Patient Education and Drug Therapy
Objectives
When you reach the end of this chapter, you will be able to do the following:
Key Terms
Affective domain The most intangible domain of the learning process. It involves affective behavior, which is conduct that expresses feelings, needs, beliefs, values, and opinions; the feeling domain. (p. 75)
Cognitive domain The domain involved in the learning and storage of basic knowledge. It is the thinking portion of the learning process and incorporates a person’s previous experiences and perceptions; the learning/thinking domain. (p. 75)
Health literacy The degree to which individuals have the capacity to obtain and then process and understand basic health information as well as basic health information and services needed to make appropriate health decisions (p. 75)
Learning The acquisition of knowledge or skill. (p. 75)
Psychomotor domain The domain involved in the learning of a new procedure or skill; often called the doing domain. (p. 75)
Teaching A system of directed and deliberate actions intended to induce learning. (p. 75)
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• Answer Key—Textbook Case Studies
• Critical Thinking and Prioritization Questions
• Review Questions for the NCLEX® Examination
Given the constant change in today’s health care climate and increased consumer awareness, the role of the nurse as an educator continues to increase and remains a significant part of patient care, both in and out of the hospital environment. Patient education is essential in any health care setting and is a critical component of quality and safe health care. Without patient education, the highest quality and safest of care cannot be provided. Patient education is also very crucial in assisting patients, family, significant others, and caregivers to adapt to illness, prevent illness, maintain health and wellness, and provide self-care. Patient education is a process, much like the nursing process; it provides patients with a framework of knowledge that assists in the learning of healthy behaviors and assimilation of these behaviors into a lifestyle.
Patient education may be one of the more satisfying aspects of nursing care because it is essential to improved health outcomes and can be easily measured. In fact, in the current era of increasing acuteness of patient conditions and the need to decrease length of stays in hospitals, patient education and family teaching become even more essential to effectively and efficiently meet outcome criteria. Patient education has also been identified as a valued and satisfying activity for the professional nurse. Additionally, patient education is a qualifier found in professional and accreditation standards. Health teaching is not only included in the American Nurses Association document Nursing: Scope and Standards of Practice (2004) but is also one of the grading criteria used by The Joint Commission (2011), which was formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Visit http://www.thejointcommission.org for more information on accreditation, certification, standards, measurement, and related topics.
Contributing to the effectiveness of patient education is an understanding of and attention to the three domains of learning: the cognitive, affective, and psychomotor domains. It is recommended that one or a combination of these domains be addressed in any patient educational session. The cognitive domain refers to the level at which basic knowledge is learned and stored. It is the thinking portion of the learning process and incorporates a person’s previous experiences and perceptions. Previous experiences with health and wellness influence the learning of new materials, and prior knowledge and experience can serve as the foundation for adding new concepts. Thus, the learning process begins with the identification of what experiences the person has had with the subject matter or content. However, it is important to remember that thinking involves more than the delivery of new information because a patient must build relationships between prior and new experiences to formulate new meanings. At a higher level in the thinking process, the new information is used to question something that is uncertain, to recognize when to seek additional information, and to make decisions during real-life situations.
The affective domain is the most intangible component of the learning process. Affective behavior is conduct that expresses feelings, needs, beliefs, values, and opinions. It is well known that individuals view events from different perspectives and often choose to internalize feelings rather than express them. You must be willing to approach patients in a nonjudgmental manner, listen to their concerns, recognize the nonverbal messages being given, and assess patient needs with an open mind. If you are successful in gaining the trust and confidence of patients and family members, it may have a powerful effect on their attitudes and thus on the learning process.
The psychomotor domain involves the learning of a new procedure or skill and is often called the doing domain. Learning is generally accomplished by demonstration of the procedure or task using a step-by-step approach with return demonstrations by the learner to verify whether the procedure or skill has been mastered. Using a teaching approach that engages these domains—whether one, two, or a combination of all three—will certainly add to the quality and effectiveness of patient education sessions and subsequent learning.
The result of effective patient education is learning. Learning is defined as a change in behavior, and teaching as a sharing of knowledge. Although you may never be certain that patients will take medications as prescribed, you may carefully assess, plan, implement, and evaluate the teaching you provide to help maximize outcome criteria. Just like the nursing process, the medication administration process and the teaching-learning process provide systematic frameworks for professional nursing practice. The remainder of this chapter provides a brief look at patient education as related to the nursing process and drug therapy.
Assessment of Learning Needs Related to Drug Therapy
As previously mentioned, the patient education process is similar to the nursing process. A very important facet of the patient education process, like the nursing process, is a thorough assessment of learning needs. Complete this assessment before patients begin any form of drug therapy. As related to patient education and drug therapy, assessment includes gathering subjective and objective data about the following:
• Age
• Barriers to learning (Box 6-1)
• Developmental status for age group with attention to cognitive and mental processing abilities
• Education received including highest grade level completed and literacy level
• Environment at home and at work
• Psychosocial growth and development level according to Erikson’s stages (Box 6-3)
• Health beliefs, including beliefs about health, wellness, and/or illness
• Level of knowledge about any medication(s) being taken
• Limitations (physical, psychological, cognitive, and motor)
• Misinformation about drug therapy
• Past and present health behaviors
• Religion or religious beliefs
During the assessment of learning needs, be astutely aware of the patient’s verbal and nonverbal communication. Often a patient will not tell you how he or she truly feels. A seeming discrepancy is an indication that the patient’s emotional or physical state may need to be further assessed in relation to his or her actual readiness and motivation for learning. Use of open-ended questions is encouraged, because they stimulate more discussion and greater clarification from the patient than closed-ended questions that require only a “yes” or “no” answer. Assess level of anxiety, because mild levels of anxiety have been identified as being motivating, whereas moderate to severe levels may be obstacles. In addition, if there are physical needs that are not being met, such as relief from pain, vomiting, or other physical distress, these needs become obstacles to learning. These physical issues must be managed appropriately before any patient teaching occurs.
Nursing Diagnoses Related to Learning Needs and Drug Therapy
Some of the most commonly used and currently approved NANDA-I (2012-2014) nursing diagnoses related to patient education and drug therapy are as follows (see Chapter 1 for a more complete listing):
As an example of how nursing diagnoses related to patient education are derived, the nursing diagnosis of deficient knowledge refers to a situation in which the patient, caregiver, or significant other has a limited knowledge base or skills with regard to the medication or medication regimen. A nursing diagnosis of deficient knowledge develops out of objective and/or subjective data showing that there is limited understanding, no understanding, or misunderstanding of the medication and its action, indications, adverse reactions, toxic effects, drug-drug and/or drug-food interactions, cautions, and contraindications. This diagnosis may also reflect decreased cognitive ability or impaired motor skill needed to perform self-medication. Deficient knowledge differs from noncompliance in that the latter occurs when the patient does not take the medication as prescribed or at all; in other words, the patient does not comply with or adhere to the instructions given about the medication. Noncompliance is usually a patient’s choice. A nursing diagnosis of noncompliance is made when data collected from the patient show that the condition or symptoms for which the patient is taking the medication have recurred or were never resolved because the patient did not take the medication per the prescriber’s orders or did not take the medication at all. Although noncompliance is usually a patient decision, other factors need to be assessed to determine the cause of the noncompliance (e.g., lack of ability of the parent, family, or caregiver to administer the medication; other physical, emotional, or socioeconomic factors). These factors are associated with the nursing diagnosis of ineffective health maintenance and provide a patient-centered approach to the plan of care.
Planning Related to Learning Needs and Drug Therapy
The planning phase of the teaching-learning process occurs as soon as a learning need has been assessed and then identified in the patient, family, or caregiver. With mutual understanding, the nurse and patient identify goals and outcome criteria that are associated with the identified nursing diagnosis and are able to relate them to the specific medication the patient is taking. The following is an example of a measurable goal with outcome criterion related to a nursing diagnosis of deficient knowledge for a patient who is self-administering an oral antidiabetic drug and has many questions about the medication therapy. Sample goal: The patient safely self-administers the prescribed oral antidiabetic drug within a given time frame. Sample outcome criterion: The patient remains without signs and symptoms of overmedication while taking an oral antidiabetic drug, such as hypoglycemia with tachycardia, palpitations, diaphoresis, hunger, and fatigue. When drug therapy goals and outcome criteria are developed, appropriate time frames for meeting outcome criteria must be identified (see Chapter 1 for more information on the nursing process). In addition, goals and outcome criteria need to be realistic, based on patient needs, stated in patient terms, and include behaviors that are measurable, such as list, identify, demonstrate, self-administer, state, describe, and discuss.
Implementation Related to Patient Education and Drug Therapy
After you have completed the assessment phase, identified nursing diagnoses, and created a plan of care, the implementation phase of the teaching-learning process begins. This phase includes conveying specific information about the medication
