This paper aims to apply the nursing process in developing a teaching plan for a 92-year old female patient admitted at Mountainview Hospital on September 23, 2019 with right lower quadrant pain.
Mrs. M.M., a 92-year old widowed Asian. She is admitted to the hospital for abdominal pain which started two days prior to admission. CT scan of abdomen revealed appendicitis with peri-appendiceal abscess. She has been on NPO status since admission sixteen hours ago. Attending surgeon discussed with the patient the possibility of performing interventional radiology-guided abscess drainage or appendectomy though the schedule was not yet set as of time of student assessment.
Topic for Educational Need
Thetopic assessed with educational need for this patient concerns her current illness which is appendicitis. The lack of knowledge about the importance of NPO status prior to surgery and how to use the incentive spirometry have also been noted on M.M. The supporting subjective and objective factors that prompted this decision are presented hereunder.
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Subjective factors. When asked what brought her to the hospital, patient said “it’s my kidney, it’s infected”. When the nurse pointed at the incentive spirometer and asked her if she used it, the patient replied “no, what is that thing?”. During the student nurse’s shift, call bell was answered three times with the same patient request. Patient stated, “can you give me even a cup of water, I’m so thirsty.”
Objective factors. M.M., a 92-year old female is diagnosed with appendicitis with peri-appendiceal abscess based on an abdominal CT scan performed on admission day (September 23, 2019). It revealed a 43 x 33 mm inflammatory lesion on the right lower quadrant. Patient has a history of stroke with no deficits and currently on warfarin treatment. The protime and activated thromboplastin time results performed on September 24, 2019, 21.8 seconds and 47 seconds respectively, were prolonged. As ordered by her doctor, she is on NPO status except for per orem medications. Vital signs include blood pressure at 152/68 mm Hg, pulse rate of 70 per minute, temperature is at 36.7C, respiratory rate is 18 per minute, oxygen saturation is 96% on room air. Breath sounds are clear on all lung fields, no adventitious sounds heard. Incentive spirometer noted on beside table.
Patient Assessment for Readiness to Learn
Factors that facilitate or a barrier to learning. Presented below are the patient factors to consider regarding readiness to learn.
Age. The patient is a 92-year old female. With advancing age, the rate of learning and ability to learn is slower and diminished. According to Speros (2009) it is not good to rush an older adult on demonstrating a new skill because it can lead to “incapacitating anxiety, frustration, and unwillingness to perform for fear of failure and shame”. Likewise, the increasing age means more life experiences. This could also hinder in her learning process as she may become complacent and impatient in learning something new.
Educational background. M.M. made it all the way through third year in college in the Philippines before childbirth and family life caught up with her. She used to work as an office clerk back in the Philippines. English is her second language and Tagalog is her primary. Her educational status and understanding of the English language will facilitate the learning process.
Health beliefs. The patient is a member of The Church of Jesus Christ of Latter-day Saints. This religion is known for practicing a healthy lifestyle. She and her family practice their religion’s health code. According to The Church of Jesus Christ of Latter-Day Saints (2019), the provisions of its health code include no drinking of alcoholic drinks or hot drinks such as coffee or tea and no smoking or chewing of tobacco. It is specifically recommended for them to eat “wholesome herbs”, fruits, grains, and eat meat “sparingly”. It is considered a violation of the health code if there is misuse of drugs be it “illegal, legal, prescription or controlled”. Her adherence to her health beliefs shows the she is a well-disciplined person. Her health practice will help facilitate the teaching process.
Socio-culture background. M.M. is a widow with three children, two of whom she alternately lives with in Las Vegas. The value of caring for the elderly has been practiced by her family. The role of caregivers in the health maintenance of the elder population is vital in the survival of this age group.
Physical condition. Aside from her advanced age, her co-morbidities such as her history of stroke (without any deficits) and chronic kidney disease (without dialysis) likely affected her cognitive functioning. Disorders of the nervous system, and renal disease can affect cognitive function (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011). The patient’s short-term memory is assessed to be intact however her remote memory is impaired. She can recall the events leading to her hospitalization, but she could not recall the dates of her previous surgeries. The patient also has glaucoma and administers ophthalmic medication regularly. Both of her pupils are noted to be miotic measuring 1 mm each. She could still read the words the bolded words written on the white board without glasses but says she needs glasses to read a paper. These physical factors are hindrances to her learning. Her on and off abdominal pain and her NPO status which bothers her are also considered barriers to learning. Patient is assessed with dry, cracked lips, dry oral mucosa and tongue. Her skin turgor (on sternum) is also noted to be poor. Thirst is a sign of dehydration. If it is not resolved, this could cause patient frustration and it will be a big hindrance to her learning. It is important to address this problem first before initiating the teaching.
Learning barriers. Patient requires eye glasses to read. Patient can hear spoken words if said out loud. She has no hearing aids. Although English is her second language, she understands it well.
Economic status. M.M. relies on social security benefits for her medical needs. Her other needs are shouldered by her children. Her college level of educational attainment, living arrangement with her family will facilitate in the learning process.
Support system. The patient has strong family ties with her children. She currently lives with them and they assist her in taking care of her everyday needs. She stays on either of the houses of her daughters here in the city. She also added that one daughter is a nurse. This daughter assists her with her health care needs including the acquisition of medicines, communication with her doctors, vital signs check, and warfarin monitoring. With the support system that she has, involving the caregivers in the health teaching is very important.
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Learning style. M.M. is assessed to be an auditory and visual learner. She stated, “I prefer learning through listening and watching someone talk to me about something. Now that I am older, I don’t read much anymore.” According to Lewis et al. (2011), to acquire new information or skills, people often use a combination of learning styles.
Current emotional state. Mrs. M’s current NPO status frustrated her more than anything else during the patient encounter. The student nurse answered her call three times with the same request. She stated, “it has been a day now since I last ate why can’t I have even just a cup of water?”
Method of Implementation
The best teaching method to implement for M.M. will be a lecture-discussion combined with the use of pictures and printed materials as supplements. These are the recommended teaching strategies based on the patient’s generation. The advantage of lecture-discussion method is that it combines short time (about 15-20 minutes) of lecture with a time for discussion (Lewis et al., 2011). Teaching these age group must be done in a “paced, slow, and deliberate manner (Speros, 2009). It is a challenging experience for the instructors, their patience and empathy are expected when dealing with older adults because they respond slower than the younger generations.
It is important to remediate the barriers or hindrances that were identified earlier before initiation of the teaching. Keeping the patient comfortable will ensure that she will be receptive for learning. Providing her comfort involves ensuring that she is well-hydrated and keeping the abdominal pain at bay should be done. Fatigue and lack of sleep will cause an inability to concentrate too (Lewis et al., 2011). Asking the patient how her sleep was and giving her time to nap if needed will be helpful. It is also important to make sure her eyeglasses are available so she can read the printed materials. Patient presented with partial hearing impairment and a declining cognitive functioning thus it is imperative to include the caregiver during the teaching sessions. Informing the caregiver about this plan should be done so she could be around during the lecture. Once all the hindrances and barriers have been resolved and eliminated only then can the teaching commence.
Timing of the implementation process would be dependent on the patient’s readiness to learn. Speros (2009) discussed that the older adults are encouraged to establish their own timeline for learning, giving them extra time during and across teaching sessions to process all the information provided for them. The above author further noted that teaching sessions is best done in mid-morning, it’s when energy levels are high. Keeping the sessions short will prevent fatigue thus scheduling several brief teaching sessions on different days or times would be appropriate.
The learning materials that can be used to supplement for teaching M.M. are audiovisual materials such as printed educational materials with pictures, videos, and CDs/DVDs. These are the best materials to use for those visual and auditory learners like Mrs. M. These materials will enhance the presentation of lecture and promote learning through visual and auditory stimulation. CDs/DVDs or videos are beneficial in teaching steps of a procedure (Lewis et al., 2011). This is could be replayed several times if needed until the patient can grasp the topic. Speros (2009) presents age-appropriate teaching strategies which include specification about the printed materials for older adults. The text should be easy to read at fifth grade level or below, font size should be large (14-16 point font), and it should be printed on high contrast (black print on white is preferred or light cream, non-glare paper). The essential points should also be bulleted or in a list format.
To determine the adequacy or the need for further teaching, it is important to evaluate the patient’s learning. Unsatisfactory answers will merit revision of the teaching plan but as mentioned earlier, it is important to keep in mind that older adults need extra time to process information as well. The strategies (Lewis et al., 2011) for evaluating M.M. are return demonstration, asking her open-ended questions, and asking the caregiver about the patient. Return demonstrations will help determine the patient’s mastery of the skill or lack thereof. For instance, the patient will correctly demonstrate how to use an incentive spirometer. Asking open-ended question such as “what is the incentive spirometer used for?” will also help in determining the level of the patient’s understanding. Involvement of the caregiver in the evaluation process, like asking her “how many times the patient used the spirometer today?”, will also help ensure that the patient followed through as instructed.
In conclusion, to become effective educators, nurses must learn and understand the how and why patients process information presented to them. A teaching plan is not a “one-size-fits-all” plan for any patient but it needs to be custom made for each. The development of a teaching plan using the nursing process ensures the success of the teaching process. For patients to be receptive to learning, identification of factors through assessment of the readiness to learn is a very important first step. Once these negating factors are identified, it is important to address and resolve these issues before proceeding to the implementation process of teaching. Finally, to ensure that the patient understood the teachings presented, an evaluation must be done. This is the only way to know if the goals are met or not. Alterations could then be done if the goals are not achieved.
- The Church of Jesus Christ of Latter-Day Saints (2019). Health practices. Retrieved from https://newsroom.churchofjesuschrist.org/article/health-practices
- Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing assessment and management of clinical problems. St. Loius, MO: Elsevier
- Speros, C. (2009). More than words: Promoting health literacy in older adults. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Health-Literacy-in-Older-Adults.aspx
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