Designing and Development of a Nursing Care Plan Based on Johnson’s Behavioural Model in Patient with Carcinoma of Larynx: A Case study

Background: Behavioural model can be very easily applied in the clinical settings and nurses will be able to design and implement an appropriate nursing care planning using Johnson’s behaviour model in patients with carcinoma of larynx. Aim: The aim of this paper was to investigate the application clinical function of Johnson’s Behavioural model in a patient with carcinoma of Larynx in a clinical setting. Methodology: This is a case study, in which nursing process has been used in accordance with the Johnson’s Behavioural model applied in Mr.X who is affected with cancer of Larynx. Result: After implementing Johnson’s Behaviour model in nursing process, the researcher achieved the goal easily. This case study was a very successful on application of Johnson’s Behaviour model. Conclusion: Johnson’s behaviour model is related to a person’s environment and can be used in a clinical setting as a frame work for identifying the problems of a patient and helps in evaluating the quality of nursing care. The patient who has been studied in this paper reveals the application of Johnson’s Behaviour model in a clinical setting. Case Study Jose et al.; JPRI, 34(11B): 8-13, 2022; Article no.JPRI.83740 9


INTRODUCTION
The Behavioural Systems model which is composed of interactive and interdependent units observes human being as a "living open behavioural system". The individual is a collection of behavioural subsystem that interrelated to form a behavioural system. The system is comprised of seven subsystems a) Aggressive-protective b) Achievement c) Affiliative d) Ingestive e) Eliminative f) Dependency g) Sexual. So the behaviour is considered as the system not the individual. Each of these subsystems can be can be described and analysed in the view of structural and functional requirements.
The system functions are regulated by the person's age, sex, motivation, values and beliefs. Structural elements include a) The drive or goal (direction and strength), b) Set (behavioural response pattern), c) Choice (behavioural alternatives available), d) The action (behaviour applied).
The functional requirements for each subsystem are nurturance, protection, and stimulation. These functional requirements, also termed sustenal imperatives. Nurses using the model believed that an additional area of behaviour needed to be addressed [1,2]. So a new subsystem also added, ie the eighth subsystem, restorative. The main components or the Metaparadigm of the theory includes, individual, nursing, environment and health. In the theory, theorist assumes the individuals as a behaviour system, with the following characters such as repetition, regularity, prediction, and goal orientation [6]. These characters focusing towards balance and that cause a relationship with the environment. Environment can be internal or external, that includes all factors which is related to individual's behavioural system and it affect the system as well [7].
Health is considered as stable and well balanced behavioural system. Nursing is an external force that organises the behaviour of the individual. Nursing activities does not depend on physician's interventions [3]. Medicine views a person as a biological system and nursing views as a behavioural system, because of this, the theorist consider nursing is unique from medicine. In this theory, nursing process is used when there is a sudden change in the environment (internal or external) which may lead to alteration in performance. Johnson believes that initial nursing intervention starts when pressure symptoms or lack of balance is observed [4]. Theorist considered nursing as an external adjustment factor, rather emphasizing on nursing process levels [3].
In behavioural model's view, nursing diagnosis is of four categories: dominance, incompatibility, insufficiency and discrepancy. Nursing interventions are planned based on the above four categories of nursing diagnosis. These interventions include providing subsystems by external mechanisms of facilitation, inhibition, restriction and defend [5].

Patient Profile
Mr. X is a 62 year old man, with a graduation in mathematics that is conscious and well oriented of time, place and person. He went to a multidisciplinary hospital on 27 February 2021 accompanied by his son, with the symptoms of cough, dyspnoea on exertion, reduced appetite and changes in voice. He is a known case of hypertension and diabetic since 15yrs and 8 yrs respectively and he is on regular medications for the same. As per his son, hoarseness in voice was noticed from 2 week. Followed by the diagnostic evaluation, he got confirmed as Ca. Larynx. He has undergone Total Laryngectomy on 9th March 2021. Followed by the surgical procedure, he reported severe pain on VAS (Visual Analogue Scale) 8 score. Patient was not willing to adequate food and his appetite was reduced. The patient weighs were 70 kg and had lost 4 kg in the past 3 months. He had three children (a 37-year-old girl, 32-year-old boy and 25-year-old boy) and he lives with his younger son. His wife was retired from service and she is caring for him. The patient had a completely non standard diet in the past 2 years ago, due to obesity; as a result, he developed stomach ulcers and get treated with medications and a recent endoscopy showed he is in a better condition. One of his problems was loss of appetite and eating less because of the disorder. He complains about excessive fatigue, numbness, constipation due to inadequate dietary intake form a week before admission to the hospital. The results of his laboratory investigations are shown in Table 1. A review of the subsystems is shown in Table 2 and components of subsystems are shown in Table.3. The study was carried out at the tertiary care hospital in March 2021.

Application of Nursing Theory -Johnson's Behavioural Model
The nursing process in a old-aged man with Carcinoma of Larynx, based on Johnson's Behavioural Model, is as follows:

Nursing diagnosis 1
Acute pain (neck) related to surgical incision (Insufficiency in protective and aggressive subsystem) as evidenced by guarding behaviour and verbal reports of the bystander.
Goal: Get relief from pain related to the surgical intervention.

Nursing diagnosis 2
Imbalanced nutrition less than body requirement related to anorexia, cough as evidenced by decreased food intake, reduction in weight.

Goal:
Mr. X will achieve and maintain adequate nutritional status.
Measures: 1. Monitor the nutritional status (facilities), 2. Monitor fluid and electrolytes (facilities),3. Check the weight daily (facilities), 4. Request the family to provide food according to his likes and dislikes (facilities), 5. Consume small and frequent diet (inhibit).

Nursing diagnosis 3
Constipation related to reduced intake dietary fibres as evidenced by verbalisation, infrequent bowel emptying.

Goal:
Mr. X will report normal bowel movements and presence of flatulence at least once in ever two days.
Measures: 1. Monitor the pattern of elimination (inhibit), 2. Evaluate the activity of the patient and type of diet he consumes (inhibit), 3. Request the patient to consume plenty of fluids, vegetables and fruits (inhibit) 4. Increase physical activity (inhibit), 5. Avoid gas forming foods (inhibit), 6. Administer laxatives as prescribed by the physician (inhibit).

Nursing diagnosis 4
Disturbed sleep pattern related to pain as evidenced by drowsiness during day.

Goal:
Mr. X will adequate sleep for at least 7 hours a day.

Nursing diagnosis 5
Deficient knowledge regarding low salt diet as evidenced by frequent questioning.

Goal:
Mr. X will name at least two foods that are harmful to hypertension and know the side effects of salty foods, and follow a low salt diet. Dependency Drive: to relate or belong to someone or something other than oneself and achieving empathy. Function: Develop and use IPR skills to achieve empathy.

Measures: 1. Educate about DASH diet (inhibit), 2. Training on complications of hypertension (inhibit).
Mr. X was frustrated by the lack of involvement in the treatment process Mr. X was asked to participate in the treatment program.

Eliminative/ Ingestive
Drive: Maintain physiological stability by removing a stress. Function: Maintain physiological stability by repelling and relieving stress, expressing emotions and ideas verbally or non-verbally, and recognising and interpreting the biological system that is readily available for secretion.
Mr. X has not had faecal excretion for the past 3 days. Anorexia Renal, respiratory, pulmonary and gastrointestinal system examinations were performed and found 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 inappropriate patters of nutrition.
Mr. X eats more than half of his food due to the effects of the non-standard diet for the past 2 years and stomach ulcer with a reduction in stool excretion.
GI system examination was normal. After 3 days of hospitalization and care, there was an improvement in eating pattern and bowel elimination.

Sexual:
Drive: Satisfaction and relaxation in sex. Function: To develop a self concept or self-identity based on gender, make a meaningful communication that provides sexual pleasure.
Mr. X suffers from sexual dysfunction, such as decreased libido after surgery and impaired parental role.
Mr. X's genital system was examined and it was normal. Mr. X's family will decorate his favourite food and the nurse will provide a relaxed setting top increase appetite and provide with small quantity of food.

Sexual:
Demonstrate that family members adhere to the absence of the person and interact positively with them Family support Accept the disease and implement training and remedies.
Nurse provides the information to the wife, like encouraging the expression of emotions and training on ways to adjust and refer to the psychologist. His wife, too aware of his problem and is taking measures to address the deficiency.

Nursing diagnosis 6
Deficient knowledge regarding low sugar diet as evidenced by frequent clarifications.

Goal:
Mr. X will name at least two foods that are most harmful sugars for diabetes, know the side effects of sweeteners, and follow a low-sugar diet.