Developing an Effective Teaching Plan for a Low Income Patient with
COPD
Introduction
Although many people know that nurses strive to restore health in sick patients, they do not realize that nurses also aim to promote maximum health potential in healthy individuals. Through patient teaching, nurses help patients and their families to develop healthy lifestyles, effective health behaviors, and basic education regarding when to seek medical attention. Without health education, citizens would be uninformed and unable to maintain and promote their own health. People with chronic illnesses and disabilities especially benefit from patient teaching. In order to avoid complications from chronic illnesses and disabilities, patients must be well informed about their disease and an effective plan of care must be developed by the health care team. Once the plan is developed, it is one of the nurse’s responsibilities to ensure that the patient understands the plan of care and why the plan is important to maintain their health. Ensuring that the patient understands and is motivated to follow the plan of care is one of the main goals of patient education. Aspects that must be taken into account when teaching a patient include learning readiness, the learning environment, teaching techniques, and the population that is being taught.
Client Background
My patient, PS, is a 39 year old female with a COPD exacerbation. In addition to COPD, her past medical history includes myotonic muscular dystrophy, hypertension, and obesity. Because of her chronic illnesses, she fatigues easily, cannot hold a steady job, and struggles financially. PS states she is “too tired to exercise and does not have the energy to cook healthy meals.” She also states that she sometimes doesn’t use her inhaler because it causes voice hoarseness. When asked how she handles difficult situations and stress, she reported that she was not religious, but that she has visited a therapist and can turn to her mother for additional emotional support. She is divorced from her husband, but her boyfriend helps her to take care of her 11 year old son who also suffers from myotonic dystrophy. At this time, her chief complaints were generalized weakness, shortness of breath on exertion, and chest pain related to chronic, productive cough. Her main concerns were that she would need to find someone to pick her son up from school and that she would not be able to afford her care.
Although many nursing diagnoses apply to this patient, some of the most important are ineffective therapeutic regimen management, impaired gas exchange, activity intolerance, deficient knowledge, and acute pain. Due to the many nursing diagnoses that apply to this patient, it is important that her nurse works with her to come up with an effective teaching plan so that she can recover from her current exacerbation and self-manage her COPD to avoid future hospitalizations.
Identification of Learning Needs
Because all patients have different learning needs, it is important to assess learner readiness in every patient. In order to assess learner readiness, I first asked what the patient already knew about COPD, how she managed this chronic illness, and what questions she had about it. The patient stated she didn’t know much about COPD, and would like to know how to manage her symptoms, reduce her risks of being hospitalized again, and why her inhaler was causing hoarseness and infections in her mouth.
As a nurse, I know that my priority is to make sure that this patient maintain and improves her respiratory function. In order for this to happen, I must first educate the patient about effective breathing techniques, how to use inhalers, the importance of adequate dietary and fluid intake, and how to pace physical activities.
Student Background
In order to be an effective teacher for my patient, I must use my resources to help me better understand the patient’s diagnosis and treatment. In this situation, because this patient suffers from a respiratory problem, I need to know about the anatomy and physiology of the respiratory system, particularly how it differs in a COPD patient. I need to know the medications my patient is taking, their interactions, side effects, and important patient teaching points. Furthermore, I must understand how and why breathing techniques are used and why COPD patients have increased dietary and fluid needs and decreased activity intolerance.
Learner Assessment
Learning assessment involves understanding the learning readiness of the patient, how they learn best, and things that may impede their learning. After learning that my patient did not have any special cultural or religious needs that would keep her from being compliant, I asked assessed her emotional readiness to learn. Because she was anxious about her son, I suggested that she call his school to let them know that her mother would be picking up her son today. I knew that her anxiety would affect her learning and must be addressed before my teaching could begin. Also, because her boyfriend was visiting in the morning, I decided to wait until he left and I could have a one-to-one teaching lesson without distraction.
I asked my patient if she had any cognitive needs that affected her learning. She stated that she did not understand much of the terminology that the doctors and nurses used and that she was too embarrassed to ask questions. After learning this information, I decided that I would refrain from using any medical jargon during my teaching and encourage PS to ask questions, no matter how “silly” she thought they were. It would also be beneficial to print out information and highlight the important points so that she could refer back to it if needed.
Knowing that PS fatigued easily because of her chronic illnesses, I knew it would be important to give her adequate rest periods during the teaching. Also, providing several small, reasonable goals would keep this patient more motivated than one unreasonable goal. If she understood that starting small and increasing her activity as her tolerance increased, she may be more likely to be physically active.
Goals
Because my patient currently needed to be on 2 L of oxygen to maintain oxygen saturation levels above 90%, her main concern was to “be able to breathe on my own again so I can get this damn thing out of my nose.” I also felt this goal was extremely important, because as a nursing student, I know that first priority is to improve gas exchange and airway clearance. I knew that I could not raise her saturation levels in just 10 minutes, but that I could help her understand what interventions would be helpful and how she should also perform these interventions on a regular basis at home.
The first objective for achieving this goal is that PS can verbalize her goal. Although she knows that she wants to be able to breathe without a nasal cannula, she needs to understand what oxygen saturation levels mean and how to increase them. This is a cognitive objective because it requires this patient to learn new information, process it, and understand how it applies to her diagnosis of COPD.
The second objective is that she performs the necessary interventions as needed in order to increase her oxygen saturation levels. This is a psychomotor objective because it involves that the patient uses breathing techniques and inhalers correctly, coughs to clear her secretions, slowly increases her activity as tolerate, and maintains adequate nutrition and hydration. I explained to the patient that certain inhalers can cause candidiasis and voice hoarseness and that in order to prevent this she should use an inhaler with a spacer and rinse her mouth and gargle after use. Since the patient experiences generalized weakness related to myotonic dystrophy, these activities may be especially hard for her to complete. Also, because she experiences chest pain on inhalation, I must be sure that she can effectively manage her pain so that her pain levels do not keep her from participating in these interventions.
The third objective is that she maintains the motivation to complete these activities. This is a behavioral objective and requires that the patient has a positive outlook. According to Dunn (2001), “A wide range of emotions–denial, anger, depression–are common before the COPD patient gets to some level of acceptance of life with a respiratory disorder.” If the patient cannot emotionally accept the diagnosis, they cannot understand why interventions are helpful. If the PS becomes frustrated with her activity intolerance, she will develop a negative attitude and be non-compliant. At this time, the patient stated that “I have been here for days and I still feel the same. I don’t understand why nothing is helping.” It is important to encourage positive thinking by addressing her concerns and explaining to her that not participating in these activities will cause undesirable complications. She must understand that by performing these activities on a daily basis, her COPD can be managed.
Teaching Strategies
Before entering the room to perform patient teaching with PS, I decided that I would use conversation as my teaching strategy. I began the conversation by asking how she normally manages her breathing at home. When she stated that normally she just “sits on the couch all day,” I knew that I would need to teach her how she could self-manage her COPD. According to Scullion (2010), “the management of COPD is complex because people need to make behavioural changes and lifestyle changes while also taking medications” (p. 33). I started to discuss the ways in which she could change her lifestyle to improve her oxygen saturation. After I began to talk about breathing techniques, she stated “but I am in too much pain. I’d rather not to do it. I don’t understand how that could help anyway.” The lack of information was keeping her from performing these interventions. I also explained that drinking 2-3 L of fluid per day would be extremely beneficial. According to Dunn (2001), coughing “will not help if the mucus is too thick. Increasing fluid intake will keep secretions thin”. Also, although her appetite was decreased, I told her that by drinking enriched shakes, she could receive adequate calories and nutrition. She complained again of being “too tired” to do any physical activity, so I explained that by pacing her activities, she would be able to increase her intolerance and perform her activities of daily living with more ease.
The patient thanked me for taking the time to provide her with information that she could understand and thus giving her motivation to be compliant. Because she was worried about her son, she was anxious to get out of the hospital as soon as possible and expressed her fears about becoming sick again. I explained to her that by living a healthier lifestyle at home, she could effectively manage her COPD and prevent future complications. She was also concerned that she would not financially be able to afford her treatment. It is important that PS understands that “poor adherence to medication regimens and disease management programmes has been identified as a major factor resulting in emergency admissions…” (Scullion, 2010, p. 34). PS stated that she was glad someone understood how the emotional and financial stress in her life affected her well being. I suggested that seeking emotional support is also important because if a person is not mentally healthy, they cannot be at their fullest potential. By using a holistic teaching approach with PS, I helped her to understand that health is affected by mental, physical, and spiritual problems. I found that this was the best teaching strategy because it dealt with all of the patient’s concerns, not just her physical needs.
In order to evaluate if my patient’s goal was achieved, the quality of my teaching, and if further steps are required, I can ask my patient if these interventions helped to decrease her difficulty breathing. I can also check her oxygen saturation at the end of my shift to see if it has improved. Furthermore, I can ask the patient to verbally tell me why these interventions are important and physically show me how they are performed. This way, I know that she understands the importance and is able to complete the interventions on her own. If not, I would have to re-assess my patients learning needs, develop another teaching plan, and re-evaluate the outcomes.
Evaluation of Outcomes
In evaluating my goal, I used subjective and objective data. I relied on my patient’s verbalization of comfort. The patient reported that her pain level went from a 6/10 to a 4/10. Objectively, I relied on the patient’s oxygen saturation level, rate and depth of breathing, and activity tolerance. Because her oxygen level went from 93% to 96% I knew that there was improvement. Although her rate and depth of breathing had not changed much, she was motivated to ambulate for a short distance with assistance and increase her fluid intake by 16 ounces.
As I approached this assignment, I was extremely nervous about patient teaching. I felt that the patient would not listen to me because I was a student. After establishing rapport with the patient during my morning assessment, I felt more comfortable teaching. Also, by learning about my patient’s personal needs, I was able to use them to motivate her to learn. Although it was hard to motivate her because she was used to living a sedentary lifestyle at home, I found that simply educating her about the basics of health maintenance in COPD was important.
Conclusion
Although I do feel that I was successful with the patient, I think she will return home and not make any changes to her lifestyle. I felt that I wasn’t very adamant about the importance of maintaining her health because I was did not want to seem too demanding. I hope that as I become more comfortable with patient teaching, I will not be as lenient. I think that if I had offered her information about COPD support groups or made an appointment for her at a pulmonary rehab, my patient could have further benefited. Since COPD is a chronic illness, I should have focused on long term goals in addition to the short term goal of decreased difficulty with breathing. I could have possibly looked into and offered information about complementary methods that would help my patient deal with anxiety, such as yoga or meditation.
References
Dunn, N. (2001). Keeping COPD patients out of the ED… chronic obstructive pulmonary
disease. RN, 64(2), 33-38. Retrieved from CINAHL Plus with Full Text database.
Scullion, J. (2010). Helping patients with chronic obstructive pulmonary disease adhere to
regimens. Primary Health Care, 20(5), 33-39. Retrieved from CINAHL Plus with Full
Text database.
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2010). Brunner and Suddarth’s
Textbook of Medical-Surgical Nursing (12thEd., Vol. 1). Philadelphia, PA: Lippincott
Williams & Wilkins.
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