Wound Management - Using Levines Conservation Model - OWM
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Wound management: Using Levine'sconservation model to guide practice
Article in Ostomy/wound management · September 2006
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Name of Submitting Author:
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Publication Information:
Title of Journal Article:
Woun
d Management: Using Levine's Conservation Model to Guide Practice
Name of Journal:
Ostom
y Wound Management
Publisher:
H M P
Communications, LLC
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United States
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Yr of
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2006 Vol & Issue No:
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52, 8 Page Numbers:
74-80
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Ostomy - Wound Management
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Matthew J. Leach; BN(Hons), ND, PhD
L
evine's
conservation model, initially construct-
ed as a teaching framework for medical-surgical
nursing,2 is based on the belief that nursing
interventions should be aimed at conserving func-
tion.3'4 Roberts and Taylor5 and Fawcett4 state that
nurses currently use Levine's model in practice by act-
ing to preserve Elient energy and integrity —
encour-
aging bed rest, maintaining pressure area care, and
preserving privacy. To clarify the relationship between
Levine's conservation model and wound manage-
ment, each of the four principles of Levine's model
will be examined. To enhance understanding of the
context in which Levine's conservation principles are
presented, the underlying assumptions, definitions,
and limitations of the model are discussed.
Levine's
conservation model' consists of four major
principles. The principles are defined as follows:
• conservation of energy
balancing
energy output
and input to avoid excessive fatigue4
• conservation of structural integrity —
maintaining
or restoring the body structure by preventing phys-
ical breakdown and promoting healing5
•
conservation of personal integrity
maintaining
or restoring the patient's sense of identity and self-
worth5 and. .
. acknowledging
uniqueness4
•
conservation of social integrity —
fostering aware-
ness that the patient. .
.
is
a social being who inter-
acts with others5 in their social environment.
Each of these principles —
the
reduction in energy
expenditure, the improvement in structural, personal
74
OstomyWound Management
Wound Management: Using
Conservation Mod&
Gifide Practice
Effective wound management is needed not only to generate positive patient outcomes, but also to reduce healthcare expenditure and
demand on healthcare services.
Implementing
Levine's four-principled conservation model — which addresses conservation of energy,
structural integrity, personal integrity, and social integrity — can provide clinical and financial benefits, as illustrated in the care of venous
leg ulceration. Using Levine's model as a theoretical framework for wound management also can contribute to good nursing practices,
enhancing a care approach that embraces wholeness and health along with cost effective care. Understanding how Levine's model can
improve patient care is further elucidated by discussing each of the principles in relation to wound management.
KEYWORDS: wounds, nursing care, nursing theory
Ostomy/ Wound Management 2006;52(8):74-80
Dr. Leach is Program. Director, University of South Australia, and a Registered Nurse, Royal District Nursing Service South
Australia. Please address correspondence to: Matthew J. Leach, BN(Hons), ND, PhD, School of Health Sciences, University of
South Australia, North Terrace Adelaide SA 5000; email: [email protected].
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is
compatible with wound
for
many
Many nursing
scientif-
e, as a theoretical
nursing
Each of Levine's principles addresses the concept of
. .
defend,
sustain, maintain, and define the integrity of
for which it functions. Conservation can be
stability of the organism through .
.
.multiple,
.
The
universal concept of conservation also
describes the way complex systems are able to function
enged. 2 Therefore, conserva-
it
is only when the individual can no longer
Despite the comprehensiveness and wide applica-
to health; thus, nursing
interventions under Levine's theory have a present
and short-term focus and do not support health pro-
motion principles, even though health promotion is
an essential component of current nursing practice.'3
Thus, Levine's model does not add support to the use
of interventions that prevent ulcer occurrence and
reoccurrence in susceptible individuals.
Assumptions
An
underlying assumption of Levine's model is that
the nurse creates an environment in which healing can
occur and adaptation is promoted.'4 Individuals are con-
stantly interacting with an external environment; conse-
quently, they adapt and preserve their energy and
integrity in accordance with that environment. However,
when an individual can no longer maintain that energy
and integrity, health is adversely affected.5 This environ-
merit pertains not only to the external milieu, but also to
the individual's internal environment. For instance,
treating VLU externally with topical dressings, as well as
modifying the physiology of the venous
internal-
ly with external compression or venotonic agents, allows
the nurse to create an environment conducive to VLU
healing. Although Levine does not explicitly relate the
four conservation principles to the environment,'5 it
may be through effective wound care that nursing can
conserve energy and skin integrity'4 and as such lend
support to Levine's conservation model.
Conservation of Energy
Energy conservation is based on the belief that
patient activity is dependent on energy balance, that
illness increases energy demand, and that increased
August 2006 Vol. 52 Issue &
75
Wound Management
KEY POINTS
Theoretical frameworks help explain relationships
between concepts, observations, facts, and theories.
•
The author uses a conservation model to illustrate
potential relationships between venous ulcer care out-
comes and optimal patient well being.
•
This model may provide a basis for making wound
management choices and facilitate research to help
strengthen the evidence base of wound care practice.
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energy demand can be measured
by the level of
fatigue.4 Even the most basic nursing procedures,
including rest and adequate nutrition,4 utilize the
principle of conserving energy.2
Nurses need to understand energy conservation as a
universal law applicable to all animate and inanimate
entities.'2 To maintain life activities, energy levels need to
be balanced and constantly renewed.2 Nurses often are
the people in contact with individuals in whom healing
and ageing challenge the ability to conserve energy.2
Therefore, nurses not only help conserve energy through
a reduction in activity, but
they also ensure energy
expenditure remains within the ..
. individual's
capabil-
ity, safety, and comfort. 4
In a normal healthy state, the body intentionally
utilizes a minimum level of energy to conserve ener-
gy. When the body's system
is disturbed, however,
energy is utilized and negative feedback systems are
activated until a normal state is obtained.3 For exam-
ple, the inflammatory and immune systems utilize
energy in order to restore homeostasis and promote
healing.3 In sick persons, energy expenditure often
becomes evident as the process of healing unfolds.
The unwell individual frequently manifests lethargy
and weakness, which subsequently reduces activity
and unnecessary energy expenditure; thus, energy can
be conserved and focused on healing.3 This energy
conservation also preserves functional integrity.'2
Nurses are in a position to conserve patient energy by
reducing the duration of leg ulceration. For instance,
nurses may select wound treatments
that restore skin
/ integrity
and minimize energy expenditure, ultimately
resulting in earlier discharge, reduced healthcare expen-
diture, and less emotional
However, in order to
assess the energy-conserving effect of
wound treat-
ments, energy needs to be measurable.
Levine3 claims that energy is measured in everyday
nursing practice via body temperature, blood gases,
pulse, and blood pressure; fluctuations determine
either energy expenditure or conservation. However,
it is unclear whether these aforementioned measure-
ments are valid and reliable indicators of changes
in
energy levels. Wound healing, on the other
hand, may
be an effective measure of energy conservation
because the conservation of structural integrity can-
not be maintained without conserving energy.
By
76
OstomyWo,,ud Management
conserving energy, the integrity of the individual ulti-
mately can be defended.'7
Conservation of Structural Integrity
Conserving structural integrity
is based on the
rationale that changes in structure ultimately affect
function, that structural integrity may be compromised
by pathophysiological processes, and that healing
restores structural integrity.4 Therefore, to regain struc-
ture and function, the body needs to restore
structural
integrity through repair and healing.'
Healing restores continuity and form through cell
replication; hence, conserving structural integrity.'2
Early detection and management of disease by nurses
reduces tissue destruction, which also conserves struc-
tural integrity.2 Specific nursing interventions that con-
serve structural integrity include
anatomic positioning
and range-of-motion exercises to prevent musculoskele-
tal deformities,'4 pressure area care to prevent pressure
ulcers, and early mobilization and chest physiotherapy
to prevent complications of bed rest.3 In
the example of
VLU; compression therapy may restore skin and venous
integrity. Through this conservation of structural
integrity, an individual can feel intact and whole and
subsequently manifest improvements in self-identity.'7
conservation of Personai Integrity
Conserving personal integrity is based on the belief
that individuals require privacy, are responsible for their
own decisions, and illness and
hospitalization compro-
mise personal integrity, self-identity, and self-respect.4
Nursing interventions aimed at conserving personal
integrity include protecting and respecting patient pri-
vacy, possessions, and defense
mechanisms4 and sup-
porting personal choice.2 The conservation of personal
integrity, therefore, aims to protect personal identity.1
Levine'2 argues that the fundamental goal of the nurse
is to provide knowledge and support so the individual
can resume a private independent
life. Personal integri-
ty, including self-identity and pride, is
compromised
when an individual becomes dependent.
Therefore,
interventions aimed at regaining individual independ-
ence ultimately conserve personal
integrity. The princi-
ple of conserving personal integrity is interdependent
with the principles of conserving energy and structural
integrity Without sufficient energy and, in the case
of
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(
Venous leg ulceration
)
.1
Compression bandaging
(venous) environment
Primary dressing
eased physical and
energy expenditure
Conservation of structural integrity
depression,
and negative
Conservation of
integrity
Figure 1. Conceptual map outlining the relationship
effective wound management and positive patient outcomes through
Levine's
Conservation Model.
wound care, intact skin integrity, dependence on other
individuals is almost certain. Therefore, interventions
/that conserve energy and restore structural integrity
will arguably re-establish independence. Thus, dress-
ings and interventions that hasten ulcer healing
and
ultimately shorten ulcer duration may reduce client
dependency on others. Given that individuals with
VLU also experience depression, helplessness, anxiety,
and negative self-image,'82° effective wound manage-
ment also may restore patient self-worth and person-
al integrity.
Conservation
of Social Integrity
Conserving
social integrity is based on the premise
that individual life has meaning only in the context of
social life, individual behavior is influenced by the
ability to relate to various social groups, families often
78
OstomyWound Management
are affected by an individual's
illness, and hospitaliza-
tion results in social isolation.4
Social factors such as family, friends, culture, reli-
gion, education, and socio-economic status all
deter-
mine how an individual defines him/herself.3 7 Thus, a
loss of these factors (eg, work, income, or family) may
arguably weaken an individual's social integrity.
Therefore, nursing strategies aimed at conserving
social integrity may include providing family support
and education, promoting family participation
in
care, and fostering patient
interaction with others.3
A change from an independent role to dependency
on the healthcare system creates
conflict for the indi-
vidual.3 For instance, patients with VLU often become
immobile,2 embarrassed, and socially, isolated and
experience financial difficulty.'8 By facilitating wound
healing, the nurse can indirectly restore the patient's
C
)
)
wound environment
Ulcer healing
)
(
)
C
Conservation of
energy
isolation,
and financial
C
Conservation of
social integrity
)
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Furthermore, by decreasing VLU duration and
recur-
rence, effective wound management may inadvertent-
ly reduce healthcare expenditure and
demand on
healthcare services.
Nursing Implications
According to Levine, a nurse
can implement either
supportive or therapeutic interventions. Supportive
interventions prevent deterioration of health;
thera-
peutic interventions promote healing
and restore
health.'5 With regard to VLU
management, it is argued
that current practice, excluding
compression therapy,
is simply semi-therapeutic
— ie,
only the external
wound environment is supported without
imple-
menting therapy intended for internal effect.
In fact,
few dressings have been
proven to enhance venous
ulcer healing.2223 The exception is
compression thera-
py. Some evidence of efficacy is available,2' which
may
explain why this therapy prevails
as the primary treat-
ment of choice for VLU.25-2 One
reason why compres-
sion therapy may be effective is that
it adequately
addresses the underlying etiology of the
wound29
in
particular, the pathological
processes that lead to
venous
Hence, it
is argued that the
combination of appropriate primary dressings
and
compression therapy will provide
a complete thera-
peutic solution to VLU
management; subsequently,
increasing the rate of wound healing.
Levine's conservation model provides
a thoughtful
management
conse-
and quality
effective wound
conservation princi-
The conservation principles address
the integrity of
to death. Every activity
works with-
on it.
abilities,
life experi-
and desires of the self who makes the choices.
to which the individual belongs.'
References
1.
Levine ME. The conservation principles:
a model for
health. In: Schaefer KM, Pond JB (eds).
Levine's
Conservation Model: A Framework for Nursing Practice.
Philadelphia, Pa: F.A. Davis Company;1991.
2.
Artigue GS, Foli KJ, Johnson T, et al. Four conservation
principles.
In: Marriner-Tomey A (ed). Nursing
Theorists and Their Work, 3rd ed.
St. Louis, Mo:
Mosby; 1994.
3.
Levine ME. The conservation principles of nursing:
twenty years later. In: Riehl-Sisca J (ed). Conceptual
Models for Nursing Practice, 3rd ed. Norwalk, Conn:
Appleton & Lange;1989.
4.
Fawcett J. Analysis and Evaluation of Conceptual Models
of Nursing, 3rd ed.
Philadelphia, Pa:
F.A. Davis
Company; 1995.
5.
Roberts K, Taylor B. Nursing Research Processes: An
Australian Perspective. South Melbourne, Australia:
Nelson Thomson Learning;1999.
6.
Cox RA. A tradition of caring. In: Schaefer KM, Pond
JB (eds). Levine's Conservation Model: A Framework for
Nursing
Practice.
Philadelphia,
Pa:
RA.
Davis
Company;1991.
7.
Foreman MD. In: Schaefer KM, Pond JB (eds). Levine's
Conservation Model: A Framework for Nursing Practice.
Philadelphia, Pa: F.A. Davis Company;1991.
8.
Pasco A, Halupa D. Chronic pain management. In:
Schaefer KM, Pond JB (eds). Levine's Conservation
Model: A Framework for Nursing Practice. Philadelphia,
Pa: RA. Davis Company;1991.
9.
Pond JB. Ambulatory care of the homeless. In: Schaefer
KM, Pond JB (eds). Levine's Conservation Model: A
Framework for Nursing Practice. Philadelphia, Pa: F.A.
Davis Company; 1991.
10. Roberts JE, Fleming N, Giese D. Perineal integrity. In:
Schaefer KM, Pond JB (eds). Levine's Conservation
Model: A Framework for Nursing Practice. Philadelphia,
Pa: F.A. Davis Company;1991.
11. Schaefer KM. Care of the patient with congestive heart
failure.
In: Schaefer KM, Pond JB (eds). Levine's
Conservation Model: A Framework for Nursing Practice.
Philadelphia, Pa: F.A. Davis Company;1991.
12. Levine ME. Conservation and integrity. In: Parker ME
(ed). Nursing Theories in Practice. New York, NY:
National League for Nursing;1990.
13. Schaefer KM, Pond JB. Levine's conservation model
as
a
guide
to
nursing
practice.
Nurs
Sci
Q.
1994;7(2):53—54.
14. Meleis Al. Theoretical Nursing: Development and
Progress, 3rd ed. Philadelphia, Pa: Lippincott; 1997.
15. Leonard MK, Myra Estrin Levine. In: George JB (Ed).
August 2006
Vol. 52
Issue 8
79
ability
to
be
mobile, productive,
and
social.
Every activity is a product of the dynamic social
systems
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OstomyWound Management
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