COMMUNICATION AND HUMAN RELATION IN NURSING

INTRODUCTION
We live in an age and culture where efficiency and productivity mean a great deal. We have become obsessed with matters of technique and our technological skills have developed tremendously. This has extended from industry and commerce to this profession, which deal more directly with human beings and their welfare. We are busy doing things and at times we are working and for whom we are also human beings. Here comes the importance of communication and human relations in our profession. Communication is a lifelong learning process for the nurse. Together with the client and family, nurses make the initiate journey from the miracle of birth to the mystery of death.

COMMUNICATION
DEFINITION
Communication is the transmission and interchange of facts, ideas, feelings of action. [Leland Brown] Communication is the interchange of thought or information to bring about mutual understanding and confidence or good human relation. [American Society of Training Directors] Communication is the process of passing information and understanding from one person to another. It is the process of imparting ideas and making oneself understood by others. [Theo Haiemann] Communication is the process of sharing experience till it becomes a common possession. It modifies the disposition of both who partakes it. (John Dewey) Communication is the process by which information, meaning and feelings are shared through the exchange of verbal and nonverbal messages between two or more people. (Brooks and Health 1993)

CONCEPT OF COMMUNICATION
Communication is a process involving the writing selecting and sending of symbols in such a way as to help the listener perceive and recreate in his/her own mind the meaning contained in

the mind of the communicator. Communication involves the certain of meaning in the listener, the transfer of information and thousands of potential stimuli. Communication enables as to grow to learn to be aware of ourselves and to adjust to our environment. The word communication is derived from the Latin word commnis which means common. It is the process of exchange of facts, ideas, opinions and means that individuals or organizations share meaning and understanding with one another. Communication may have a more personal connotation than the interchange of ideas or thoughts. It can be a transmission of feelings or a more personal and social interaction between people. Communication contains both the elements of a science and art. The science of communication provide a body of principles which can guide the managers to find a solution to the specific problems and objective evaluation of results. Communication is creative like an art. It develops new situations, designs and new systems needed for further improvement. Communication art and communication science are interwoven and overlapping in nature. The art of communication is as old as human history, but the science of communication is an event in the recent past the emergence of communication as a district and leading technology is a pivotal event in a Social history.

THEORIES OF COMMUNICATION
I. BULLS EYE THEORY Action view is the basis for the theory of communication. The whole process ofcommunication is based on one-way action doing something to someone. The sender plays an important role who encodes the message with the help of arbitrary symbols. The demonstration or doing skills of the sender is for the purpose to change the behavior of receiver. The action believes that words have a meaning and there would be no misunderstanding, which is the core of effective communication, provided the right words are used to convey the right message. Misperceptions or misunderstandings are bound to occur but according to information theory, the sender has to play effectively and adequately. II. PING-PONG THEORY This theory is also called interaction or interpersonal view. This approach to the study of human communication is the Ping-Pong theory of communication. Ping-Pong is the game of table tennis, represents the interaction theory of communication. It is compared with turns at a table tennis match. In communication process, the turns take place between

the sender and the receiver. It is a complex theory of communication than the Bulls theory which recognizes the concept of linear feedback. In this theory, there is linear cause and effect. III. SPIRAL THEORY The spiral theory of communication is called as transactions view of communication. It recognizes more than one interaction between sender and the receiver. A transaction implies independence, mutual and reciprocal causality. Myers and Myers say that human communication is best understood as a system in which senders are simultaneously receivers and senders. Communication is not static but dynamic and life time experience. THE COMMUNICATION PROCESS Face to face communication involves a sender, a message, a receiver and a response, or feedback. In its simplest form, communication is a two way process involving the sending and the receiving of a message. Because the intent of communication is to elicit a response, the process is ongoing, the receiver of the message then becomes the sender of a response, and the original sender then becomes the receiver. SENDER The sender, a person or group who wishes to convey a message to another, can be considered the source-encoder. This term suggests that the person or group sending the message must have an ideas or reason for communicating (source) and must put the idea or feeling into a form that can be transmitted. Encoding involves the selection of specific signs or symbols (codes) to transmit the message, such as which language and words to use, how to arrange the words and what tone of voice and gestures to case. The nurse must not only deal with dialects and foreign languages but also must cope with two language levels. The laypersons and the health professionals. MESSAGE The second component of the communication process is the message itself- what is actually said or written, the body language that accompanies the words, and how the message is transmitted. The medium used to convey the message is the channel, and it can largest any of the receivers senses. It is importantfor the channel to be appropriate for the message and it should help make the intent of message more clear. Talking face to face with a person may be more effective in some instance than telephoning or writing a message. Recording messages on tape or communicating or communicating by radio or television may be more appropriate for larger audiences. Written communication is often

appropriate for long explanations or for a communication that need to be preserved. The nonverbal channel of touch is often highly effective. RECEIVER The receiver, the third component of the communication process, is the listener, who must listen, observe and attend. This person is the decoder, who must perceive what the sender intended. Perception uses all of the senses to receive verbal and nonverbal messages. To decode means to relate the message perceived to the receivers store house of knowledge and experience and to sort out the meaning of the message. Whether the message is decoded accurately by the receiver, according to the senders intent, depends largely on their similarities in knowledge and experience and sociocultural background. If the meaning of the decoded message matches the intent of the sender then the communication has been effective. In effective communication occer. When the message sent is misinterpreted by the receiver. RESPONSE The fourth component of the communication process, the response, is the message that the receiver returns to the sender. It is also called feedback. Feedback can be either verbal or nonverbal of both. Non-verbal examples are nod of the head or a yawn. Either way, feedback allows the sender to correct or reword a message. Now the original sender becomes the receiver, who is required to decode and respond.

MODES OF COMMUNICATION
Communication is generally carried out in two different modes : verbal and non-verbal. Verbal communication uses the spoken or written word; non-verbal communication uses other forms such as gestures or facial expressions and touch. 1. VERBAL COMMUNICATION Verbal communication is largely conscious because people choose the words they use. The words used very among individuals according to culture, socio economic background, age and education. In addition, a wide variety of feelings can be conveyed when people talk. When closing words to say or write, nurses need to consider. a. Pace and intonation. b. Simplicity. c. Clarity and brevity. d. Timing and relevance.

e. Adaptability. f. Credibility. g. Humor. a. Pace and intonation The manner of speak, as in the pace or rhythm and intonation, will modify the feeling and impact of the message. The information can express enthusiasm, sadness, anger or amusement. The pace of speech may indicate interest, anxiety, boredom, or fear. For example, speaking slowly and softly to an excited client may help calm the client. b. Simplicity Simplicity includes the use of commonly understood words, brevity and completeness. Many complex technical terms become natural to nurses. Words such as vaso constriction or cholecystectomy are meaningful to the nurse and easy to use but are ill advised when communicating with clients. Nurses need to learn to select appropriate understand able terms based on the age, knowledge, culture and education of the client. c. Clarity and brevity A message that is direct and simple will be more effective clarity is saying precisely what is meant and brevity is using the fewest words necessary. The result is a message that is simple and clear. d. Timing and relevance Nurse need to be aware of both relevance and timing. When communicating with clients. No matter how clearly or simply words are stated or written, the timing needs to be appropriate to ensure that words are beard. Moreover, the message need to relate to the person or to the persons interests and concerns. e. Adaptability Spoken messages need to be altered in accordance with behavioral cues from the client. This adjustment is referred to as adaptability. What the nurse says and how it is said must be individualized and carefully considered. This requires astute assessment and sensitivity on the part of the nurse. f. Credibility Credibility means worthiness of belief, trust worthiness, reliability. Credibility may be the most important criterion of effective communication. Nurse foster credibility by being consistent, dependable and honest. The nurse needs to be knowledgeable about what is being discussed and to have accurate information. Nurse should convey confidence and certainty in what they are saying, while being able to acknowledge their limitations.

g. Humor. The use of humor can be a positive and powerful fool in the nurse client relationship, but it must be used with care. Humor can be used to help clients adjust to difficult and painful situations. The physical act of laughter can be both an emotional and physical release, reducing tension by providing a different perspective and promotion a sense of well-being. 2. NONVERBAL COMMUNICATION Nonverbal communication is sometime called body language. It includes gestures, body movements, use of touch, and physical appearance, including adornment. Nonverbal communication offer tells others more about what a person is feeling than what is actually said, because non-verbal behaviours is controlled less consciously then verbal behaviours. Observing and interpreting the clients non-verbal behaviours is an essential skill for nurse to develop.

PERSONAL APPEARANCE
Clothing and adornments can be sources of information about persons. Although choice of apparel is highly personal, it may convey social and financial status, culture, religion, group association and self-concept. How a person dresses is often an indicator of how the person feels. Someone who is tired or ill may not have the energy or the desire to maintain their normal grooming. For acutely ill client is hospital or home care settings, a change is grooming habits may signed that the client is feeling better. A man may request a share or a woman may request a shampoo and some makeup.

POSTURE AND GAIT

The ways people walk and carry themselves are often reliable indicators of self-concepts current mood and health. Erect pasture and an active, purposeful stride suggest a feeling of wellbeing. Slouched pasture and a slow, staffing gait suggest depression or physical discomfort. Tens posture and a rapid determined gait suggest anxiety or anger.

FACIAL EXPRESSION
No part of body is as expressive as the face. Feelings of surprise, fear, anxiety, anger, digest, happiness and scenes can be converged by facial expression. Nurse need to be aware to their own expressions. Nurses need to be aware of their own expressions and what they are communication to others. Clients are quick to notice the nurse facial expression. Particularly when the patient feels unsure or uncomfortable. Eye contact is another essential element of facial

communication. A person who feels weak or defenseless often events the eyes or avoids eye contact, the communication received may be too embarrassing. GESTURES Hand and body gestures may emphasize and clarify the spoken work, or they may occur without words to indicate a particular feeling or to give a sign. A father awaiting information about his daughter in surgery may wring his hands, tap his foot, picks at his nails or pace back and forth. A gesture may more clearly indicate the size and shape of an object. For people with special communication problems, such as the deaf, the hands are invaluable in communication problems, such as the deaf, the hands are invaluable in communication.

MODELS OF COMMUNICATION
1. Aristotle model The first step towards development of a communication model has been taken by Aristotle. He had developed an easy, simple and elementary model of communication event, there are three ingredients and they are speakers, speech and audience. 2. David.K.Berlos Model David Barks process theory is one of the basic theories for all communication theorists. In this model, be identified essential elements and also other factors affecting them such as five senses. This model does not consider verbal and non-verbal stimuli. The following nine components are included in this model

NOISE

SOURCE

ENCOUER

MESSAGE

CHANNEL

RECEIVER

DECPDER

MEANING

FEED BACK

3. Linear Model One way communication or one directional communication is explained in linear model of communication. According to this, a speaker encode a message and sends it to a listener through one or more of the sensory channels. The listener then receives and decodes the message.

Source Encodes Message 4. Interaction model

Channel

Listener Decodes Message

In this model the source, encodes a message and sends it to the receiver through one or more sensory channels. The receiver then decodes the message received. The receiver then encodes the feedback and then sends the feedback to the source, making it two way or interaction communication

Source Encodes Message

Channel

Listener Decodes Message

FACTORS INFLUENCING COMMUNICATION

There are many factors that influence communication and they are i. Development factors. Age, development tasks. ii. Environmental factors. Noise, privacy, comfort and safety, distraction. iii. Situational factors Stress, pain and discomfort, fear and anxiety, dyspnea, fatigue, hearing impaired, selective listening. iv. Social factors Gender, social class, language, power, social scripts, social roles, education. v. Cultural factors Standards of communication, canquage, etnnicity, custom, self expression pattern values and beliefs. vi. Psychological factors Emotions, defense mechanisms, attitudes, assumptions, prejudices,

perceptual distortions.

LEVELS OF COMMUNICATION Nurse use different levels of communication in their daily practice. A. INTRAPERSONAL COMMUNICATION It is a powerful form of communication that occurs within an individual. This level of communication is also called self-talk, self-verbalization and inner thought. Nurses and patients can use intrapersonal communication to develop self-awareness and a positive selfconcept by positive talk and defeating negative thoughts. B. INTERPERSONAL COMMUNICATION It is on to one interaction that occurs face to face. This level of communication is frequently used in nursing situations. It results in expression of feelings, exchange of ideas, decision making, team building, goal accomplishment, problem solving and personal growth when happens meaning fully.

C. TRANSPERSONAL COMMUNICATION It is the interaction that occurs within a persons spiritual domain. Nurses who value human spiritually use this level for patients and for themselves.

D. SMALL GROUP COMMUNICATION It is interaction that takes place with gathering of group dynamic. Nurses use this form for committee work, to lead client support group, form research team and so on.

E. PUBLIC COMMUNICATION It is the interaction with an audience. Nurse use this form for group health education, class room discussion with students or peers.

F. ORGANIZATIONAL COMMUNICATION It is the interaction between an individual and groups within an organization in order to achieve established goals.

SEVEN CS OF COMMUNICATION

CONTENT CREDIBILITY CLALTY CONTINUITY AND CONSISTENCY CAPABILITY

CHANNELS

CONTEXT

1. CREDIBILITY Communication starts with the climate of belief which is built by performance o the part of the practitioner. The performance reflects an earnest desire to serve the receiver and receiver must have confidence in the sender. 2. CONTENT The message must have meaning for the receiver and it must be compatible with his/her value system. The content determines the audience. 3. CONTEXT A Communication program must square with realities of its environment. The context must confirm, not contradict the message. 4. CHANNELS Different channels have different effects. 5. CLARITY Complex issues should be compressed into themes that have simplicity and clarity. 6. CAPABILITY Communication must take into account the capability of receiver. Communication is most effective when they require the least effort on the part of the receiver.

7. CONTINUITY AND CONSISTENCE Communication is an unending process. Repetition with variation contributes to factual and attitude learning, the content must be consistent.

FUNCTIONS OF COMMUNICATION
1. Instructive Function The communication transmits the necessary directives and guidance as to enable them to accomplish his/her tasks. 2. Integration Function It involves bringing about interrelationship among various functions. 3. Informing Function The function or purpose of communication is to inform the individual or group about the subject. 4. Evaluation Function It is tool to appraise the individual. 5. Directive Function Communication is necessary to issue directions by top management to the lower level. Directing others cannot take place without a complete communication process. 6. Influencing Function It implies the provision of feedback which reflects the effect of communication. Motivational forces in an individual are to be provided and then stimulated through communication. 7. Interview Function Interviews selects qualified and worthy people for enterprise. Recruitment process implies face to face oral communication. 8. Teaching Function A complete communication process is required to teach and educate the health workers with regard to procedures, ensuring safety needs of patients, policies, cost control etc. 9. Orientation Function Communication helps to make people acquainted with colleagues and superiors with policies, rules and regulations of the institution. Similarly nurse orients the newly admitted patient to the word through communication.

10. Decision Making Function Communication either verbal or written helps the process of decision making such as a nurse following data collection arrives at a nursing diagnosis and decides a problem solving technique.

STRUCTURE OF COMMUNICATION
In traditional framework of organization communications are largely structures ie, they go through authorized channels. The channels of communication is terms of structure include a. Downward communication b. Upward communication. a. Downward Communication It means the flow in from higher to lower authority. This is usually considered to be from management to employees. It may be oral or written. Eg: - Personal instructions, bells and signals, circulars, bulletins, notices etc. b. Upward Communication. Here the information must be fed upwards to enable management to enable management to evaluate the effectiveness with which its orders have been carried out as well as to become the basis of fresh orders and directions. It may also be oral or written. Eg: Meeting, conferences, face to face talks etc. BARRIERS OF COMMUNICATION The word Barriers means hindrances or hurdles or difficulties or problems. Any difficulty which party or fully prevents an activity is called a barrier. Barriers with reference to communication imply hurdles or problems on the way which adversely affect the transmission of information form sender to the receiver.

1. Organizational Barriers These barriers arise when duties and tine of authority are not clearly defined. They arise on the account of distance communication, more layers of communication, heavy communication load etc. Eg:- Policy, Rules and Regulations, Status and Position etc. 2. Semantic Barriers Problems of language are called semantic barriers. They arise on account of linguistic background and ability of the communicator. Linguistic barriers occur in both oral and written communication common types of semantic barriers are: Badly expressed Message. Jargon Language. Unclarified assumptions. Faulty translations.

3. Personal Barriers a. Barriers to supervisors Prejudice Complex Regard Attitude.

b. Barriers in subordinates resistance to new idea. Lack of encouragement.

4. Psychological Barriers. Poor pronunciation. Confused thinking. Communication overload. Attitude. Fear and anxiety. Lack of interest.

5. Physical Barriers. Environmental disturbances. Physical health. Poor hearing. Distance.

6. Mechanical Barriers Non-availability of proper machines. Presence of defective machines. Interruption. Power failure.

7. Cross Cultural Barriers Culture Political beliefs. Ethics and values. Rules and regulations.

8. Perceptional Barriers Lack of common experience. Linguistic. Look of knowledge of any language Low I.Q

9. Interpersonal Barriers Withdrawal. Rituals. Pastimes Women want empathy not solutions are more likely to compliment emphasize politeness. Men - works out problems on a individualized basis. Are more directive in conversation. Call attention to their accomplishments Tend to dominate discussions during meetings.

10. Gender Barriers

METHODS TO OVERCOME BARRIERS OF COMMUNICATION

The above said barriers can be thought of a fitter, that is, message leaves the sender, goes through these filters and then received by the receiver which may muffle the message. The following strategies can be adopted to overcome such fitters. SUITABLE LANGUAGE The appropriate language and tone definitely minimizes linguistic banners to communication. Use of technical terms should be avoided as per as possible and the message

should be direct simple and meaningful language. Different people perceive the message differently. The term should use common language to avoid semantic distortions. ACTIVE LISTENING Hearing and listening is not the same. Hearing is the act of perceiving sound. It is involuntary and simple refers to the reception of a rural stimuli. Listening is a selective activity which involves the reception and the interpretation of rural stimuli. It involves decoking the sound into meaning. EVALUATIVE Making a judgment about the worth, goodness or appropriateness of the persons statement. FEED BACK When you know something say you know. When you do not know something say that you do not know. That is knowledge. The purpose of feedback is to alter messages so the intention of the original communicator. It includes verbal and non-verbal responses to another persons message. Carl Rogers listed five categories of feedback. Evaluative Interpretive Supportive Probing Understanding

ACTION AND DEEDS Communication through actions and deeds is the principle of effective communication. A message is one to be acted upon. Otherwise it tends to distort the current and also the message hence forth from the individuals involved in communication. A meaning to a message is achieved only when it is acted upon. Action and words must hand in hand. CLARITY Every communication should have skills to have clarity of the message. The greater part relies on the sender of the message to achieve clarity. The message should be as clear as possible in the mind of sender. The purpose of communication is to make the receiver understand the message which can be achieved through clarity.

KNOWING THE RECEIVER The importance of understanding the receiver and the needs of the receiver cannot be over looked. The message content is to meet the needs of the receiver. Sender of message should have capabilities, back ground and level of intelligence, social climate, receptiveness, temperament, and attitudes and soon. INTER PERSONAL RELATIONSHIP Developing optimum interpersonal relationship can be more helpful in overcoming the barriers of communication. Lack of co-operation among people results in non-accomplishing their goal. Principles of personal contact, appreciation, recognition and so on help in eliminating the barrier. COMMUNICATION AND THE NURSING PROCESS Communication is an integral part of the nursing process. Nurses are communication skills in each. Phase of the nursing process. Communication is also important whencaring for clients who have communication problems. Communication skills are even more important when the client has sensory, language or cognitive deficits. ASSESMENT To assess the clients communication the nurse determines communication impairment or barriers and communication style. Remember that culture may influence when and how a client speaks. Obviously, language varies according to age and development with children, the nurse observes sounds, gestures and vocabulary. DIAGNOSIS Impaired verbal communication may be used as a nursing diagnosis when an individual experiences a decreased, delayed or absent ability to receive, process, transmit and use a system of symbols anything that has meaning. Communication problem may be receptive (eg.difficulty haring) or expressive (eg. difficulty speaking). Nursing diagnosis used for clients experiencing communication problems that involve impaired. Verbal communication include the following, Anxiety related to impaired verbal communication. Social isolation related to impaired verbal communication. Impaired social interaction related to impaired verbal communication.

PLANNING When a nursing diagnosis related to impaired verbal communication has been made, the nurse and client determine outcomes and begin planning ways to promote effective communication. The overall client outcome for persons with impaired verbal communication is to reduce or resolve the factors impairing the communication. IMPLEMENTING Nursing interventions to facilitate communication with clients who have problems with speech or language include manipulating the environment, providing support, employing measures to enhance communication and educating the client and support person. A quiet environment with limited distractions will make the most of the communication efforts of both the client and the nurse and increase the possibility of effective communication. The nurse should convey encouragement to the client and provide nonverbal reassurance, perhaps by touch if appropriate. EVALUATING Evaluation is useful for both client and nurse communication. To establish whether client outcomes have been met in relation to communication, the nurse must listen actively, observe nonverbal cues and use therapeutic communication skills to determine that communication was effective. For nurses to evaluate the effectiveness of their own communication with clients, process recordings are frequently used.

Application of Theory of Goal Attainment

This page was last updated on October 17, 2011

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

Kings theory offers insight into nurses interactions with individuals

and groups within the environment.

It highlights the importance of clients 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 persons representation of reality

4. Transaction

5. Role

Purposeful interaction leading to goal attainment

6. Stress

A set of behaviours expected of persons occupying a position in a social system Rules that define rights and obligations in a position

Dynamic state Human being interacts with the environment

7. Growth and development

Continuous changes in individuals At cellular, molecular and behavioural levels of activities


8. Time

Helps individuals move towards maturity

9. Space

Sequence of events Moving onwards to the future

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

NURSING PARADIGMS Nursing

Person

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

Health

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

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. Patient says I have undergone surgery for hernia. The wound is getting healed, I have no other What is the problem I have pain in the area of patients surgery when moving Im taking perception of the medicines for hypertension for the situation? 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. Patient underwent herniorahaphy operation on 30th March for indirect What are my inguinal hernia which he kept perceptions of the untreated for 35 years. Patient has situation? 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 Patients 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

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. 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?

What conclusion (judgment) does this patient make? Nursing diagnosis

Based on the assessment following nursing diagnoses were formulated, i.e. the clinical judgment about the patients actual and potential problems.

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.

1. Acute pain related to surgical incision 2. Risk for infection related to surgical incision 3. Risk for constipation related to bed rest, pain medication and NPO or soft diet 4. Deficient knowledge regarding the treatment and home care 5. 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 clients 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)

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, What goals do I think will serve the patients best interest? 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 Patients goals are:

What are the patients goals?

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

Are the patients goals and professional goals are congruent?

Yes Relief of pain

What are the priority goals?

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

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

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

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:

Goal 2:

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 clients requests.

Goal 3:

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 4:

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 5:

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.

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 Yes On a mutually acceptable manner in accordance with the goals set. According to priority, a few interventions require immediate attention. Other interventions are carried out during the period of hospitalization till 5th April. Patients condition demands nursing car. Yes

Am I doing what the patient and I have agreed upon? How am I carrying out the actions? When do I carry out the action?

Why am I carrying out the action? Is it reasonable to think that the identified goals will be reached by carrying out the action?

Evaluation

It involves to finding out weather goals are achieved or not. In Kings 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 patients response to my actions? Patient is satisfied with my actions Are other factors hindering goal achievement? Patients 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. Personal systems are individuals, who are regarded as rational, sentient, social beings. Concepts related to the personal system are: Perception a process of organizing, interpreting, and transforming information from sense data and memory that gives meaning to one's experience, represents one's image of reality, and influences one's behavior. Self a composite of thoughts and feelings that constitute a person's awareness of individual existence, of who and what he or she is. Growth and development cellular, molecular, and behavioral changes in human beings that are a function of genetic endowment, meaningful and satisfying experiences, and an environment conducive to helping individuals move toward maturity. 1. Body imagea person's perceptions of his or her body. 2. Timethe duration between the occurrence of one event and the occurrence of another event. 3. Spacethe physical area called territory that exists in all directions. 4. Learninggaining knowledge. Interpersonal systems are composed of two, three, or more individuals interacting in a given situation. The concepts associated with this system are: 0. Interactionsthe acts of two or more persons in mutual presence; a sequence of verbal and nonverbal behaviors that are goal directed. 1. Communicationthe vehicle by which human relations are developed and maintained; encompasses intrapersonal, interpersonal, verbal, and nonverbal communication. 2. Transactiona process of interaction in which human beings communicate with the environment to achieve goals that are valued; goal-directed human behaviors. 3. Rolea set of behaviors expected of a person occupying a position in a social system. 4. Stressa dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance, involving an exchange of energy and information between the person and the environment for regulation and control of stressors. 5. Copinga way of dealing with stress. Social systems are organized boundary systems of social roles, behaviors, and practices developed to maintain values and the mechanisms to regulate the practices and roles. The concepts related to social systems are:

0.

Implications for Nursing Practice Nursing practice is directed toward helping individuals maintain their health so they can function in their roles. King's practice methodology, which is the essence of the Theory of Goal Attainment, is called the Interaction-Transaction Process.

1. Assessment phase 1. Perception The nurse and the client meet in some nursing situation and perceive each other. Accuracy of perception will depend upon verifying the nurse's inferences with the client. The nurse can use the Goal-Oriented Nursing Record (GONR) throughout the assessment phase. 2. Judgment The nurse and the client make mental judgments about the other. 3. Action The nurse and the client take some mental action. 4. Reaction The nurse and the client mentally react to each one's perceptions of the other. Disturbanceis the diagnosis phase of the interaction-transaction process. The nurse and the

client communicate and interact, and the nurse identifies the client's concerns, problems, and disturbances in health. The nurse conducts a nursing history to determine the client's activities of daily living, using the Criterion-Referenced Measure of Goal Attainment Tool (CRMGAT); roles; environmental stressors; perceptions; and values, learning needs, and goals. The nurse records the data from the nursing history on the GONR, the medical history and physical examination data, results of laboratory tests and x-ray examination, and information gathered from other health professionals and the client's family members on the GONR. The nurse also records diagnoses on the GONR. Planning phase Mutual Goal Setting The nurse and the client interact purposefully to set mutually agreed on goals. The nurse interacts with family members if the client cannot verbally participate in goal setting. Mutual goal setting is based on the nurse's assessment of the client's concerns, problems, and disturbances in health; the nurse's and client's perceptions of the interference; and the nurse's sharing of information with the client and his or her family to help the client attain the goals identified. The nurse records the goals on the GONR. 0. Exploration of Means to Achieve Goals The nurse and the client interact purposefully to explore the means to achieve the mutually set goals. 1. Agreement on Means to Achieve Goals The nurse and the client interact purposefully to agree on the means to achieve the mutually set goals. The nurse records the nursing orders with regard to the means to achieve goals on the GONR. Transactionis the implementation phase of the interaction-transaction process. Transaction refers to the valuational components of the interaction. The nurse and the client carry out the measures agreed upon to achieve the mutually set goals. The nurse can use the GONR flow sheet and progress notes to record the implementation of measures used to achieve goals. Attainment of goalsis the evaluation phase of the interaction-transaction process. The nurse and the client identify the outcome of the interaction-transaction process. The outcome is expressed in terms of the client's state of health, or ability to function in social roles. The nurse and the client make a decision with regard to whether the goal was attained and, if necessary, determine why the goal was not attained. The nurse can use the CRMGAT to record the outcome and the GONR to record the discharge summary. Implications for Nursing Education King's Conceptual System and the theory of goal attainment lead to a focus on the dynamic interaction of the nurse-client dyad. This focus, in turn, leads to emphasis on nursing student behavior as well as client behavior. The concepts related to the personal, interpersonal, and social systems serve as the theoretical content for nursing courses in associate degree, baccalaureate, and master's nursing programs. The theoretical knowledge is used by students in learning experiences involving concrete nursing situations. References

King, I. M. (1981). A theory for nursing. Systems, concepts, process. New York: Wiley. [Reissued 1990. Albany, NY: Delmar.] King, I. M. (1986). Curriculum and instruction in nursing. Norwalk, CT: Appleton-CenturyCrofts. King, I.M. (1992). King's theory of goal attainment. Nursing Science Quarterly, 5, 1926. King, I.M. (2006). Part One: Imogene M. Kings theory of goal attainment. In M.E. Parker, Nursing theories and nursing practice (2nd ed., pp. 235-243). Philadelphia: F.A. Davis.

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