Coronavirus infections: health care planning based on Orem’s Nursing Theory

e20200281 http://dx.doi.org/10.1590/0034-7167-2020-0281 8 of ABSTRACT Objective: to report the experience of professors and students of a graduate course on nursing care in coping with the new coronavirus (COVID-19) based on Self-Care Theory. Method: the active methodologies used were a literature search and seminar presentations, with an understanding of Orem’s theoretical concepts: health; man; self-care; universal, developmental and health deviation requirements; self-care activities; self-care deficits; the required therapeutic demand; nursing systems. The pandemic was considered a health deviation that requires critical thinking and nursing care planning. Methodological frameworks to classify nursing diagnoses, interventions, and outcomes were used. Results: for each health deviation, nursing systems were identified; self-care deficits, diagnoses; actions, interventions; and the form of assessment, outcomes. Final considerations: theoreticalpractical reflections of the academic context support nursing care planning. Descriptors: Nursing Process; Patient Care Planning; Nursing Theory; Nursing Diagnosis; Coronavirus Infections.


INTRODUCTION
This experience report describes the discussions and reflections in one-to-one and virtual classroom of an optional subject called "Nursing Theories: from the construction of knowledge to NANDA, NIC, and NOC taxonomies" and offered annually by the Nursing Graduate Programs levels of Academic and Professional Master's and Doctorate from the Nursing Department of Escola de Medicina de Botucatu of Universidade Estadual Paulista "Júlio de Mesquita Filho". In 2020, four students were enrolled: a doctoral student, two master's students and a special student, not yet linked to the Graduate Program.
The course aimed to: provide subsidies for discussions and reflections on nursing care based on theoretical concepts and assumptions, based on the construction proposed by nursing theorists; correlate the Dorothea Elizabeth Orem assumptions with NANDA-I Nursing Diagnosis Classifications (1) , NIC Nursing Interventions (2) and NOC Nursing Outcomes (3) , in order to contribute to nursing care planning and the interrelation of theory with practice in nurses' work process in teaching, research, and care (4) .
In the second week of class, due to social distancing and quarantine preventive measures to cope with COVID-19, there was a need to organize the virtual meetings. Then, Google Meet was used. The planning proposed in the teaching plan for that course was carried out remotely, maintaining the use of active methodology in the form of presentation of seminars. The themes were related to Dorothea Orem's Theory, Madeleine Leininger's Theory, Jean Watson's Theory, and Betty Newman's Theory.
The proposed methodology favored the reflections and discussions on the theoretical assumptions, and the points of convergence and attention of all discussions were, without a doubt, the pandemic, the quarantine and the world health setting. The first seminar presented was on Dorothea Orem's Theory. The three theoretical constructs' concepts postulated provided subsidies for exemplification of some phenomena related to the pandemic and the way in which the population reacted to preventive measures and to coping with the new coronavirus.
Thus, in line with the phenomena described about world health and the assumptions of the three sub-theories that comprise Orem's Theory, a Nursing Process (NP) model was delimited to the population affected by the pandemic, with the proposition of nursing diagnoses, interventions, and outcomes, according to NANDA-I (1) , NIC (2) , and NOC (3) classifications.

Orem's theoretical framework
NP is based on theoretical frameworks. Orem's Self-Care Deficit Theory (SCDT) is widely used in Brazil and other countries to guide nursing practice and care in relation to people's self-care requirements, according to the demand client or community therapy (5)(6) .
Orem's premise is that man has an innate ability to take care of himself. In this sense, the condition that will validate the existence of a nursing requirement would be the absence of continuously maintaining the quantity and quality of care, which are therapeutic for sustaining life and health in the recovery of the disease or injury and in facing its effects.
Orem's General Theory consists of three interrelated factors: Self-Care Theory, which shows how and why people take care of themselves; Self-Care Deficit Theory, which shows why patients can be assisted by nursing; Nursing Systems Theory, which explains why nursing is performed (7) .
Self-Care Theory proposes that people should be instructed in self-care or that the same be carried out by their Self-Care Agent, i.e., a caregiver who understands, accepts and fulfills dependent people's self-care needs. Orem identified three categories of selfcare: universal, development and health deviation (5) .
Universal requirements, according to Orem (5) , are associated with life processes, with human integrity maintenance, as well as human structure and functioning, such as breathing in air and drinking enough water and having food.
Development requirements refer to new events and situations that occur in the human environment for the purpose of development. To fulfill the requirements, man needs biological, psychological and social development, in addition to universal self-care requirements (5) . Self-care requirements in health deviation "refer to care or decision making in relation to the health problem identified or diagnosed for the purpose of recovery, rehabilitation and control" (5) .
Self-Care Deficit Theory reveals the role of nurses in moments of patient limitations in developing their self-care according to the identification of individuals' self-care needs (7) .
Nursing Systems Theory recommends that nursing practices establish and clarify the relationships that need to be created and maintained, encompassing the fully compensatory, partially compensatory system and the educational support system (6) .

OBJECTIVE
To report the experience of professors and students of a graduate course on nursing care in coping with the new coronavirus (COVID-19) based on Self-Care Theory.

Characterization of the problem amidst the pandemic
In December 2019, in Wuhan, China, cases of pneumonia were reported in thousands of people and which were supposedly related to the location where there is a wholesale market for seafood, dried meat, perishable items, live wild animals used for human consumption (8) .
In January 2020, a new coronavirus named 2019-nCoV was officially identified as the reason for the outbreak of pneumonia cases. The signs, clinical symptoms and indicators for the identification of the disease were fever, radiological image with the presence of pneumonia, normal or below normal leukocytes, treatment without improvement for three days with antibiotics, a history of visiting the market and a positive and confirmed sample for 2019-nCoV (8) .
The new coronavirus spread quickly around the world and proved to be highly contagious. On January 30, 2020, the World Health Organization (WHO) declared the outbreak as a Public Health Emergency of International Interest. Thus, a pandemic caused by COVID-19 was declared, due to the increase in the number of cases and deaths in all countries (9) . Considering this world setting, the Ministry of Health (MoH) of Brazil declared it a Public Health Emergency of National Concern (PHENC) on February 6, by Law 13,979/2020, published on 02/07/2020 in Diário Oficial da União (Federal Official Gazette). Therefore, measures were taken to deal with this public health emergency resulting from coronavirus (COVID-19) (10) .
The Brazilian Sanitary Surveillance Agency (ANVISA -Agência Nacional de Vigilância Epidemiológica do Brasil) has carried out periodic weekly reviews of Technical Note (11) on the guidelines for health services regarding prevention and control measures to be adopted in suspected or confirmed cases by the new coronavirus.
The State Health Departments of Brazil, in line with the MoH, in view of local realities, plan and disseminate the measures adopted to contain the pandemic. Like Brazil, governments in other countries incorporate actions to contain the pandemic and minimize the impact of the disease. However, the moment is characterized by uncertainties (9) .
Concerning treatment, scientific research has been carried out by scholars from universities, public and private national and international institutes, in search of drug treatment or vaccine against the new coronavirus. Therapies and medications are implemented based on symptoms. The most frequent complication is Acute Respiratory Discomfort Syndrome, followed by cardiac injury and secondary infections. Patients with intractable hypoxemia are progressing to invasive mechanical ventilation (12) .
Guidelines for health service professionals in Brazil can be accessed through the manuals produced by ANVISA (11) . However, the best scientific evidence at the moment, to face the pandemic, is to control the sources of infection. To control dissemination, the population has been instructed to maintain environments with good ventilation, wear a mask and adopt personal and hand hygiene measures.
Considering the current global situation and that of Brazil, Brazilian nurses need to organize nursing care for the affected populations. Nursing is one of the professions that is directly facing health problems related to the illness of people infected with the new coronavirus. Nurses play an essential role in the health team and work in the fields of prevention, monitoring and direct assistance in pre and hospital and emergency services in intensive care.
Thus, the present report proposes a NP construction based on Orem's Theory, based on the discussions and reflections carried out during the course's classes, which provided scenery and learning according to the programmatic content.
The teaching strategies employed were carried out in a Virtual Learning Environment, with an active methodology, with students as protagonists in activities of literature review, preparation, and presentation of seminars.
The reflections and theoretical deepening were mediated by professors in relation to the practical application of the Self-Care Deficit theory and concepts for patients with health problems due to the pandemic caused by the coronavirus, based on literature of NANDA-I (1) , NIC (2) , and NOC (3) . For this purpose, the main nursing interventions were sought, covering the largest number of activities and which, in a certain way, could lead to the expected outcome, in addition to being measured and assessed. The reflections originated by the practical application of Orem's theory encouraged the realization of this report to demonstrate the results obtained.
Thus, the following question emerged: in the face of the pandemic setting, how would NP be characterized from Orem's Self-Care Theoretical Framework (5)(6) and the NANDA-I (1) , NIC (2) and NOC Nursing Classifications (3) ?

Experience outline
The discussions held during virtual classes contributed to formulating and characterizing the mentioned problem. The contributions of Orem's Theory to NP application, in this pandemic moment, support nurses' autonomy and direct the required actions, including those recommended by professional and governmental bodies.
Universal requirements, such as sufficient air intake, balance activities between activity and rest, the balance between loneliness and social interaction and the prevention of dangers to human life, are clearly affected in the current COVID-19 pandemic setting. Development requirements are affected, such as those responsible for promoting life and maturation processes, such as the necessary adaptations for the moment; attitudes of social detachment established to control the spread of the disease; challenges for school activities at all levels of education; difficulties encountered in conducting human activities and, mainly, in relation to internet access.
It is noticed that the way of life development of the population in general is affected and adaptations are being made; however, social conduct and hygiene practices and recommendations are underway that seem momentary and fleeting, but should be transformed into a new way of life in the near future and different from the one that existed before the pandemic.
Regarding the health deviations identified in relation to prevention and treatment to control COVID-19 to spread, the universal requirements for social coexistence that would be hampered by the distance, social isolation and the quarantine established should be considered.
Charts 1, 2 and 3 exemplify how care planning was structured during the course's activities and relate them to Orem's three Nursing Systems and the health deviations arising from COVID-19.

Fully Compensatory System: due to suppressed oxygenation needs, oxygen therapy and invasive ventilation
Chart 1 shows the NP based on Totally Compensatory System. Patients infected with COVID-19 have a demand for the affected health deviation, require invasive and non-invasive oxygenation and are totally dependent on nursing and artificial equipment to provide gas exchange (5) .

Partially Compensatory System: patient with mild dyspnea with and without the need for non-invasive oxygen therapy
Chart 2 presents an assistance plan based on Partially Compensatory System. Some infected patients may experience mild respiratory symptoms and need support from non-invasive oxygen therapy, such as inhalations, nasal catheter, or face mask (5) .

Support-Education System: intended for groups at risk in need of maintaining isolation
Chart 3 presents a care plan to prevent COVID-19 to spread, based on Support-Education System and applies to groups at risk, those who have comorbidities, elderly people and individuals with chronic lung problems.
The general population, who did not have contact with people infected with the new coronavirus, or who do not have symptoms of the disease, maintains universal requirements (13) for preserved oxygenation and elimination. However, it is noteworthy that the same population is vulnerable to having the same requirements shaken if there is no respect for the recommendations of health authorities, such as social distancing and strict hygiene measures. Self-care should be encouraged by nurses as knowledge about COVID-19 advances in order to promote alignment with health education actions. The interventions and activities described above may change if new scientific discoveries about COVID-19 arise.

Lessons learned
The teaching strategies provided the development of different skills, research, elaboration, preparation and oral exposure in a virtual environment, reflection and theoretical deepening and exercise using nurses' clinical reasoning, in order to correlate which nursing outcomes and indicators would be appropriate to obtain an improved status compared to the current one, within this setting. Reflection activities and subsequent discussion in the light of Nursing Theories provide meaning and strengthen nursing as a science.
The course contributed as an exercise in appropriating the theoretical concepts that underlie nursing practice in current pandemic. Each nursing system, proposed by Orem, was related to the type of health deviation presented and provided guidance to nurses and visibility of nursing care, through appointment of ND, NI, and NO. Thus, it was sought, in a didactic way, to cover care in order to compile the outcomes and indicators that demonstrate its relevance to the named phenomena concomitant with the proposal for nursing interventions.
Nursing systems demonstrate their importance because they also cooperate with nursing planning, not only in relation to care dependency, but also for patients' criticality. In this context, the systems demonstrate patients' dependence on nursing in the face of care needs and the worsening of the disease.
In light of the assumptions and conceptual models of Orem's SCDT, the importance of the role of a care agent as a person who contributes to maintaining the needs of those who are at risk and oriented to maintain the social distancing and/or home isolation, strongly recommended to reduce COVID-19 to spread. In the current management of the spread of a disease, the importance of taking care of oneself and the other is highlighted, corroborating collective care.

Study limitations
The lack of nursing studies on COVID-19 and the systematization of care related to the current pandemic were the limitations of this report.

Contributions to nursing
This report points to the need to develop studies on the systematic nursing care planning for patients with COVID-19 at national and international levels. It corroborates the health care of the population in general so that taking care of oneself is a form of collective care. Orem's Theory provided a basis for understanding the current phenomena of nursing care.

CONCLUSION
In conclusion, the therapeutic demand required by the health deviations pointed out in this report was identified by ND, called self-care deficits according to Orem. The proposed NI are the actions that reinforce global recommendations to cope with the pandemic. NO portray the benefits to health, management and monitoring of actions implemented to infected individuals, contacts and the population.