Application of Theory of Goal Attainment

OBJECTIVES

• to assess the patient condition by the various methods explained by the nursing theory
  
• to identify the needs of the patient
  
• to demonstrate an effective communication and interaction with the patient.
  
• to select a theory for the application according to the need of the patient
  
• to apply the theory to solve the identified problems of the patient
• to evaluate the extent to which the process was fruitful

INTRODUCTION

• King’s theory offers insight into nurses’ interactions with individuals and groups within the environment.
• It highlights the importance of client’s participation in decision that influences care and focuses on both the process of nurse-client interaction and the outcomes of care.
• Mr.Sy (74 years) was admitted in L3 ward of ...Hospital, for a herniorrhaphy on ... for his left indirect inguinal hernia and was expecting discharge from hospital... the theory of goal attainment was used in his nursing process.

CONCEPTS AND DEFINITIONS

1. Interaction

• · A process of perception and communication
• · Between person and environment
• · Between person and person
• · Represented by verbal and nonverbal behaviours
• · Goal-directed
• · Each individual brings different knowledge , needs, goals, past experiences and perceptions, which influence interaction

2. Communication

• · Information from person to person
• · Directly or indirectly
• · Information component of interaction

3. Perception

• · Each person’s representation of reality

4. Transaction

• · Purposeful interaction leading to goal attainment

5. Role

• · A set of behaviours expected of person’s occupying a position in a social system
• · Rules that define rights and obligations in a position

6. Stress

• · Dynamic state
• · Human being interacts with the environment

7. Growth and development

• · Continuous changes in individuals
• · At cellular, molecular and behavioural levels of activities
• · Helps individuals move towards maturity

8. Time

• · Sequence of events
• · Moving onwards to the future

9. Space

• · Existing in all directions
• · Same everywhere
• · Immediate environment (nurse and client interaction)

NURSING PARADIGMS

Nursing

• · Observable behaviour
• · In health care system in society
• · Goal – to help individuals maintain health
• · Interpersonal process of action; reaction, interaction and transaction

Person

• 1. Social beings
• 2. Sentient beings
• 3. Rational beings
• 4. Perceiving beings
• 5. Controlling beings
• 6. Purposeful beings
• 7. Action – oriented beings
• 8. Time – oriented beings

Health

• · Dynamic state in the life cycle
• · Continuous adaptation to stress
• · To achieve maximum potential for daily living
• · Function of nurse, patient, physicians, family and other interactions

Environment

• Open system
• Constantly changing
• Influences adjustment to life and health
• Dynamic Interacting Systems

PERSONAL SYSTEM

Concepts

• · Perception
• · Self
• · Body image
• · Growth and development
• · Time
• · Space

INTERPERSONAL SYSTEM

Concepts

• 1. Interaction
• 2. Transaction
• 3. Communication
• 4. Role
• 5. Stress

SOCIAL SYSTEM

Concepts

• 1. Organization
• 2. Authority
• 3. Power
• 4. Status,
• 5. Decision making

ASSUMPTIONS

• Basic assumption of goal attainment theory is that nurse and client communicate information, set goal mutually and then act to attain those goals, is also the basic assumption of nursing process.
•  Perceptions, goals, needs and values of the nurses and client influence interaction process
• Individuals have the right to knowledge about themselves and to participate in decisions that influence their life, health and community services
• Health professionals have the responsibility that helps individuals to make informed decisions about their health care
• Individuals have the right to accept or reject health care
• Goals of health professionals and recipients of health care may not be congruent

PROPOSITIONS

From the theory of goal attainment king developed predictive propositions, which includes:

• · If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur
• · If nurse and client make transaction, goal will be attained
• · If goal are attained, satisfaction will occur
• · If transactions are made in nurse-client interactions, growth & development will be enhanced
• · If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur
• · If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur 
• · If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur.

NURSING PROCESS

Assessment

• 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

Planning

• After diagnosis, planning for interventions to solve those problems is done. In goal attainment planning is represented by setting goals and making decisions about and being agreed on the means to achieve goals.
• This part of transaction and client’s participation is encouraged in making decision on the means to achieve the goals.

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.

Implementation

• 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

Evaluation

• It involves to finding out weather goals are achieved or not.
• In King’s description evaluation speaks about attainment of goal and effectiveness of nursing care.

Are my actions helping the patient achieve mutually defined goals?	Yes
How well are goals being met?	Short-term goals are met before discharge from hospital Long-term goals are expected to be met, because the patient is motivated to continue home care.
What actions are not working?
What is patient’s response to my actions?	Patient is satisfied with my actions
Are other factors hindering goal achievement?	Patient’s age is a hindering factor in goal achievement regarding health maintenance.
How should the plan be changed to achieve goals?	Health teaching can be modified according to developmental stage. Involvement of family member in care of the patient.

REFERENCES

1. Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical practice.6th edition. Philadelphia. Mosby publications. 1996.
2. Black M. Joice, Hawks Hokanson Jane. Medical Surgical Nursing: Clinical Management for positive outcomes. St Lois, Missouri. 2005.
3. Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.).  Mosby,  Philadelphia, 2002
4. Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed. Mosby,  Philadelphia, 2000.