing emotions and ideas verbally or non-verbally, and recognizing and interpreting the biological system that is readily available for secretion.
|
The patient has not had fecal excretion for the past three days. Reluctant to eat.
|
Renal, respiratory, pulmonary and gastrointestinal systems examinations were performed and client had no problems. Urinary excretion and stools are normal.
|
Restorative
Drive: Internalizing the external environment to maintain and integrate the internal environment to satisfy or satisfy appetite.
Function: Continue living through nutrition and correcting ineffective patterns of nutrition.
|
The client eats more than half of her food due to the effects of the non-standard diet for the past 3 years and stomach ulcers, with movement limitations and with this a reduction in stool excretion.
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Gastrointestinal system examination was normal. After 3 days of hospitalization and care, with a partial improvement of the hand hematoma and a movement restriction, he has no problem eating and has normal stool disposal.
|
Sexual
Drive: Satisfaction and Relaxation in sex.
Function: To develop a self-concept or self-identity based on gender, make meaningful communication that provides sexual pleasure.
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The client suffers from sexual dysfunction, such as decreased Libido after menopause and consequently impaired maternal-parental role.
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The patient's breast and genital system were examined and normal.
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Table 3. Subsystem and its components
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Drive
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Set
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Choice
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Action
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Aggressive/Protective
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Reduce client pain and calmness for her and get a score of 3 out of 10 on the VAS score.
|
Family and nurse support
|
Accept training given to reduce client pain
|
The nurse examines the client's pain on a VAS scale, and applies distraction techniques, prioritizing wrist placement under the pillow, applying cold compresses, giving narcotic medications to relieve pain as prescribed by a physician.
|
Achievement
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Have a comfortable sleep at least 7 hours a day
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Family support
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Accept training given to improve the quality of the client's sleep
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The nurse provides the client with a calm, dark, and non-stressful environment and gives her husband training on actions to improve her sleep quality.
|
Affiliative
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Reducing the client's dependence on personal actions and ultimately contributing to her own independence
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Family and nurse support
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Accept the participation of the client in therapeutic and personal actions to achieve complete independence
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The nurse provides the necessary training to help the client participate in therapies action to achieve complete independence.
|
Dependency
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To relieve the discomfort and depression of the client and to accept the complications of the disease
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Family and nurse support
|
Accept the complications of the disease and existing conditions as transient and treatable conditions, and participate in health and personal actions until full independence.
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The nurse at the hospital and her husband at home give her the training and emotional support she needs.
|
Eliminative/Ingestive
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Reduce abdominal flatulence, relieve constipation, and have bowel movements for at least three days.
|
Family and nurse support
|
Adopt the necessary training to improve excretion
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Nurses provide essential training such as consuming plenty of liquids and fruits and vegetables, recommending increased activity, and training non-consuming foods that cause flatulence.
|
Restorative
|
Show more interest in eating
|
Family and nurse support
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Adopt the necessary training to increase food craving
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The client's family will decorate her favorite food, and the nurse will provide a relaxed setting to increase appetite and provide the patient with a small volume of food.
|
Sexual
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Demonstrate that family members adhere to the lack of a client and interact positively with them.
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Family and nurse support
|
Accept this disorder and implement training and remedies
|
The nurse provides the necessary training, such as encouraging the expression of emotions and training on ways to adapt and refer to the psychologist. Her husband, too, is aware of her problem and is taking steps to address this lack.
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What was expected about the case, after 9 days of care based on Johnson's behavioral model nursing process, the client gained sufficient confidence in the treatment staff and she independently satisfied with participating in personal and medical work. After receiving medical care, her wrist swelling and pain decreased and she was able to gain relative independence on the seventh day onward in her personal work, such as eating, brushing and bathing. she had no movement restrictions on the affected limbs and easily did his favorite work, such as reading a book. Her sleep disorder problem was also remedied by implementing nursing care processes. the client's appetite improved and he did not feel uneasy about eating and had stool disposal. in the context of sexual dysfunction, her husband was also provided with the necessary information about the physiological and natural processes of the body after the necessary training. the client is fully aware of the disease process and its complications, diet and physical activity, and is successful in controlling diabetes and hypertension. she is aware of the consequences of failing to comply with the necessary training, both medicinal and non-medicinal, and strives to maintain and improve his health. The client missed her children, and her husband was asked to raise their spirits, asking the children to pay more attention to their mother.