Fundamentals - Principles, part 8: Patient Education and Nursing Documentation

by Meris Shuwarger July 16, 2021

Full Transcript

Hi. I'm Meris, and in this video, we're going to be talking about patient education and nursing documentation. I will be following along with our Fundamentals of Nursing flashcards, which are available on leveluprn.com.

If you already have a set and you are following along with me, I am starting on card number 22. So be sure to pay attention to the bold red text and anything we call out with a key point icon.

Alright, let's get started.

First up, we're going to be talking about the domains of learning. So this has to do with how a patient is learning information, how it affects them. So we have cognitive, psychomotor, and affective.

The cognitive domain of learning is the thinking portion. This is where, maybe, a patient is getting information about how insulin works, for instance. That's cognitive.

Psychomotor. Psycho-, meaning thinking about, and motor-, meaning doing. So they're thinking and doing. This is the best way for a patient to learn because it's combining those senses. So this is going to be such as a patient practicing administering insulin. That would be using the psychomotor domain of learning.

And then the affective domain of learning is how it affects the patient. So this is going to be the patient thinking about their emotions and feelings about a subject. Maybe this is, the patient is really eager to learn about how to manage their diabetes because they realize how having diabetes can affect their lives. So they are eager and motivated so that they can minimize the impact on their life.

So those are the domains of learning.

Next up, we're going to be talking about health literacy. And we're also going to be talking about what aids the patient's learning, and what might hinder it. So health literacy just refers to a patient's ability to learn and synthesize health-related information.

You, as a nurse, probably have pretty good health literacy. But remember that most of your patients do not, so you're going to have to put things in lay terms, meaning in plain English.

So what aids learning? Well, an intrinsic motivation is one of the biggest aids to learn. This means I want to learn so that I can change and better myself. I want to learn because I'm motivated to learn. That's an intrinsic motivation.

Then we also have things like the environment. We want to make sure we have a quiet and brightly lit environment because that's going to be ideal for a patient's learning. If it is dimly lit, very busy, and loud, that's not going to be very good.

Now, when it comes to things that hinder learning, if I have pain, decreased strength, decreased dexterity, all of those things may hinder my ability to learn.

For instance, if I'm trying to learn how to use an inhaler, if I have weak hand strength, that may make me frustrated when I'm trying to learn. Now, as I said before, most of your patients are not very health-literate.

So if I come into the room and I start saying, "So we're going to talk about how to use your short-acting Beta 2 adrenergic agonist Albuterol," I've lost my patient already.

If I come in and say, "Okay, so we're going to talk about how to use your new medication, it's called albuterol." Okay, we're off to a better start. So don't use medical jargon, medical terms, instead use lay terms or simple, plain English.

Visual and hearing deficits. If I'm having a hard time understanding you because I have sensory deficits, it's not going to be very beneficial to me what you're trying to get across.

So make sure that your patients have their glasses, their hearing aids, that you're speaking facing them, that you're doing whatever it takes to best communicate with your patient.

And then also, like we said, presence of symptoms. If your patient is in severe pain or they are exceedingly fatigued because of things like chemotherapy, then that's not really a great time to teach them. Let them rest, treat their symptoms, and when they're feeling better, come back and teach.

Next up we're going to be talking about some of the instructional methods for education, and some of the evaluation methods.

So when it comes to instructing your patients, we have written materials we can provide to them which should always be in your patient's primary language.

And then we also have demonstration. Demonstration, of course, is going to be much better than written materials. Only providing written materials is never going to be sufficient education. So keep that in mind when you're thinking of patient education on your test.

Now, when it comes to evaluation methods, how do I know my patient understands understood what I taught them. The best way to assess that the patient understood is the teach-back method or return demonstration.

So this means after completing the teaching, I'm going to say, "Okay, now tell me how you're going to use your inhaler." That lets the patient demonstrate their understanding.

Or, "Show me how you give yourself your injection of insulin." That's teach-back. That is return demonstration. And that is going to be the best way to assess their comprehension.

Lastly, we're going to talk about nursing documentation. So nursing documentation can be objective or subjective.

So objective is what you observe. It is something like grimacing. I can see the patient's facial expression. Vital signs. It's something that, it is tangible data. It's right there on the screen. There is no argument. It is observable data.

Now, subjective is what the patient or family says. So if the patient says, "I am in pain," or, "I am nauseated," that is subjective.

So any time we document subjective data, we're going to use direct quotes. I'm not documenting and saying that this is what I assume.

I'm documenting and saying, The patient stated, quote, 'I am feeling very nauseated.' That way, when it comes to the charting, we know for sure this is what the patient said.

Now, our Cool Chicken here is that objective is observed and subjective is what the patient says. So that's how you can keep it straight in your mind.

But if you have a better way to remember this, definitely tell me in the comments.

Now, when it comes to documentation, we do have some best practices.

So one of them is going to be that we document right after we do something, but never before. What if I get delayed, or what if I end up going to give the medication and the patient refuses? We never document before doing something, but we also don't want to put it off until the end of the shift.

Also, we've got to use approved abbreviations. You will want to verify with your facility what their approved abbreviations are. But we do have an extensive list of abbreviations that are pretty comprehensively not used because they can be confusing.

We don't use humor or slang. We don't put any kind of negative descriptions of the patient. We always just document the facts. That is the best practice because it's the patient's medical record.

Also, if you are documenting on a written record, something you're actually writing on, you may make errors. It happens. Best practices are to put one single line through. Don't scribble it out. A single line so that the error is still legible.

Then, you're going to put your initials, the date, and time.

Do not use whiteout or correction fluid because we need to still be able to see what was written underneath.

Okay. So that is it for patient education and nursing documentation.

I hope that review was helpful to you. If it was, please be sure to give us a like here on this video.

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Up next, I'm going to be talking about cultural considerations, culturally competent care, and complementary and alternative medicine. I promise you don't want to miss this one. Thank you so much, and happy studying!


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