Application of Theory of Goal Attainment and Nursing Process

King indicates that assessment occur during interaction. The nurse brings special knowledge and skills whereas client brings knowledge of self and perception of problems of concern, to this interaction.
During assessment nurse collects data regarding client (his/her growth & development, perception of self and current health status, roles etc.)
·Perception is the base for collection and interpretation of data.
·Communication is required to verify accuracy of perception, for interaction and transaction.

The first process in nursing process is nurse meets the patient and communicates and interacts with him. Assessment is conducted by gathering data about the patient based on relevant concepts.
Mr. Sy is 74yrs married, got admitted in L3 ward of ...Hospital on 27/03/08 with a diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh done on 30/03/08. The following areas were addressed to for gathering data.
What is the patient’s perception of the situation?	Patient says ” I have undergone surgery for hernia”. “ The wound is getting healed, I have no other problem” “I have pain in the area of surgery when moving” “I’m taking medicines for hypertension for the last 7 years from here” “I have vision problem to my left eye. I had undergone a surgery for my right eye about 10 years back”.
What are my perceptions of the situation?	Patient underwent herniorahaphy operation on 30th March for indirect inguinal hernia which he kept untreated for 35 years. Patient has health maintenance related problems. Patient is at risk of developing infection. Patient has pain related to surgical incision. Patient may develop hypertension related complications in future.
What other information do I need to assist this patient to achieve health?	HISTORY Identification details Mr. Sy is 74yrs married, male, studied up to 7th Std is doing Business, a practicing Muslim, got admitted in L3 ward of ...Hospital on 27/03/08 with a diagnosis of indirect inguinal hernia underwent herniorraphy with prolene mesh done on 30/03/08. Present History of Illness Abdominal swelling for 35 years with difficulty in activities and occasional abdominal pain. He has hypertension for seven years. The swelling remained stable with uncomplicated progress, getting increasing size when standing for long and reducible on applying pressure No h/o severe pain but increasing size for the last few years Relived after pressing the swelling back to position and on taking rest and applying pressure. Past health history Patient underwent cataract surgery about 10 years back On treatment for hypertension No other significant illness Family History Patient’s next elder brother and next younger brother had inguinal hernia and were operated Elder brother underwent 3 surgeries for hernia Socioeconomic Status High economic status >Rs.20000/- per month. Life Style Non vegetarian No habit of smoking or alcoholism. Aware about health care facilities Physical examination Alert, conscious and oriented Moderately built, adequate nourishment, with BMI of 22 Vital signs – normal except BP 140/90 mmHg General head-to-foot examination reveals normal finding except for the vision difficulty of the right eye and healing surgical wound on the left inguinal region. Subjective problems Pain at the surgical wound site Lack of bowel movement for 2 days Review of relevant systems GI system Inspection: Healing wound, No infection, No redness, No swelling. Auscultation: Normal bowel sounds Palpation No pain at the site, Normal abdominal organs Percussion: No dull sound suggesting fluid collection or ascitis Genito-Urinary system Inspection: Testicles in position, No infection, No swelling or enlargement. Palpation No c/o pain,No prostate enlargement Percussion No fluid collection in scrotum Auscultation Normal Bowel sounds Laboratory Investigations FBS - 91 mg/dl Na(130-143mEq/dl) - 134 mEq / dl K+ (3.5-5 mg/dl) - 3.5 mEq / dl Urea(8-35mg/dl)-29 mg / dl Sr. Cr (0.6-1.6 mg/ dl)- <1 mg/ dl Other investigations Electro cardio gram -Ant. Fascicular block Left atrial enlargement and normal axis
What does this information means to this situation?	Patient neglected a health problem for 35 years · Ptiient has acute pain at the site of surgical wound · Patient has family history of inguinal hernia and risk for recurrence · Patient has a risk for recurrence due to constipation. Patient has risk for infection due to inadequate knowledge and age. · Patient is at risk of developing complications of hypertension Patient requires education regarding health maintenance.
What conclusion (judgment) does this patient make?	Patient requires management for his pain Patient understands the need taking care of health risks and agrees to work on these aspects
What conclusion (judgment) does this patient make?	Based on the assessment following nursing diagnoses were formulated, i.e. the clinical judgment about the patient’s actual and potential problems.
Nursing diagnosis The data collected by assessment are used to make nursing diagnosis in nursing process. Acc. to King in process of attaining goal, the nurse identifies the problems, concerns and disturbances about which person seek help.	Acute pain related to surgical incision Risk for infection related to surgical incision Risk for constipation related to bed rest, pain medication and NPO or soft diet Deficient knowledge regarding the treatment and home care Ineffective health maintenance

Identifying the goals and planning to achieve these goals (this step is congruent with planning in the traditional nursing process)

What goals do I think will serve the patient’s best interest?

1. The client will experience improved comfort, as evidenced by:

a decrease in the rating of the pain,
the ability to rest and sleep comfortably

2. The client will be free of infection as evidenced by normal temperature, normal vital signs.
3.The client will have improved bowel elimination, as evidenced by:

Elimination of stool without straining

4. Client will acquire adequate knowledge regarding the treatment and home care.
5.Client will attend to health problems promptly

What are the patient’s goals?

Patient’s goals are:

Freedom from pain
Rapid healing
Adequate bowel movement
Acquiring adequate knowledge regarding his health problems

Are the patient’s goals and professional goals are congruent?

Yes

What are the priority goals?

Relief of pain

Freedom from infection
Adequate bowel movement
Improvement knowledge aspect of health conditions
Prompt attendance to health problems

What does the patient perceives as the best way to achieve goals?

Working with the health professionals
Gaining knowledge
Disclosing adequate information regarding health problems

Is the patient willing to work towards the goals?

Yes

What do I perceive to be the best way to achieve the goals?

Goal 1:

Assess the characteristics of pain
Administration of prescribed medicine
Monitor the responses to drug therapy
Provide calm, efficient manner that reassures the client and minimizes anxiety
Provide a comfortable position as per client’s requests.

Goal 2:

Monitor vital signs
Administer antibiotics as advised
Use aseptic techniques while changing dressing
Kept the surgical wound site clean
Report surgeon regarding early signs of infection

Goal 3:

Ensure that the client has adequate bulk in diet and adequate fluid intake
Instruct the client on prevention of straining and avoiding valsalva maneuvers
Consult treating physician regarding medications.

Goal 4:

Explain the treatment measures to the patient and their benefits in a simple understandable language.
Explain demonstrate about the home care.
Clarify the doubts of the patient as the patient may present with some matters of importance.
Repeat the information whenever necessary to reinforce learning.

Goal 5:
Health education given about the following:

Restriction of heavy weight lifting (more than 20kg) for 6 months
Further management which may be necessary
Diet control for his hypertension
Rehabilitation measures to promote better living
For regular examination of the site for recurrence of hernia

Are the goals short-term or long term?

Goals are both short-term and long term

What modifications required based on mutuality?

Pain is tolerable to the patient and requires no SOS medication
Constipation is not that severe enough to take medication
Other interventions are mutually acceptable.

In nursing process implementation involves the actual activities to achieve the goals.
This step results in transactions being made.
Transactions occur as a result of perceiving the other person and the situation, making judgments about those perceptions, and taking some actions in response.
Reactions to action lead to transactions that reflect a shared view and commitment
This step reflects implementation in the traditional nursing process

Am I doing what the patient and I have agreed upon?	Yes
How am I carrying out the actions?	On a mutually acceptable manner in accordance with the goals set.
When do I carry out the action?	According to priority, a few interventions require immediate attention. Other interventions are carried out during the period of hospitalization till 5th April.
Why am I carrying out the action?	Patient’s condition demands nursing car.
Is it reasonable to think that the identified goals will be reached by carrying out the action?	Yes

Disclaimer