Get to know GUARD

Connect the facts.
Explain the thinking.

A structured approach to learning and organizing nursing knowledge, created by Oksana Semenets-Ana, MSN, RN.

A familiar place to start

GUARD stands for Goal, Unsafe Outcomes, Affecting Factors, Results, and Do or Don’t. Each area gives you a question to think with.

It is a framework for making connections. A detail can fit in more than one area, and the reason for placing it there matters. You can keep a decision or change it when new information arrives.

The five areas

GoalWhat are we trying to accomplish?
Unsafe OutcomesWhat could harm this patient?
Affecting FactorsWhat changes the situation?
ResultsWhat tells us what is actually happening?
Do or Don'tWhat should the nurse do or not do?

Goal

What are we trying to accomplish?

Give the information a purpose. Identify the desired outcome for this person, then ask what improvement would look like.

Connect it: which findings would tell you whether the goal is being met safely?

Unsafe Outcomes

What could harm this patient?

Identify possible harm, then consider which concern matters most in this situation. Explain what draws your attention and what still needs to be assessed.

Connect it: what result would change your level of concern or your next response?

Affecting Factors

What changes the situation?

Consider the actual person: other conditions, medications, access, support, and circumstances can influence the goal and the risks.

Connect it: how does this context change the meaning of a finding or a possible action?

Results

What tells us what is actually happening?

Interpret available information before and after an action. Findings include patient reports and changes over time, as well as numbers.

Connect it: compare what is known now with what was known before. Missing information is not a reassuring finding.

Do or Don't

What should the nurse do or not do?

Explain what you would assess, monitor, teach, report, question, or avoid—and why. A response depends on assessment, orders, parameters, and applicable policy.

Connect it: what supports your decision, and what new information would make you reconsider?

GUARD in practice

Same insulin. New routine.

Sam uses rapid-acting insulin with meals. The prescription has not changed. A planned diabetes education visit.

What would you ask Sam about insulin and meal timing—and what glucose information would you review?

Sam
“Since I started evening shifts, my meal break is sometimes an hour later than planned.”

Educator Goal

Let’s start with what a good shift looks like for you.

How can Sam work toward an agreed glucose goal while avoiding low blood glucose during shifts?

Educator Unsafe Outcomes

Could the wait between your insulin and your meal make a low more likely?

Could a gap between mealtime insulin and food increase the risk of low blood glucose?

Educator Affecting Factors

Tell me about the shift itself: your breaks, your food, how busy you are.

What do the shift pattern, meal access, work activity and insulin regimen change about how the plan fits Sam?

Educator Results

What have your readings and any symptoms shown on the late-break days?

What do glucose readings and any symptoms show around the delayed meals, and what information is missing?

Educator Do or Don't

Before anything changes, let’s agree what to check with your diabetes team.

What needs to be clarified and reviewed with Sam and the diabetes care team before recommending a change?

One possible connection

AAffecting Factors UUnsafe Outcomes

Meal timing is an Affecting Factor. Whether it changes concern about an Unsafe Outcome depends on when Sam takes insulin relative to the actual meal.

This detail alone does not confirm low blood glucose or justify a dose change.

The five GUARD questions

These are connected questions, not steps of care.

Goal
How can Sam work toward an agreed glucose goal while avoiding low blood glucose during shifts?

Educator
Let’s start with what a good shift looks like for you.
Unsafe Outcomes
Could a gap between mealtime insulin and food increase the risk of low blood glucose?

Educator
Could the wait between your insulin and your meal make a low more likely?
Affecting Factors
What do the shift pattern, meal access, work activity and insulin regimen change about how the plan fits Sam?

Educator
Tell me about the shift itself: your breaks, your food, how busy you are.
Results
What do glucose readings and any symptoms show around the delayed meals, and what information is missing?

Educator
What have your readings and any symptoms shown on the late-break days?
Do or Don't
What needs to be clarified and reviewed with Sam and the diabetes care team before recommending a change?

Educator
Before anything changes, let’s agree what to check with your diabetes team.

What the example leaves open

A delay between mealtime insulin and food may increase the risk of low blood glucose. Glucose readings and any symptoms help establish what is happening.

The example does not provide glucose readings or say when Sam takes insulin relative to meals.

Sources

In the book

The book's five-column GUARD overview. The five questions and their meaning are explained in the sections above. — Picture 1 from The GUARD Method. The five areas organize questions; they do not prescribe a sequence of care.