CHAPTER 51. Patient Discharge Education in the Phase II Setting
Nancy Saufl
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Utilize the nursing process in providing patient, family, and/or accompanying responsible adult appropriate education (assessment, nursing diagnosis, planning, intervention, and evaluation).
2. Review The Joint Commission’s patient education standards.
3. Identify postoperative education needs for the patient, family, and/or accompanying responsible adult.
4. Identify learning deficits of the patient, family, and/or accompanying responsible adult.
5. Develop the education plan for the patient, family, and/or accompanying responsible adult based on learning deficits and needs.
6. Define the postoperative education needed for patient, family, and/or accompanying responsible adult.
7. Define documentation standards for education of patient, family, and/or accompanying responsible adult.
I. REVIEW OF THE JOINT COMMISSION’S (TJC) PATIENT EDUCATION STANDARDS
A. “The goal of patient and family education is to improve patient health by promoting healthy behavior and involving the patient in care and care decisions.”
B. Expectations
1. Provide the patient and family or accompanying responsible adult with information that will enhance their knowledge and the skills necessary to promote recovery and improve function.
2. Provide the patient with education and training as appropriate.
a. Assessed needs
b. Abilities and learning preferences
c. Readiness to learn
3. Consider barriers in education assessment.
a. Cultural
b. Religious
c. Physical
d. Cognitive limitations
e. Language
f. Financial
4. Educate patients about:
a. Their medications according to their needs
b. Equipment and supplies and means of obtaining them
5. Teach patients regarding foods and diets appropriate to illness as well as possible food-drug interactions.
6. Provide patients with information on obtaining follow-up care and accessing community resources.
7. Provide patients with education about pain management as part of treatment.
8. Provide patients with information about their rights and responsibilities.
a. Patient’s Bill of Rights acknowledges the patient’s right to participate in his or her own health care.
b. TJC “Speak Up” initiative: urges patients to take a role in preventing health care errors by becoming active, involved, and informed participants
9. Provide discharge instructions that contain information about:
a. Diet
b. Activity
c. Medications
d. Follow-up care
e. Contact number if the patient has questions
10. Document patient education provided to patient and family in:
a. Verbal form
b. Written form
11. Promote the education process among the multidisciplinary health care team members.
a. Include the opportunity for health care providers to ask questions.
C. Patient’s rights information emphasizes the importance of educating patients regarding ongoing health care requirements after discharge.
D. When the nurse evaluates the patient’s discharge status, the American Society of PeriAnesthesia Nurses (ASPAN) states that the nurse must:
1. Review the discharge instructions with the patient, family, and accompanying responsible adult as appropriate.
2. Assess the patient and home care provider’s knowledge of the discharge instructions.
3. Ensure that written discharge instructions have been given to the patient/accompanying responsible adult.
II. EDUCATION ASSESSMENT
A. Use information collected through:
1. Needs assessment (see Chapter 15)
2. Health history
3. Interview with patient, family, and/or responsible accompanying adult
B. Determine patient’s preferred methods of learning (see Chapter 3).
C. Consider the patient’s, family’s, and/or responsible accompanying adult’s understanding of the surgical or invasive procedure and the process.
D. Evaluate
1. Health beliefs
2. Practices
3. Economic factors
4. Cultural factors
E. Ascertain the patient’s support system.
F. Determine:
G. Determine home care and postoperative education needs based on:
1. Patient learning and knowledge deficits
2. Method/type of anesthesia
3. Procedure
a. Learning needs and deficits are determined by:
(1) Anticipated diet
(2) Activity
(3) Potential emergency conditions
(4) Dressing and wound care
(5) Medication reconciliation
(a) Medications prescribed for postoperative period
(b) Routine home medications
(6) Follow-up care
(7) Home care requirements
(8) Typical recovery progression
III. NURSING DIAGNOSIS
A. Identify patient’s, family’s, and/or responsible accompanying adult’s learning deficits.
1. Learning needs can be designated in two ways.
a. Primary concerns or problems
b. As the etiology of a nursing diagnosis associated response to health alterations or dysfunction
c. Nursing diagnosis from North American Nursing Diagnostic Association (NANDA) and ASPAN’s Perianesthesia Data Elements (PDE) may be used.
(1) Knowledge deficit: deficiency in cognitive knowledge or psychomotor skills concerning the condition or treatment plan, or information-seeking behaviors
(2) Health-seeking behavior: the state in which an individual in stable health actively seeks ways to alter personal health habits and/or the environment in order to move toward a higher level of wellness
(3) If the knowledge deficit is considered the etiology, then the nursing diagnosis will be identified as the “risk for …” (risk for infection …).
d. Examples of nursing diagnosis may include the following:
(1) Altered skin integrity related to (R/T) surgical wound
(2) Potential for infection at surgical site
(3) Alterations in comfort—pain
(4) Alterations in comfort—nausea and vomiting
(5) Self-care deficit
(6) Actual or perceived loss of privacy or dignity
(7) Risk of hemorrhage
(8) Anxiety R/T fear of home care without nursing support, separation from family
(9) Potential for injury R/T faintness, weakness, fatigue, prolonged regional block, altered sensory perception
(10) Altered thought processes and/or memory loss R/T sedation and analgesia
(11) Ineffective airway clearance
(12) Potential for aspiration
(13) Ineffective breathing patterns, respiratory depression R/T sedation, anesthesia, positioning, pain, increased respiratory secretions, vomiting, or untoward reactions to medications or local anesthetics
(14) Potential alteration in tissue perfusion, cardiovascular instability
e. Outcome goals, nursing interventions, and resources determined as part of the patient discharge education plan may be R/T the preceding examples or other identified problems.
(1) Education provided must address the outcome goals and nursing interventions to provide consistency and safe care.
IV. PLANNING
A. Develop the patient’s, family’s, and responsible accompanying adult’s education plans based on learning deficits and needs.
1. Formulate the teaching plan and modify as needed.
a. Be conscious of sensory or language barriers.
b. Discharge planning begins with initial contacts, preoperative assessment, and evaluation.
2. Identify patient discharge education materials.
a. Base planning of materials on “need to know versus nice to know.”
b. Generic information and procedure-specific information
c. Large print size—12-point font or larger
(1) Sans serif or serif fonts (Arial, Tahoma, etc.)
d. Readability
(1) Should be at fifth grade level or less
(a) Various readability programs: Simple Measure of Gobbledygook (SMOG) index, RIGHTwriter, Grammatique, Suitability Assessment of Materials (SAM); readability formulas are also available in at least 12 languages.
(b) Allows information to be more easily understood
(2) Most individuals will read at four to five grade levels less than last formally completed grade level, unless they are reading technical journal type materials routinely.
3. Develop educational materials
a. Evaluate color contrast between ink and paper—avoid blues and greens for geriatric patients.
b. Simple sentences instead of complex sentence structures—short sentences
c. Limit number of three syllable words—increases reading level.
d. Use familiar words, not medical terminology.
e. Use active voice, not passive voice.
f. Limit number of components and facts in each paragraph.
g. Limit to two pages or less.
h. Layout should be easy to read—pleasant format that provides adequate “white space.”
4. Review and/or revise education materials on a predetermined schedule.
a. Every 1 to 2 years
b. Avoid duplication and distribution of copy—keep a master.
5. Develop content for education material by using data from:
a. Physician interviews
b. Current literature
c. Standards of practice—regulatory agencies, medical associations, nursing and medical textbooks, etc.
6. Personalize instructions.
V. INTERVENTIONS
A. Define education needed for the postoperative patient, family, and/or responsible accompanying adult.
1. Education can be formal or informal.
a. Encourage and facilitate learning—assess patient’s understanding of process, information, etc.
b. Assist in verbalization of concerns, questions, etc.
c. Build on knowledge that is available at the point in time.
d. Use questions to reveal knowledge and deficits.
e. Provide education based on information obtained in planning section.
2. Methods
a. Written instructions
b. Pamphlets
c. Brochures
d. Verbal discussion
e. Classes with return demonstration
f. Television
g. Video
h. Internet
3. Successful teaching techniques
a. Maintaining eye contact
b. Providing a quiet, distraction-free environment
c. Providing only necessary information
d. Requesting feedback
e. Using short sentences, simple words, and a conversational voice tone
f. Using visual aids
g. Progressing in the order that the information will be used
h. Using familiar words and phrases
i. Showing respect for the learner
B. Postoperative education—key points for standard discharge instructions
1. Patient must be in the care of a responsible adult for 24 hours.
2. Patients should not drive and make any important personal or business decisions for 24 hours.
3. Medication reconciliation—prescribed medications and over-the-counter medications
a. Name, purpose, dosage schedule for each medication; emphasize importance of following directions on label.
b. Resume medications taken before surgery per physician’s order and instructions.
c. Pain medication as prescribed
(1) Purpose and limitations of the medication must be clearly understood.
(2) Patient should realize surgery is not a continual pain-free situation.
(3) Patient should be advised to take a prophylactic approach to pain control and not wait until the pain is significantly pronounced before taking pain medication (but must understand dosage limitations).
(4) Patient should clearly understand to contact physician for any questions or concerns or if pain medication is not effective.
d. Caregiver needs to clearly communicate the possibility of medication interactions with food and other drugs.
e. Common side effects of medication should be reviewed.
f. Taking medications alone or in combination with other medications should be discussed.
g. Patients should be cautioned against taking additional acetaminophen if indicated.
h. If the patient received a medication (pain medication, antibiotics, etc.) at the facility that will be continued at home, the time the next dose is due must be documented on the patient’s written discharge instruction sheet.
4. Activity
a. Patient, family, and/or responsible accompanying adult should be informed of the minor discomforts that may be experienced in the recovery process.
(1) Minor headache, muscle aches, sore throat that are relieved by mild over-the-counter analgesics (unless contraindicated)
b. Patient should be advised to rest the remainder of the day or for the next 24 hours—fatigue, dizziness, and drowsiness are to be expected.
(1) Plan a gradual return to normal activities.
(2) Plan periods of rest during the day’s activities.
c. In general, there is no driving for 24 hours postoperatively or as long as regularly taking opioids or sedatives.
(1) Surgeon may restrict for longer period.
(2) Dependent on procedure
d. Specifics about lifting or performing strenuous activities require clearance from the surgeon.
e. Unless contraindicated by the patient’s procedure, sexual activity may be resumed when patient comfort permits.
f. Limited activity instructions (i.e., weight bearing) may be related to the patient’s procedure.
g. Patients should also be cautioned against the lack of activity.
(1) Importance of ambulation (as allowed)
(2) Frequent change of position (as allowed)
(3) Deep breathing
5. Diet and elimination
a. Any specific restrictions; for example, start with liquids, progress as tolerated.
b. If no restrictions needed, instruct to progress to a regular diet as tolerated.
c. Foods to avoid—spicy, fatty, heavy foods on day of surgery
d. Precautions if history of reflux or gastroesophageal reflux disease
e. Avoidance of foods or liquids that might increase or potentiate nausea and vomiting
f. Use of laxatives, stool softeners based on opioids and/or procedure
g. Voiding—by when and what to do if unable to urinate
h. Patient should be advised not to consume any alcoholic beverages, including beer and wine, for 24 hours or while taking pain medications.
6. Anesthesia precautions
a. Typically determined by anesthesia type used
b. Possibility of sleepiness, drowsiness, and fatigue
c. Possibility of impaired cognitive and psychomotor skills
(1) Impaired judgment
(2) Slower reaction times
d. Potential for postoperative nausea and vomiting
e. Potential for postoperative myalgia or sore throat
f. Sensory blocks
(1) Instruct patient that he or she won’t have normal response to painful stimuli until block subsides.
(2) Advise patient to be mindful of positioning and protecting extremity until block has subsided.
g. Signs and symptoms that should be reported
7. Hygiene
a. Importance of hand washing by patient and caregivers
b. When patient can shower or bathe will be dependent on type of procedure, dressings, drains, etc.
c. How to protect dressings or incision
d. Keeping casts clean and dry
8. Surgical considerations
a. Postoperative pain expectations—report pain not relieved by prescribed pain medication.
b. Expected postoperative bleeding—be procedure specific.
c. Pertinent signs and symptoms that could indicate postoperative complications and should be reported
(1) Fever with a temperature >38.3º C [101º F]
(2) Breathing problems
(3) Bleeding problems—dressing saturated with continually increasing amount of blood
(4) Pain not relieved by pain medication
(5) Urinary retention or inability to urinate within defined time frame
(6) Continual nausea and vomiting
(7) Extreme swelling or redness around surgical wound, drainage that has changed to yellow or green
(8) Persistent, atypical pain or increased pain
(9) Intravenous catheter site observation and care if needed
9. Treatments and tests
a. Procedures that the patient or responsible adult is expected to perform (dressing changes, warm compresses, ice packs, etc.)
b. Complete list of supplies needed
c. Date, time, and location of follow-up tests if ordered
d. Postoperative follow-up care (i.e., time, physician phone number, necessity of calling to make appointment)
e. Crutches, incentive spirometer, antiembolic stockings, emptying of drains, catheters, etc.
10. Operative site and wound care
a. Instructions for appropriate care
b. Incision care
c. Preventing infection
d. Dressing changes
e. Drains
f. Swelling, numbness, or tingling of affected extremity
g. Ice, elevation as appropriate or ordered
11. Emergency care
a. Patient and caregiver must have a clear understanding of what to do in the event of an emergency or an unexpected problem.
b. Patient and caregiver should be advised to contact emergency services for serious problems such as respiratory distress or postoperative hemorrhage (dial 911 or report to nearest emergency department).
C. Transcultural considerations (see Chapter 20)
1. Obtain teaching materials in language of patient and family if possible.
a. Required by law to provide materials for cultural group that is 5% or greater of the general population
2. Use visual aids to communicate meaning.
a. Pictures, charts, or diagrams
3. Use concrete instead of abstract words.
a. Simple language
b. Present only one idea at a time.
4. Allow time for questions.
5. Avoid the use of medical terminology or health care language.
6. Validate brief information in writing if having difficulty understanding patient’s, family’s, or accompanying responsible adult’s pronunciations.
7. Use humor cautiously.
8. Do not use slang words or colloquialisms.
9. Do not assume that a patient and family who nod, use eye contact, or smile are communicating an understanding of what is being taught.
10. Invite and encourage questions during teaching.
a. Avoid asking negative questions.
b. In some cultures, expressing a need or confusion may be perceived as inappropriate or rude.
11. Be cautious when explaining procedures or functions R/T personal areas of the body.
a. May be appropriate to have a nurse of the same sex do the teaching
b. Be aware of need to have family member or interpreter of same sex present when giving instructions.
12. Include the family in planning and teaching.
13. Ask the patient or family member, the patient’s nickname or what the patient prefers to be called.
14. Identify cultural health practices and beliefs.
15. Provide interpreter if needed.
VI. EVALUATION
A. Determine effectiveness of education provided to patient, family, and/or accompanying responsible adult.
1. Evaluation is an ongoing and final process when determining what has been learned.
2. Learning is measured against the predetermined learning objectives.
3. Evaluation can occur using a variety of methods.
a. Direct observation of behavior—return demonstration
b. Oral questioning
c. Self-reports and self-monitoring
d. Postoperative phone call
e. Patient satisfaction surveys
f. Feedback from physicians
4. Evaluate teaching.
a. It is important for nurses to evaluate own teaching and content of teaching programs.
(1) Consider timing, teaching strategies, amount of information, and whether teaching was helpful.
b. Patients, families, and accompanying responsible adults should be given opportunity to evaluate learning experiences.
(1) Feedback questionnaires
(2) Patient satisfaction surveys
(3) Postoperative phone call contacts
c. Forgetting is normal and should be anticipated.
(1) Increases with level of anxiety
VII. DOCUMENTATION
A. Define documentation standards for patient’s, family’s, and accompanying responsible adult’s education.
1. Document information provided.
a. Preoperative instructions
b. Postoperative instructions
(1) Procedure-specific information—what to expect, activity R/T procedure, pain, general care, and when to call the doctor
(2) Information R/T anesthesia, diet, medications, activity, special instructions
(3) Indicate to whom education was given (who will be caring for patient).
(4) Follow-up contact information—phone number and who will be receiving information (Adhere to Health Insurance Portability and Accountability Act [HIPAA] guidelines).
(5) Discharge orders for treatments, medications, nutrition, and activity
(6) How and whom to contact in case of emergency
(7) Procedure-specific instruction sheets provided as indicated
(8) Method of discharge instruction—verbal, written, return demonstration, for example
(9) Time of follow-up medical appointments
(10) Provide copy of written instructions—follow facility policy.
c. Physician’s specific verbal instructions that vary from routine
d. Patient’s response to instructions documented
e. Nurse’s assessment of understanding of postoperative instructions
f. Any specific instructions and requests from the patient for confidentiality that vary from the norm
g. Instructions should be signed by nurse and person to whom they were delivered—family or accompanying responsible adult.
(1) If instructions given preoperatively, patient can sign if necessary—should only be for procedure-specific information.
(2) Anesthesia and medication information should be given to family member or accompanying responsible adult and signed for by this individual.
BIBLIOGRAPHY
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