Patient Teaching Plan

Patient Teaching Plan

The Importance of Patient Teaching
A teacher is one of the most crucial roles of many that nurses perform every day. One may not initially think of a nurse as a teacher, however, patient education is a primary duty shared by many healthcare providers. In fact, according to Freda, “Nurses and nurse midwives have historically considered patient education one of their most important responsibilities” (2004, p. 203). Patient teaching is especially critical when related to cardiac issues in the elderly because patient cases can be complex and involve numerous medications. There is often client confusion about the beneficial effects of different medications, their side effects, risks, and how often they should take each dose. Patient teaching is useful when introducing any new medication. It is especially important with cardiac medications because when these drugs are not taken properly their adverse effects can be damaging or even deadly.
Client Background
S.R., accompanied by her daughter, presented to the emergency room complaining of chest pain. S.R. is a widowed 89 year-old, Caucasian female who lives in Lowell, Massachusetts with her daughter. She was a home- maker for many years before the death of her husband and recent decline in health status. She has Medicare and Medicaid, and sees a doctor regularly. She finished high school and graduated with a diploma and did not attend college. S.R. considers herself a devoted Roman Catholic. She has a family history of heart disease; her mother died of a heart attack when S.R. was in her forties. She and her daughter were on vacation for the week in York, Maine. It was their last day of vacation and they were driving back home when S.R. began to experience chest pain. She described the pain as substernal pressure that came and went about every five minutes (personal communication, September 15, 2008). Eventually the pain would not go away and that was when her daughter became frightened for her mother’s health. Her daughter pulled the car over and called an ambulance. S.R. was transferred from the emergency department to the coronary care unit for monitoring and to receive a stress test after two days. Prior to this episode, S.R. had never experienced chest pain, however was on medications to lower her blood pressure. After evaluation, S.R. was diagnosed with chest pain and angina. Her nursing diagnoses were Fear related to separation from support system during hospitalization and unfamiliarity with the environment and Deficient Knowledge (of Stress Test Procedure and New Medications) related to lack of exposure and unfamiliarity with information resources. A nursing diagnosis of Fear was chosen because according to Newfield, S.A, Hinz, M.D., Scott Tilley, D., Sridaromont, K.L., & Maramba, P.J. (2007), Fear is defined as a “response to a perceived threat that is consciously recognized as danger” (p. 553). S.R. would be separated from her daughter, or support system, during the test and also perceived the test as an immediate threat. A nursing diagnosis of Deficient Knowledge was also applied because the patient verbalized a lack of understanding of concepts related to the procedures and medications.
Learning Needs
S.R. had a lot of new information to learn. She needed to learn what to expect with the procedure of a stress test and what the results meant to her care. The patient verbalized she was quite anxious about the test by stating, “I have never heard of a stress test. What will I have to do?” (Personal communication, September 15, 2008). Her doctor also prescribed Toprol- XL, which was a new cardiac medication for S.R. Its effect, use and side effects needed to be discussed. S.R. and her daughter had some questions about how this medication fit into her existing regimen and its side effects.
Based on the schedule for the day, the priority learning need was the information about the stress test because she was scheduled to leave the coronary care unit in the morning for the procedure. After she returned from the test, more discussion about the medications would take place and teaching would begin about her new medication. It was important to wait until after the test because S.R.’s anxiety level was so high. The patient’s responses helped to guide the decision about what was a top priority. S.R. needed to be reassured about her test in the morning so it was the most important goal.
Student Knowledge
I had to review some information and increase my own knowledge level prior to the patient education session. I had never seen an Adenosine stress test so I needed to learn how the procedure was going to be performed and its approximate length. I also had to understand the difference between the adenosine stress test for which she was scheduled versus the treadmill stress test. I needed to know what the Adenosine was going to feel like so she could be prepared to feel the side effects, like a racing heartbeat. S.R. needed to receive nuclear imaging before and after the test, so I had to learn how this procedure was performed, what radionuclides were, the position she would have to maintain throughout the test and its approximate length. Finally, I needed to know that the results would take approximately two hours to come back from the stress test. I got this information speaking with more experienced nurses and also from the American Heart Association’s Website. In terms of her medications, I needed to know Toprol’s action, use, dosage and how often she would have to take it, the side effects and adverse effects. I then needed to arrange all the information in a way that was easy to understand.
Client Learner Assessment
Assessing client readiness for learning is extremely important. If a client is not ready to learn then the amount of information they understand or retain from the teaching session is severely reduced. Because S.R. was anxious about her stress test, the first teaching session was limited to reassuring her and informing her about this specific procedure. Attempting to teach other material at the time would not have been effective. It was clear from the start that due to her anxiety the type of learner she was right now was one that was asking a lot of questions. She needed someone to sit down with her and explain the procedure calmly while immediately answering her questions so she would not have to dig for answers. Reading materials such as pamphlets at the time would have been less effective because she was too anxious to focus on the material. Similarly, her daughter was very concerned and would find it helpful to ask questions.
S.R. was in the acute stage of the Trajectory theory. According to Samuels, the acute stage of the Trajectory theory is characterized as an “active illness or complications that require hospitalization or management” (2008). S.R.’s illness had progressed from hypertension to angina, which ultimately required hospitalization. In addition to this somewhat fragile state, S.R. also had some barriers to her learning. She was hard of hearing and wore an assistive hearing device, however, would frequently have to ask people to repeat what they had just said or to speak up. In order to work around this barrier, it would be important not only to speak loudly and in a clear voice, but also to check more frequently to be sure that she was hearing and understanding the information correctly.
Each assessment prior to the teaching session was of utmost importance because it allowed the teaching to go smoothly and also to be individualized to the patient. Discovering S.R.’s readiness, her learning style, stage of change and some barriers allowed me to anticipate problems and work out solutions prior to the teaching. Similarly, the teaching plan must be altered and individualized, especially for the elderly, in order to be more effective. According to Ryan, A.A. & Chambers, M., (2000), “Older people are not a homogenous group and consequently education programs must be tailored to acknowledge individual differences in perceived need and motivation” (p. 733). Therefore, great care was taken to find out what S.R. considered to be most important and tailor the teaching to address those concerns.
Patient Goals
Several goals were set for S.R. by discussing her priorities and individual needs. The goals that were created were then reviewed and agreed to by the patient prior to beginning to achieve them. Due to the timing of her stress test and anxiety level, it was agreed that the teaching would be split into two sessions. The first session focused on teaching related to the stress test. The outcomes for this session were that S.R. should feel less anxious about the stress test and be able to describe the basic process of a stress test. During the first teaching session both of these outcomes could be completed because learning the basic steps of a stress test will lead to a reduction in anxiety. The behavioral objectives for achieving this outcome were:
• Client will verbalize the basic steps of a stress test prior to testing.
• Client will verbalize a reduction in anxiety/ fear level prior to the stress test.
The first objective is in the cognitive domain of Bloom’s Taxonomy of Learning (Bloom, B.S., 1956). It is in the cognitive domain because it requires the client to learn and understand the basic process of a stress test. The second objective is a combination of both the cognitive and affective domains in Bloom’s Taxonomy because through learning and understanding the process of the test the client will feel less anxious about the process (Bloom, B.S., 1956).
The second teaching session focused primarily on the new cardiac medications. The outcomes for this teaching session were that S.R. would understand why she is taking the new medications, the basic principles of how they work and when to take them. All of these objectives should be achieved within the timeline stated because the information is important for patient safety. The behavioral objectives for achieving these outcomes were:
• Client will verbalize at least one therapeutic effect and at least one adverse side effect of Toprol- XL prior to discharge.
• Client will demonstrate correct technique of checking for minimal pulse prior to administration of Toprol- XL prior to discharge.
• Client will verbalize one reason why Toprol- XL cannot be abruptly discontinued prior to discharge.
The first objective is in the cognitive domain of Bloom’s Taxonomy because she is required to learn information about the medications (Bloom, B.S., 1956). The second objective is a combination of the psychomotor and cognitive domains of Bloom’s Taxonomy because it requires S.R. to physically check her pulse to be sure it is not too low and also to cognitively remember what number is too low for the medication (Bloom, B.S., 1956). Finally, the third objective falls into the cognitive domain of Bloom’s Taxonomy because S.R. must understand the possible adverse effects of abruptly discontinuing Toprol- XL (Bloom, B.S., 1956).
Teaching Strategies
The Health Belief model was used to frame the teaching and proved to be a very effective strategy. According to the University of Twente (2004) a person will “take a health- related action if: they feel a negative condition can be avoided, have a positive expectation that by taking a recommended action he/she will avoid a negative health condition, and believe that he/she can successfully take a recommended health action (¶ 2)”. Due to S.R.’s fear about her recent change in cardiac status it had motivated her to avoid a negative outcome. She believed it could be accomplished through teaching because she could learn how to prevent further complications. My goal through teaching was to show S.R. that the best way she could avoid negative complications was to closely follow her medication regimen and to complete the stress test. Unfortunately, exercise was not an option for her due to her age and painful degenerative disk disease. The Health Belief model was the best approach because it allowed the teaching to be tailored to the patient’s situation.
The teaching strategy for the first teaching session was to talk calmly with S.R. and her daughter to ease their anxiety prior to the stress test. For the second teaching session the plan was to again speak with S.R. and be available to answer questions but also give a tailored hand- out so she has something to reference about her cardiac medications at home. The teaching strategy was based on the cognitive theory of learning. According to Rankin, S.H., Stallings, K.D. & London, F., the cognitive theory of learning is “one that requires thinking” (p.87). Most of the teaching involves the learning of new concepts and information.
The teaching will be evaluated based on whether the outcome was met by the timeline set. For example, if S.R. can verbalize a reduction in her anxiety level prior to the stress test then that objective will be considered successful. If the outcome was only partially met, for example, if S.R. can only verbalize one therapeutic effect of Toprol- XL but cannot verbalize an adverse side effect, then the teaching strategy will be adjusted. For example, if it were found that S.R. simply could not complete the outcomes, perhaps it would be helpful if just her daughter can understand the information about the medications because she lives with S.R. full-time and helps administer her medications at home. The quality of teaching will be evaluated by asking S.R. if she has understood the concepts and if she has met the goals.
Evaluation of Outcomes
S.R. was able to meet all of the objectives set for both of the teaching sessions. She was able to meet all of the objectives successfully for a number of reasons. She was motivated as indicated by the Health Belief model and was very involved in the planning of the goals. The goals were tailored to her specific needs and were relative to her situation at the time. Prior to beginning the teaching the goals were discussed and S.R. believed them to be realistic and achievable.
My thinking process for the teaching session was very structured by the Health Belief model and by the patient’s individual needs. The goals set were within the framework of the Health Belief model, however, they also kept the patient’s wishes and needs in mind. I specifically looked for information that the patient was telling me was the most important thing to her at the time, which for S.R. was her fear of the stress test. Therefore, the teaching was structured around her feelings and abilities. The only problem encountered was her anxiety level. Because of her stress the teaching session had to be split into two parts, otherwise the teaching would not have been as effective.
Conclusion
The patient education session was very successful. S.R. completed all the goals previously set. This was due to her involvement with the planning of the goals and also because of the individualization of the teaching plan. It is essential that these two principles be involved in the planning for subsequent patient education experiences. It was due to the incorporation of patient involvement in planning and also the individualization of the teaching that this particular experience was so successful. While nurses and other healthcare providers agree that patient teaching is one of the most important responsibilities of their roles, it is easy to rely solely on standardized teaching plans and pamphlets for patients due to time constraints. However, with careful planning and individualization of teaching a much more effective education session can take place. Patients will experience better completion of objectives and better outcomes.






References

Bloom B. S. (1956). Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc

Freda, Margaret. (2004). Issues in Patient Education. Journal of Midwifery & Women’s Health, 49, 203-209

Newfield, S.A, Hinz, M.D., Scott Tilley, D., Sridaromont, K.L., & Maramba, P.J. (2007). Cox’s Clinical Application of Nursing Diagnosis. Philadelphia, P.A.: F.A. Davis Company

Ryan, A.A. & Chambers, M. (2000). Medication Management and Older Patients: An Individualized and Systematic Approach. Journal of Clinical Nursing, 9, 732-741.

Samuels, Joanne. (2008, September 11). Transition and Trajectory: Module 1: Knowing your Patient. Presented at a Nursing 619 lecture at the University of New Hampshire

University of Twente. (2004). Health Belief Model. Retrieved September 23, 2008 from http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Health_Belief_Model.doc/