SDS TRC AND RGICD COLLEGE OF

NURSING
BENGALURU-29.

Seminar: Orem’s Theory.

Subject: Advance Nursing Practice.

Submitted To: Submitted By:

Mrs. Archana S Sonar Miss. Revathi H K

Lecturer, 1ST Year, M.Sc (N).

Obstetric & Gynaecological Nursing .

Date of Submission:
 OREM’S THEORY

1.INTRODUCTION1,2

Dorothea Elizabeth Orem (1914-2007) is one of America’s foremost nursing theorists.

She was born at Baltimore, Maryland. She started her nursing education by joining at the
Providence Hospital School of Nursing. She earned her Bachelor of Science in nursing education
in 1939 and Master’s of Science in Nursing in 1945.She received honorary doctor of science
degree in 1976 , Doctor of Humane Letters 1988 and Doctor of Nursing Honoris Causae in
1998.Dorothea E Orem in her nursing experience includes private duty nursing, hospital staff
nursing and teaching. Orem’s dedicated her life to creating and developing a theoretical structure
to improve nursing practice.

2. DEVELOPMENT OF THEORY3,4

A definitive movement towards nursing as a field of knowledge as well as a field of

practice occurred in the 1950s where she worked as a consultant with the division of hospital and
Institutional Service of The Indiana State Board of Health. Her contact with nurses impressed
upon her, their interest for nursing, desires for progress as well as absence of knowing leaders in
nursing. She was overwhelmed by the nurses’ inability to communicate nursing in their patients,
physicians and others. She plans to upgrade the quality of nursing in general hospitals throughout
the state. During this time she developed her definition of nursing practice. In 1957 Orem moved
to Washington D.C where she was working as curriculum consultant. In that period she wrote
“Hope of Nursing”, which was published in the journal of nursing education. This work
stimulated her to consider the question “what condition exist in a person when that person or
other determines that the person need nursing care”-this idea also evolved her into concept of
self care. She continued to develop her concept of nursing and self care during this time and she
published her Concept Of Nursing Practice in 1971. Subsequent edition was published in 1980,
1985, 1991, 1995 and 2001. She participates in conferences and prepares paper about various
conceptual developments of theory. She urges that nursing is distinguished from other human
services and other forms of care by the way in which it focuses on human beings.
3. MAJOR ASSUMPTIONS5:

Assumption basic to the general theory were formulated in the early 1970s and were first
presented at Marquette University School of nursing 1973.

Orem identifies the five premises underlying the general theory of nursing.

 Human beings required continuous deliberate inputs to themselves and their

environments to remain alive and function in accordance with natural human
endowments.
 Human agency, power to act deliberately is exercised in the form of care for self and
others in identifying needs and making needed inputs.
 Mature human beings experience privations in the form of limitations of actions in care
for self and others involving and making of life sustaining and function regulation inputs.
 Human agency is exercised in discovering, developing and transmitting ways and means
to identify needs for and make inputs to self and others.
 Groups of human beings with structured relationships cluster tasks and allocate
responsibilities for providing care to group members who experience privations for
making required, deliberate input to self and others.

4. USE OF EMPIRICAL EVIDENCE5,6

In 1958, Orem experienced a spontaneous insight about why individuals required and
could be helped through nursing. This knowledge enables her to formulate and express her
concept of nursing.

DOMAIN CONCEPTS:

 Nursing: is an art, a helping service and a technology; it is the actions deliberately

selected and performed by nurses to help individuals or groups under their care to
maintain or change conditions in themselves on their environment.
Goals being-maintaining health, to regain normal state of health, to minimize, stabilized
and control poor health or disability.
  Health: it is a state of physical, mental, social and spiritual wellbeing and not merely the
absence of illness.
 Environment: the environment components are environmental factors, environmental
elements, conditions and developmental environment.
 Human being: it has the capacity to reflect, symbolize and use of symbols; it is the unity
that can function biologically symbolically and socially.
 Client: a human being who has little health related/ health derived limitation that renders
him incapable of continuous self care or limitation that result in ineffective/ incomplete
care.
 Developmental self care requisites: occurs due to a health condition or life events.
Includes disease process, injury, effects related to aging etc.
 Universal self care requisites: Are common to all human beings. Consist of basic life
requirements such as air, food, elimination ,activity etc
 Deviation requisites: action necessary to employ when a deficit in self care exists.
Procuring medical treatment and nursing intervention.
 Nursing therapeutics: it is a deliberate, systematic and purposeful action
 Nursing process: it is a system to determine
-Why a person is under care
-A plan for care
-The implementation of care

5. OREM’S WORK AND THE CHARACTERISTICS OF A

THEORY:7

Orem’s theory:

 Interrelate concepts in such a way as to create a different way of looking at a

particular phenomenon.
 Is logical in nature.
 Is relatively simple yet generalizable.
 Is basis for hypothesis that can be tested.
  Contribute to and assist in increasing the general body of knowledge within
the discipline through the research implemented to validate them.
 can be used by the practitioners to guide and improve their practice.
 must be consistent with other validated theories ,laws and principles.

6. OREM’S GENERAL THEORY OF NURSING:7,8

It includes three related parts

SELF CARE DEFECIT

SELF CARE NURSING SYSTEMS

Occurs when the demand of

Self care is greater than the

individual ability to satisfactorily

attain it.

Activities that an individual identifies action that the

completes or assists with an nurse and client can take

order to maintain life and to reduce or eliminate

higher level of well being. the identified self care

deficit.

6.1. THEORY OF SELF CARE:7

 Self care– The performance of activities that individual initiates and perform on
their behalf to maintain life, health and wellbeing.
 Self care agency – is a human ability which is "the ability for engaging in self care"
and conditioned by age developmental state, life experience socio-cultural
orientation health and available resources.

Consists of two agent

-self care agent (person who provides the self care)

-Dependent Care Agent(person other than the individual who provides care such as
parents)

 Therapeutic self care demand- Totality of self care actions to be performed for
some duration in order to meet self care requisites by using valid methods and
related sets of operations and actions.

 Self care requisites– action directed towards provision of self care.

 Three categories of self care requisites are:--

a. Universal b. Developmental c. Health deviation

6.1(a)UNIVERSAL SELF CARE REQUISITES:

Universal self care requisites are associated with life processes and the maintenance
of the integrity of human structure and functioning. They are common to all human
beings during all stages of life cycle and should be viewed as interrelated factors,
each affecting the others. Such as
 The maintenance of sufficient intake of air, water , food.
 The provision of care associated with elimination processes and excretion.
 The maintenance of a balance between activity and rest.
 The maintenance of a balance between solitude and social interaction.
 The prevention of hazards to human life, functioning and well being.
 The promotion of human functioning and development within social groups in
accordance with human potentials, human limitations and desire to be normal.

6.1(b) DEVELOPMENTAL SELF CARE REQUISITES:

Developmental self care requisites promotes process for life and maturation and prevents
conditions delirious to maturation or those that mitigates those effects. These are
associated with developmental processes/derived from a condition or associated with an
event, e.g. Adjusting to a new job, adjusting to body changes.

6.1(c) HEALTH DEVIATION SELF CARE

Health deviation self care is required in conditions of illness, injury or disease or and
may result from medical measures required to diagnosed and correct the condition E.g.
right upper quadrant abdominal pain when oily foods are eaten or learning to walk using
crutches following the casting of a fractured leg.

Health deviation of self care requisites are-

 Seeking and securing appropriate medical assistance.

 Being aware of and attending to the effects and results of pathologic conditions
 Effectively carrying out medically prescribed measures.
 Modifying self concepts in accepting oneself as being in a particular state of health
and in specific forms of health care.
 Learning to live with effects of pathologic conditions

6.2.THEORY OF SELF CARE DEFICIT:7

The central idea of the theory of self care deficit is that requirement of persons
for nursing are associated with the subjectivity of mature and maturing persons to
health related action limitation. These limitation render them partially or completely
unable to know exciting and emerging requisites for regulatory care. It specifies
when nursing is needed. Self care is the term that expresses the relationship between
the action capabilities of individual and their demands for self care. It is an abstract
concept and provides guides for the selection of methods for helping and
understanding patients role in self care. According to Orem’s, nursing is required
when an adult is incapable or limited in the provision of continuous effective self
care. Orem identifies 5 methods of helping:--
 Acting for and doing for others.
 Guiding others.
 Supporting another [physical or psychological].
 Providing an environment promoting personal development in relation to meet
future demands.
 Teaching another.

6.2.1.CONCEPTUAL MODEL:7

Orem presents a model to show the relationship between her concepts. From this model
it can be seen that at a given time an individual has specific self care abilities as well as
self care demand. If there are more demand than abilities, nursing is needed.

 Entering into and maintaining nurse patient relationship with individual, families
or groups until patients can legitimately be discharged from nursing.
 Determining if and how patient can be helped through nursing.
 Responding to patient requests desires and need for nursing contacts and
assistance.
 Prescribing, providing and regulating direct help to patient and their significant
others in the form of nursing.
 Coordinating and integrating nursing with the patient’s daily living, other health
care, social and educational services needed.

Fig:1. Diagrammatic presentation of conceptual model.

 6.3. THEORY OF NURSING SYSTEMS:7

It describes how the patient self care needs will be met by the nurse, patients or
both. The theory of nursing system propose that nursing is human action, nursing system
are action system formed by nurses through the exercise of their nursing agency for
person with health deviated or health associated limitations in self care. Orem’s
identifies three classification of nursing system to meet self care requisites of the
patients.
Wholly Patient actions
compensatory are limited.
System.
Partly Patient actions are
Nurse Action
compensatory partially limited.

system
Supportive Patient actions are not
educative limited.
system.
6.3(a) Wholly compensatory nursing system: Wholly compensatory system are

nursing system for people who are—

 Unable to engage in any form of deliberate action for e.g person in coma
 Aware and who are able to make observation, judgments and decisions about self care
and other matters but cannot or perform actions requiring ambulation or manipulative
movements.
 Unable to attend to themselves and make reasoned judgments and decision about self
care and other matters but who can be ambulatory and may be able to perform some
measures of self care with continuous guidance and supervision.

6.3(b) Partly compensatory nursing system: it exists when both nurse and patient perform care
measures or other actions involving manipulative tasks or ambulation. Either the nurse or the
patient may have the major role in the performance of care measures.

E.g. an individual who has had recent abdominal surgery, the patient might be able to wash his
or her face and brush but needs nurse for help in ambulatory and in changing the dressings.
6.3(c) Supportive educative system: The third nursing system is the supportive educative
system. In this system the patient is doing all of his self care and the patient requirement for help
are confined to decision making, behavior control and acquiring knowledge and skills. Role of a
nurse is to regulate the exercise and development of self care agency.

7.OREM’S THEORY AND NURSING PROCESS:7,8

 Orem’s approach to the nursing process presents a method to determine the self
care deficits and then to define the roles of person or nurse to meet the self care
demands.
 The steps within the approach are considered to be the technical component of
the nursing process.
 Orem emphasizes that the technological component "must be coordinated with
interpersonal and social processes within nursing situations.

7.1.Comparison of Orem’s Nursing Process and the Nursing Process:8

NURSING PROCESS OREM’S NURSING PROCESS

 Assessment  Diagnosis and prescription, determine

why nursing is needed. analyze and
interpret ,make judgment regarding
care
 Design of a nursing system and plan
for delivery of care.
 Production and management of
nursing system.

Step 1. Collect data in six areas.

 person’s health status

  physician’s perspective of the
person’s health status
 person’s perspective of his or her
health
 health goals within the context of life
history ,life style, and health status
 person’s requirements for self care
 person’s capacity to perform self care

 Nursing diagnosis Step 2.

 Plans with scientific  Nurse designs a system that is wholly
rationale or partly compensatory or supportive-
educative.
The 2 actions are:-
 Bringing out a good organization of
the components of patients’
therapeutic self care demands
 Selection of combination of ways of
helping that will be effective and
efficient in compensating for/
overcoming patient’s self care deficits

 Implementation Step 3.
 Evaluation  Nurse assists the patient or family in
self care matters to achieve identified
and described health and health
related results ..collecting evidence in
evaluating results achieved against
results specified in the nursing system
design
 Actions are directed by etiology
 component of nursing diagnosis
 Evaluation

8. THEORY TESTING:8

 Orem’s theory has been used as the basis for the development of research
instruments to assist researchers in using the theory
 A self care questionnaire was developed and tested by Moore(1995) for the
special purpose of measuring the self care practice of children and adolescents
 The theory has been used as a conceptual framework in associate degree
programs (Fenner 1979) also in many nursing schools.

9.STRENGTHS OF THEORY:8

 Provides a comprehensive base to nursing practice

 It has utility for professional nursing in the areas of nursing practice, nursing education,
administration and nursing research
 Specifies when nursing is needed
 Also includes continuing education as a part of the professional component of nursing
education
 Herself care approach is contemporary with the concepts of health promotion and health
maintenance
 Expanded her focus of individual self care to include multi person units.

10. LIMITATIONS:8

 In general theory a system is viewed as a single whole thing while Orem defines a
system as single whole things.
 Health is often viewed as dynamic and ever-changing Orem’s visual presentation of the
boxed nursing system implies three static conditions of health.
  Appears that the theory is illness oriented rather with no indication of its use is
wellness setting.

11. CRITICAL THINKING IN OREM’S THEORY:9,10

Critical thinking emanates from four structured cognitive operations: diagnostic,
prescriptive, regulatory, and control. Each operation fulfils a distinct phase in the use of the
theory. Sequencing of the phases may vary throughout the process in order to reassess and
continue to prescribe and regulate the nursing system for the best interest of self-care. The
operations are intended to be collaborative and to provide the self-care agent or dependent-care
agent input into the decision making.

11.1.Diagnostic Operations
The first phase, diagnostic operations begins with establishing the nurse-client
relationship and proceeds to contracting to work toward identifying and discussing current and
potential therapeutic self-care demands. An analysis of the assessment data results in a diagnosis
concerning the type of self-care demands. Self-care agency is addressed through an assessment
of self-care practices and the effects of related limitations and abilities. Finally, self-care deficits
are diagnosed by reflecting on the adequacy of agency to meet specific requisites. In instances in
which self-care agency is inadequate, a self-care deficit is stated.

11.2. Prescriptive Operations

In the prescriptive phase, ideal therapeutic self-care requisites for each self-care requisite
are determined by reviewing possible helping methods, considering related basic conditioning
factors, and identifying the most appropriate helping methods. Actions required for the
therapeutic self-care demands are discussed with the client and are designed for maximal
efficiency and compatibility. Priority is given those therapeutic self-care demands that are the
most essential to physiological processes. Client and nurse expectations are formalized and
recognized as supportive of continued development of self-care agency.

11.3.Regulatory Operations
 The prescriptions that evolve are used in the regulatory phase to design, plan, and
produce the regulatory nursing system. Factors entering decisions about design include
conditioning factors, effective regulation of health and developmental state, timing, assignment
of actions, and degree of cooperation. Further planning specifies conditions for the regulatory
operations such as frequency, equipment and supplies, and personnel needed. Throughout the
production of regulatory care, there is emphasis on development of self-care agency by using
helping methods that encourage learning, increase feelings of well-being, and stimulate interest
in self-care.

11.4.Control Operations
Evaluation occurs in the control phase. The effectiveness of regulatory operations and
client outcome is estimated. Regulatory operations are evaluated for correctness and
appropriateness. Client outcome is appraised for regulation of functioning, developmental
change, and adjustments to varying levels of self-care ability.

12.APPLICATION OF OREM'S SELF-CARE DEFICIT THEORY IN

NURSING PRACTICE:9,10

For Mr. XXY

 Came to the hospital with complaints of decreased social interactions, repeated hand
washing present for the past fourteen years
 Muttering to self, suspiciousness for the past nine years.
 Maintaining postures, poor oral intake, idea of reference and mutism for two months.
 Was on treatment for almost ten years with poor medical compliance.
 All this symptoms aggravated more prior to his admission.

12.1. PATIENT PROFILE:

AREAS PATIENT DETAILS

 Name Mr. XXY
Age 33years
Sex Male
Education 8th failed
Occupation Unemployed
Marital status Unmarried
Religion Hindu
Diagnosis IDD, RDD with current severe depression with catatonia.
Theory applied Orem’s self care deficit theory.
12.2. DATA COLLECTION ACCORDING TO OREM’S THEORY

12.2(a) BASIC CONDITIONING FACTORS.

Health status Known case of of IDD, disability due to his

health condition and therapeutic self care
demand.
Developmental state Delay in developmental milestone.
Sociocultural orientation Studied till 8th class, Indian , Hindu.

Health care system Institutional health care.

Family system Unmarried living with parents.
Patterns of living At home with family.

Environment Urban , not easy for him as he was bullied and

teased around
Resources Parents and elder brother.

12.2(b) UNIVERSAL SELF-CARE REQUISITES.

Air Breaths without difficulty.

 Water Fluid intake not sufficient looks mildly
dehydrated.

Food Food intake is not adequate

Elimination Voids and eliminate bowel without difficulty.

-Patient is catatonic
Activity/rest -not talking much
-not maintaining eye contact.
Social interaction Decreased social interaction.

Prevention of hazards Need instruction to avoid frequent handwashing

and long bathing time.
Promotion of normalcy Has good relation with elder brother.

12.2(c) DEVELOPMENTAL SELF-CARE REQUISITES

Maintenance of developmental Able to feed and is partially able to

environment. perform activities of daily living

Prevention/management of the condition Does not believe that he is sick or ill.

threatening the normal development. Believes that his parents bought him
here as the environment back home as
not good for him as he was being teased
and bullied around.

12.2(d) HEALTH DEVIATION SELF CARE REQUISITES

Adherence to medical regimen Reports the problem to the physician and

nurse when in the hospital. Cooperates with
 the medication .Not much aware about the
side effects of medication.
Awareness of potential problem associated He is not aware about the actual disease
with the regimen process. He is compliant with the planned
diet and activities scheduled.
Modification of self image to incorporate He adopted dietary pattern and lifestyle
changes in health status changes to improve health status.

Adjustment of lifestyle to accommodate Learning to adjust with his disability.

changes in the health status and medical
regimen.

13. NURSING CARE PLAN ACCORDING TO OREM’S THEORY OF SELF CARE

DEFICIT. 10
Nsg. diagnosis Outcome and plans Implementation Evaluations
(diagnostic (prescriptive operations) (control operations) (regulatory operations)
operations)
 Nurse-patient actions 1. effectiveness of the
Based on self a. Outcome to- nurse patient action to
care deficit. -promote patient as
b. Nursing goal and self care agent -promote patient as
objectives self care agent
-meet self care needs -meet self care needs
c. Design of nursing -Decrease the self care
system -Decrease the self deficit
care deficit
d. Appropriate method of 2. Effectiveness of the
helping selected nursing
system to meet the
needs.

13.1. AREAS AND PRIORITYACCORDING TO OREM’STHEORY OF

SELF CARE DEFICIT:11

1. Water
2. Food
3. Activity/rest
4. Solitude/interaction
5. Prevention of hazards
6. Maintenance of developmental environment
7. Prevention/management of the condition threatening the normal development.
8. Adherence to medical regimen
9. Awareness of potential problem associated with the regimen.

13.2.PSYCHIATRIC PROBLEM AND PLAN:

Diagnosed with:

Intellectual developmental disorder, RDD with current severe depression with catatonia.

Started with treatment-

Tab Olanzapine 10mg 0-0-1

Tab Fluoxetine 20mg 3-0-0

Inj. Lorazepam 2mg 1-0-1

Nursing diagnosis Outcome and plans Implementation Evaluations

(diagnostic (prescriptive operations) (regulatory operations) (control operations)
operations)
Imbalance Outcome: -assessment done and -Mr.xxy understood
nutrition less than -improve nutrition found poor oral intake, the importance of
body requirement -maintenance of balance lack of interest in food maintaining an
related to loss of diet and poor appetite. optimum nutrition.
appetite, fatigue Goals and objectives:
evidence by loss of Goal: To achieve the -provided small and -was able to take
subcutaneous fats, optimal level of nutrition frequent meal small and frequent
poor oral intake Objective: meal.
and lack of interest Mr.xxy will be able to -listed down foods of
in food. state the importance of his choice and -he was able to list
maintaining a balance preferences. the food of his
diet. preferences.
Design of Nursing -encouraged the patient
system: supportive to take food high in -the supportive
education protein and education system
Method of helping: carbohydrates was useful for
Guidance : Mr.xxy
To assess the various - provided/served the
factors responsible for food attractively
poor nutrition and to
correct it. -family members
support: educated about the
-to provide small and importance of
 frequent meal maintenance balance
-to list down food of his diet and its importance
preferences and choice. in response to medicine.
-diet rich in proteins and
carbohydrates.
-To serve food
attractively.
Teaching:
To teach family members
and patient the
importance of
maintaining balance diet
or good health.
Providing developmental
environment.
Encourage family
members to actively
participate to help the
patient needs.

Nursing diagnosis Outcome and plans Implementation Evaluations

(diagnostic (prescriptive operations) (control operations) (regulatory
operations) operations)
Outcome:
Impaired skin -maintenance of normal -assessment of the skin -Patient able to avoid
integrity related to skin integrity. done and was found to peeling of
frequent hand Goals and objectives: be dry and presence of desquamated skin.
washing and Goal: maintain the skin desquamation found in -identifies measure
bathing as integrity and take the hands. to avoid frequent
evidence by dry measures to prevent skin washing of hands.
skin and impairments. -advised to avoid -able to keep the
desquamation of Objective: peeling of the skin as it skin moisturized
both hands. -Mr.xxy will maintain might cause itching and for prevention of
normal skin integrity redness. rash and cracks.
-identify the measures to -the supportive
avoid frequent hand -advised to keep the educative system
washing and bathing. moisturized by applying was useful for
Design of Nursing lotion in the body and Mr.xxy.
system: supportive hands.
education
-explained to avoid
Method of helping: frequent washing of
Support: hands and to avoid
-Assess the skin for any bathing by trying to
dryness, cracks and controlled the thought
colour changes. and doing other activity
-avoid peeling of the to cause distraction.
desquamation skin
-provision for keeping -checked the skin for
the skin moisturized signs of infection and
-explain to the patient the inflammation and
need for avoiding too advised to report it.
much washing and
bathing.
-provision to check for
signs of inflammation
and infection.
Providing developmental
environment.
Encourage family
members to actively
 participate in helping
him.

Nursing diagnosis Outcome and plans Implementation Evaluations

(diagnostic (prescriptive operations) (control operations) (regulatory operations)
operations)
Withdrawn Outcome: -assessment done -rapport was partially
behaviour related -improve social regarding clients established.
to idea of reference interaction level of functioning
as evidence by -feeling of security and communication. -nutrition maintaining
mutism, decreased -talked with the adequately.
motor activity and Goals and objectives: patient, introduced -partially maintaining
inadequate fluid or Goal: and talked with him contact with the
food intake. -increase the clients in a soft and clear environment and is
interaction with his voice. opening up regarding
environment and other -gave the client his thoughts and
people. positive feedback for emotions.
-increase the client response and
physical activity. encouraged him to
Objective: open up his feelings.
-able to established -diet maintenance
contact and support properly planned and
-patient will be carried out.
maintaining contact with -encouraged patient
the environment to spend short period
Design of Nursing of time outside and
system: supportive interact with other
education inpatients and he is
going for morning
Method of helping: walk and offering
Guidance : prayer in temple.
To assess the patient -encouraged the
level of functioning and patient to express
communication. himself verbally and
support: non verbally.
-provision to establish -encouraged to
contact and rapport. ventilate his feelings
-to maintain adequate as much as possible.
oral intake
-helps to maintain contact
with environment.
Providing developmental
environment.
Encourage family
members to actively
participate to provide
secure environment
CONCLUSION
Orem’s theory is relatively simple, but generalizable to apply to a wide variety of
patients. It explains the terms self-care, nursing systems, and self-care deficit which are very
essential to students who plan to start their career in nursing.

Moreover, this theory signifies that all patients want to care for themselves, and they are able to
recover more quickly and holistically by performing their own self-care as much as they’re able.
This theory is particularly used in rehabilitation and primary care or other settings in which
patients are encouraged to be independent.
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