Understanding learning domains—cognitive, psychomotor, and affective—can make your teaching more precise and effective. By giving consideration to each domain as you prepare to teach, you’ll be better able to identify what the patient needs and is ready to learn. This will help you develop effective teaching strategies and determine appropriate expected outcomes, which allow you to evaluate what the patient has actually learned.
Within each domain, learning can take place on several progressively complex levels. You’ll want to assess what your patient is capable of understanding and what his functional ability is before targeting a specific level within a domain. The information below will help you identify the specific learning levels within each domain. (An example of a patient outcome is given for each level.)
Cognitive domain
Knowledge: Recalling information. (The patient can identify signs and symptoms of hypoglycemia.)
Comprehension: Understanding information and being able to draw conclusions. (The patient can state the relationship between ostomy care and skin integrity.)
Application: Adapting rules to specific problems. (The patient uses sterile technique when giving himself a subcutaneous injection.)
Analysis: Breaking down concepts into separate elements and identifying the relationships among them. (The patient can distinguish cancer facts from myths.)
Synthesis: Reassembling elements to create new concepts. (The patient can use food exchange lists to develop weekly meal plans.)
Evaluation: Appraising the value of material for a given purpose. (The patient can judge the effectiveness of muscle relaxation to relieve stress.)
Psychomotor domain
Perception: Becoming aware of stimuli through the senses. (The patient can recognize the difference between a fast and slow pulse.)
Set: Readiness for a specific action or experience. (The patient correctly places his fingers over his wrist before taking his pulse.)
Guided response: Performing a procedure. (The patient changes his dressing correctly.)
Mechanism: Learning a behavior to the point of habit. (The patient can calibrate temperature with an oral glass thermometer without instruction.)
Complex overt response: Performing a complex motor pattern. (The patient can measure blood pressure accurately within 4 mm Hg of the expert’s finding.)
Adaptation: Altering a motor response to solve new problems. (The patient can adapt principles of applying a disposable colostomy pouch to applying a reusable pouch.)
Affective domain
Receiving: Attending to and allowing continuation of a stimulus. (The patient allows nongastric tube placement.)
Responding: Reacting voluntarily to a stimulus. (The patient cooperates with urinary catheter insertion.)
Valuing: Accepting the preferred value of behavior to the point of acting it out. (The patient accepts activity limitations that surgery has imposed.)
Organization: Systematizing a behavior framework based on values. (The patient organizes a schedule that includes relaxation time.)
Value characterization: Expressing feelings that portray philosophy of life. (The patient participates in a support group for cancer survivors.)
Saving time for teaching
Teaching patients what they need to know is time-consuming—there’s too much to cover and seldom enough time. This is especially true with critically ill patients; teaching is commonly delayed until they’re more medically stable. Try the method below to make teaching effective, even when time is tight:
• List the patient’s learning needs.
• Rank them: most important first, next most important second, and so on.
• Write your teaching to-do list based on this ranking.
This method helps you distinguish the patient’s learning needs from his nursing care needs. It also helps you organize your time or quickly redirect your actions after an interruption.
To simplify ranking the patient’s learning needs, classify each learning need as:
• Immediate (one that must be met promptly such as teaching the patient who’s being discharged in 2 hours) or long range
• Survival (life-dependent such as teaching the warning signs of adrenal crisis) or related to well-being (good to know but not essential such as describing the effects of stress in cardiovascular disease)
• Specific (related to the patient’s disorder, medication, or treatment such as preparing him for upcoming coronary artery bypass) or general (teaching that’s done for every patient such as explaining hospital visiting hours).
After you have classified the patient’s learning needs, establish priorities and gather available teaching materials.
Four steps to take before teaching
Follow these four steps to prepare for effective teaching. First, set teaching outcomes for your patient. Last, form a statement of his readiness, willingness, and ability to achieve those outcomes—your “teaching diagnosis.” In between, collect and evaluate data. You may discover more areas for teaching based on what your patient and his family want to learn. If so, reassess, and modify your outcomes accordingly to create a workable teaching plan.
1. Set teaching outcomes.
• What must the patient learn?
• What does the health care team want him to learn?
• When should teaching occur?
2. Collect data.
• What do patient and family interviews tell you about learning needs, outcomes, and response?
• What does the patient’s chart reveal?
• What information can the health care team give?
• How does the patient learn best?
3. Evaluate data.
• What does the patient want to learn?
• Do his goals conflict with his family’s or the health care team’s goals?
• Determine learning barriers, such as language or literacy level.
• What factors can promote learning?
• Does the patient use the Internet to access information?
4. Establish a teaching diagnosis.
• What is the patient ready, willing, and able to learn?
• Do the patient, his family, and health care team confirm your findings?
• Do you need to set new teaching outcomes?
Teaching tips
You can make your teaching more effective if you give careful thought to the words you choose and the way you organize your teaching points. These tips can help:
Word choice
• Use language appropriate to your patient’s age, educational level, cultural background, and language ability. Select simple words with few syllables, make your sentences short, and use action verbs.
• Express complex medical and scientific concepts in layman’s terms. Use analogies to make your meaning clear. Whenever possible, avoid complex clinical terms and abbreviations.
• Choose specific rather than general words when giving instructions. This applies particularly to directions for the patient’s medications and self-care.
Organization
• To enhance clarity, break your information into large, distinct categories. You might say to the patient, “I have three important things to tell you. Number one is …” This is a good teaching technique whether you’re in the patient’s room or in a lecture room.
• Use examples and hypothetical cases to humanize your teaching.
• State your most important points first and last. Commonly, the first and last points are remembered best.
• Repeat important points, and don’t be afraid to repeat them again if you suspect that the patient hasn’t grasped them.
• Ask for feedback to clarify understanding. Be aware of non-verbal cues from your patient that may indicate his degree of learning and comprehension.
Documenting teaching: A legal safeguard
Protecting yourself from litigation is one of the most compelling reasons for you to create clear, complete documentation of all of your patient teaching efforts. The courts recognize the patient’s right to informed consent—that is, to have appropriate information when making decisions about his health care. This puts the burden of decision on the patient, but it also makes you responsible for helping him make an intelligent choice.
Nurse practice acts in many states hold nurses responsible for patient teaching. The Joint Commission has set national standards for documentation that the courts use as guidelines. So, if a patient claims he was harmed by inadequate teaching and your documentation falls short of these standards, the courts may decide that you provided substandard nursing care—even if you taught the patient thoroughly.
Delegate wisely
Of course, dietitians, physical therapists, and others also do patient teaching. However, nurses commonly do the referring to ancillary staff members, making nurses ultimately responsible for the teaching outcomes. So document each referral and what you expect that person to teach, and delegate only to those qualified to teach. Remember: Licensed practical nurses aren’t taught the fundamentals of patient teaching—it’s beyond the scope of their practice. However, they can reinforce what you have already taught the patient, as long as you follow up, evaluate, and document what the patient understands.
Document what you don’t teach
Keep in mind that documenting what you didn’t teach is just as important as documenting what you did teach. For example, you’ll have to postpone or redirect your teaching if it causes the patient too much stress or if he decides that he would rather have you teach a family member instead. Just make sure you record your teaching attempts and the cause for delay.
A last caution
As health care agencies and consumer groups become more educated about patients’ rights to information, careless patient teaching may become a common ground for lawsuits against nurses. To avoid litigation, document what is taught, the patient’s response to teaching, and the patient’s understanding of what was taught.
Tips for improving drug compliance
Some older adults habitually forget to take their prescribed medication or take it incorrectly. They may even fail to have their prescriptions filled. If you know your patient hasn’t been following his medication regimen as ordered, ask him why he’s been unable to comply with it. Then, try these tips to help improve compliance.
Coping with costs
An older adult may not be able to afford his medications. Refer the patient to a social worker who can explore payment options and assistance programs.
Maintaining a schedule
Some older adults may take many medications, each with a different dosage schedule. Whenever possible, ask the health care provider to substitute formulations that can be taken less often.
If possible, suggest that the patient choose a regular time for taking his medication, such as just after a meal or at bedtime, so that it’s part of his daily routine. Or suggest that he use a check-off system or a commercial device as a reminder.
Dealing with physical limitations
If the patient has difficulty reading labels, suggest that he use a magnifying glass. Tell him that many pharmacies provide largeprint labels; he may want to ask about this when he fills his prescription.
If the patient has limited mobility or can no longer drive, he may have difficulty obtaining his medication. Review community resources that can help, such as delivery systems, transportation services, or home care agencies.
Preventing drug interactions
Adverse effects and noncompliance can stem from drug interactions. Review all the medications the patient is taking, and point out potential interactions. Advise the patient to review all medications with the pharmacist every time he has a new prescription filled.
Teaching topics: Acute coronary syndrome
• Definition of acute coronary syndrome (ACS) specific to how it affects the patient: unstable angina, non-ST-segment elevation myocardial infarction (MI), or ST-segment elevation MI
• Causes of ACS: atherosclerosis, thrombosis, or coronary artery spasm or stenosis
• Potential complications: myocardial necrosis, cardiac arrhythmia, death
• Follow-up care
CAD risk factors
A risk factor is defined as any factor—whether arising from one’s genes, environment, personal habits, or lifestyle choices—that can be used to predict a person’s probability of developing a particular disease. Risk factors for coronary artery disease (CAD) have been studied and followed for more than 50 years through the Framingham Heart Study. In patients with CAD and angina, decreasing or eliminating specific risk factors is seen as a way to deter further disease progression. Intervention is possible after risk factors are identified. Some risk factors (such as age, sex, and family history) aren’t modifiable; other risk factors (such as smoking and obesity) can be reduced or eliminated with treatments and lifestyle modifications.
Risk factors
Relationship to CAD
Major independent
Cigarette or tobacco use
Smoking doubles the risk of cardiovascular disease and increases mortality by 50% in patients with a myocardial infarction.
High blood pressure
A strong relationship exists between hypertension and CAD. Hypertension is defined as an abnormally high blood pressure—that is, a systolic reading of 140 mm Hg or higher or a diastolic reading of 90 mm Hg or higher.
An elevated LDL cholesterol level is a well-established risk in CAD. Control of LDL cholesterol level is a cornerstone in the treatment of heart disease.
Advancing age
Men older than age 45 and women older than age 55 are at increased risk for heart disease.
A low level of HDL, or “good,” cholesterol is an independent risk, regardless of the total cholesterol value. A level below 35 mg/dl is considered significant. An HDL level of greater than 60 mg/dl is considered protective and a “negative” risk factor.
Diabetes mellitus
Type I and type II diabetes increase the risk of heart disease, so it’s important to keep the diabetes under good control to decrease the risk of developing heart disease. Diabetes is characterized by a fasting glucose level of greater than 126 mg/dl.
Other
Obesity
Obesity is a risk factor for heart disease. It’s characterized by a body mass index of 30 or higher.
Abdominal obesity
Patients who have the apple shape, who carry weight in the trunk, are at higher risk than those who have the pear shape, who carry weight in the hips. The apple shape may be an indicator of insulin resistance.
Physical inactivity
Americans are becoming increasingly sedentary and aren’t getting enough daily exercise to stay healthy, creating an increased risk of heart disease.
Teaching topics: Anaphylaxis
• Definition of anaphylaxis
• Cause of the anaphylactic reaction
• Signs and symptoms: swelling and difficulty breathing
• Potential complications: brain damage, death
• Identification of, and ways to avoid exposure to, the allergen
• Use of Epi-Pen
• Wearing medical identification jewelry to identify allergy
Teaching topics: Aneurysm
• Definition of aneurysm
• Information on specific type of aneurysm affecting the patient, such as cerebral or abdominal
• Causes of the aneurysm, such as congenital defect or hypertension
• Diagnostic tests: computed tomography scan, magnetic resonance imaging
• Signs and symptoms (based on type of aneurysm), such as headache or retroperitoneal pain
• Medication use and possible adverse effects
• Surgical repair, such as resection, clipping, or bypass
• Preoperative and postoperative care: coughing and deepbreathing exercises, incentive spirometry, sequential compression stockings, mechanical ventilation, hemodynamic monitoring, pain management, wound care, activity recommendations
• Potential complications: rupture, death
• Follow-up care
Teaching topics: Arrhythmia
• Explanation of normal cardiac conduction
• Information on the specific type of arrhythmia affecting the patient such as atrial fibrillation
• Diagnostic tests, such as electrocardiography or electrophysiologic studies
• Signs and symptoms (based on type of arrhythmia), such as palpitations or chest pain
• Smoking cessation
• Activity recommendations: regular exercise program
• Surgical options: pacemaker or implantable cardioverter-defibrillator (ICD), if indicated
• Preoperative and postoperative care: coughing and deepbreathing exercises, incentive spirometry, cardiac monitoring, wound care
• Potential complications: stroke, myocardial infarction, death
• Medical identification jewelry (for pacemaker or ICD)
• Follow-up care
Teaching about drugs for arrhythmias
Drug
Adverse reactions
Teaching points
Antiarrhythmics
amiodarone (Cordarone)
• Watch for diaphoresis, dyspnea, lethargy, tingling in the extremities, weight loss or gain, and yellow eyes or fingernails. • Other reactions include corneal microdeposits, hyperthyroidism or hypothyroidism, photophobia, and bluish pigmentation.
• Tell the patient to take a missed dose any time in the same day or to skip it entirely. Warn him not to take a double dose. • Advise him to have an eye examination if his vision changes. • Tell him that limiting sun exposure will prevent sunburn and skin discoloration. Suggest using sunblock with a skin protection factor of at least 15 when outdoors. • Stress the importance of keeping follow-up appointments to monitor thyroid, pulmonary, and liver function.
disopyramide (Norpace)
• Watch for ankle edema, dizziness, drowsiness, excessive hunger, hypotension, impotence, irregular heart rate, rapid weight gain, shortness of breath, urine retention, and weakness. • Other reactions include anorexia, constipation, and mouth, nose, and eye dryness.
• Tell the patient who experiences excessive hunger, weakness, drowsiness, and shakiness to eat sweets or drink a sugar-containing beverage and then call his health care provider at once. • Instruct him to rise slowly from a sitting or lying position to prevent dizziness or fainting from hypotension. • Tell him to avoid operating machinery until he no longer experiences adverse reactions to the drug. • Urge him to avoid alcohol, which can reduce blood pressure. • Instruct him to take the drug on an empty stomach—1 hour before or 3 hours after a meal for faster absorption. Tell him to take the drug with meals if stomach upset occurs. • Tell him to take a missed dose as soon as possible, but warn him not to take a double dose.
flecainide (Tambocor)
• Watch for ankle edema, chest pain, dizziness, irregular heart rate, shortness of breath, vision disturbances, and weight gain. • Other reactions include fatigue, headache, nausea, and palpitations.
• Tell the patient to take a missed dose as soon as possible, but warn him not to take a double dose. • Teach him how to take his pulse. Advise him to report an unusually high or low rate or a new irregularity. • Warn against driving or using machinery if dizziness occurs. • Instruct the patient to weigh himself at least every other day and to report sudden weight gain. • If the patient has a permanent pacemaker, explain that the device may need modification after flecainide takes effect.
mexiletine (Mexitil)
• Watch for ataxia, blurred vision, confusion, dizziness, headache, nystagmus, and tremors. • Other reactions include anorexia, constipation, and nausea.
• Tell the patient that he can help relieve nausea by taking the medicine with food or antacids. • Instruct the patient to take a missed dose as soon as possible, but warn him not to take a double dose.
procainamide (Procan SR, Pronestyl)
• Watch for anorexia, nausea, and systemic lupus-like syndrome (chills and fever, joint pain, malaise, and rash). • Other reactions include bitter taste, diarrhea, and dizziness.
• Advise him to reduce GI symptoms by taking procainamide with food. • Inform him that although the tablet’s shell may appear in the stool, the drug has been absorbed. • Tell him to take a missed dose as soon as possible, but warn him not to take a double dose.
propafenone (Rhythmol)
• Watch for dizziness, nausea, vomiting, shortness of breath, edema, and signs of cardiac arrhythmias. • Other reactions include anxiety, fatigue, insomnia, blurred vision, abdominal pain or cramps, constipation or diarrhea, dyspepsia, arthralgia, or rash.
• Stress the importance of taking the drug exactly as prescribed. • Tell the patient not to double the dose if he misses one, but to take the next dose at the usual time. • Tell the patient not to crush, chew, or open the extended-release capsules.
Anticoagulants
heparin
• Watch for bleeding, increased bruising, and hypersensitivity reactions. • Other reactions include fever, chills, rhinitis, mild pain, and hematomas.
• Instruct the patient and his family to watch for signs of bleeding or bruising and to notify the prescriber immediately if any occur. • Tell the patient to avoid over-the-counter (OTC) drugs containing aspirin, other salicylates, or drugs that may interact with heparin unless ordered by the prescriber.
warfarin (Coumadin)
• Watch for signs of bleeding, fever, diarrhea, jaundice, or rash. • Other reactions include headache, nausea, vomiting, mouth ulcerations, melena, dermatitis, and alopecia.
• Stress the importance of complying with the prescribed dosage and follow-up appointments. Tell the patient to carry a card that identifies his increased risk of bleeding. • Tell the patient and his family to watch for signs of bleeding or abnormal bruising and to call the prescriber at once if they occur. • Tell him to avoid OTC drugs containing aspirin, other salicylates, or drugs that may interact with warfarin unless ordered by the prescriber. • Tell the patient to read food labels. Food, nutritional supplements, and multivitamins that contain vitamin K may impair anticoagulation. • Tell him to use an electric razor when shaving and a soft toothbrush.
• Watch for bradycardia, depression, dizziness, dyspnea, rash, and wheezing. • Other reactions include diarrhea, fatigue, headache, impotence, insomnia, nasal stuffiness, nausea, vivid dreams and nightmares, and vomiting.
• Teach the patient to take his pulse before taking the drug and to notify his health care provider if the rate falls below 50 beats/minute. • If the patient complains of insomnia, suggest that he take the drug no later than 2 hours before bedtime. • Instruct him to take labetalol, metoprolol, and propranolol with food to increase drug absorption. • If the patient takes one dose daily, instruct him to take a missed dose within 8 hours. If he takes two or more doses each day, instruct him to take a missed dose as soon as possible, but warn him not to take a double dose. • Warn against suddenly discontinuing the drug. He must taper the dosage, as directed, to avoid serious complications.
Calcium channel blockers
diltiazem (Cardizem) verapamil (Calan, Isoptin)
• Watch for ankle edema, bradycardia, chest pain, dyspnea, fainting, and tachycardia. • Other reactions include constipation, dizziness, flushing, headache, and nausea.
• Tell the patient to rise slowly from a sitting or lying position to minimize dizziness. • Explain that the drug won’t relieve acute chest pain. He must continue to use sublingual nitroglycerin, if prescribed. • Reassure him that he can continue to eat and drink calcium-containing foods in reasonable amounts. • Teach him to prevent constipation by increasing his fluid and fiber intake and by using a bulk laxative, as necessary. • Advise him to limit alcohol intake to avoid dizziness. • Tell him to take a missed dose within 4 hours, but warn him not to take a double dose.
Cardiac glycosides
digoxin (Lanoxicaps, Lanoxin)
• Watch for abdominal pain, anorexia, blurred vision, color vision changes, diplopia, dizziness, drowsiness, fatigue, headache, irregular heart rate, malaise, and nausea.
• Teach the patient to take his pulse before taking digoxin and to report an unusually low, high, or irregular pulse rate. • Tell him to establish a daily routine for taking digoxin. • Instruct him to take a missed dose within 12 hours, but warn him not to take a double dose. • Warn him not to take another person’s tablets; different generic digoxin tablets are absorbed at different rates. • Tell the patient not to take this drug with liquid antacids, kaolin-pectin mixtures (Kaopectate), or cholestyramine (Questran) because doing so may decrease absorption. Separating the administration times by 2 hours will help avoid this interaction.
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