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

July 16, 2021 Updated: August 23, 2021 11 min read

In this article, we cover what you need to know about patient education and nursing documentation, including what they are, how patients learn best and how to teach well, what can hinder learning, charting best practices, and what NOT to write in a patient's chart.

The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Cool Chicken When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!

Patient education

Patient education helps patients take care of themselves and improve their health outcomes through at-home practices. The patient education topics we'll cover here are domains of learning, health literacy, what aids learning, and what hinders learning.

Domains of learning

Domains of learning are how a patient is learning information and how they are interacting with their learning. The domains of learning you need to know on patient education are cognitive, psychomotor, and affective.

Cognitive

The cognitive domain of learning is the thinking portion.

For example, a patient getting information about how insulin works is in the cognitive domain of learning.

Psychomotor

Psychomotor is thinking and doing at the same time. This is the best way for a patient to learn because it combines two senses.

For example, a patient practicing administering insulin is using the psychomotor domain of learning. They are hearing the information and absorbing it, thinking about it (psycho-) and physically giving the injection (-motor).

Affective

The affective domain of learning concerns emotions and feelings. How is a patient feeling about what they are learning?

For example, a patient might be really eager to learn about how to manage their diabetes, because they realize how having diabetes can affect their lives. They are eager and motivated to minimize the impact on their life.

Health literacy

Health literacy refers to a patient's ability to learn, gather, process, synthesize and understand health-related information.

You, as a nurse or nursing student learning these topics, probably have pretty good health literacy. It will be important for you to remember that most patients will not be as health-literate as you are, and that your communication with patients will best serve them if it's in non-medical terms.

What aids learning

Several factors can aid patient learning, including intrinsic motivation and the environment.

Intrinsic motivation

Intrinsic motivation is one of the biggest aids to patient learning. To have intrinsic motivation means that you want to learn so that you can change, and better yourself. There's an internal reward.

This is as opposed to extrinsic motivation, which would be wanting to learn because someone is paying you $500 if you learn. That's an external motivator.

Environment

The right environments can be conducive to learning. When teaching a patient, ensure you have a quiet, brightly-lit environment, because that's going to be ideal for a patient's learning. If it is dimly lit, very busy, and loud, their other senses are distracted and the patient will not learn and retain the information as effectively.

What hinders learning

Several factors can hinder learning, including pain, mobility issues, use of jargon, visual or hearing deficits, and presence of symptoms.

Pain or mobility issues

If a patient has pain, decreased strength, or decreased dexterity this can hinder their ability to use their body in the psychomotor domain of learning.

For example, if a patient is trying to learn how to use an inhaler, if they have weak hand strength, they may not be able to get a good grip on the inhaler which can result in frustration and impaired learning.

Jargon

Remember that patients will usually not have the same level of health literacy as you do. So if you speak to them using jargon and medical terms, they likely will not absorb the information as well as if you use non-medical terms.

For example, if you enter a patient's room and say, "Let's talk about how to use your short-acting Beta 2 adrenergic agonist albuterol," you'll lose their attention and comprehension fast.

But if you enter the room and say, "We're going to talk about how to use your new medication, it's called albuterol," then you will be 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

Visual and hearing deficits can hinder patient learning. If a patient is having a hard time understanding you because they have sensory deficits, it is unlikely that they will fully absorb and comprehend.

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

Presence of symptoms

If your patient is in severe pain or they are exceedingly fatigued (e.g., from 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.

Instructional methods

There are several instructional methods that can be used to help instruct a patient.

Written

There are usually written materials that you can provide to your patient to help them learn the information that they need. These materials should always be given to your patient in their primary language.

The benefit of written materials is that a patient can take them home and refer to them later.

Demonstration

Demonstration is showing a patient how a skill is performed. Demonstration is almost always going to be more effective than written materials alone.

Keep that in mind when you encounter a question on an exam regarding patient education—written teaching alone will never be sufficient information.

Others

There are also simulation/training devices, videos, books, websites that can be used for patient education. The key takeaway from this part of your fundamentals instruction, though, is that demonstration is more effective than written materials alone.

Evaluation methods

Evaluating patient comprehension of teaching is how you can check to see how well they understand what you taught them. The primary method of education evaluation for your patient is going to be the teach-back method.

Teach-back method

The best way to assess that the patient understood their teaching is the teach-back method, also called return demonstration. After the nurse explains or demonstrates something, the patient will explain or demonstrate it back to ensure full comprehension.

This gives you the opportunity to correct misunderstandings.

For example, after completing teaching on how to use an inhaler, you would say, "Okay, now tell me how you're going to use your inhaler." And the patient can then demonstrate their understanding.

Another example, after completing teaching on how to inject insulin, you would say, "Show me how you give yourself your injection of insulin." And the patient can then demonstrate their understanding of that skill.

Nursing documentation

Nursing documentation is a key component of nursing practice, and the findings that you document will be objective or subjective. Documentation is also called charting, because you are writing in the patient's chart.

Objective

Objective findings are what you observe—tangible data and facts. For example, wincing, limping, blood pressure, heart rate, the patient ate at this time, they were given a specific amount of a specific medication, etc.

Subjective

Subjective findings that you will document as a nurse are what the patient or family says. For example, "I am in pain," or, "I am nauseated," are subjective findings that the patient shared with you that you could document.

Cool Chicken Objective data is observed. Subjective is what the patient says.

Any time we document subjective data, it is important to use direct quotes. That way, when it comes to the charting, we know for sure this is what the patient said.

Best practices

When it comes to nursing documentation, we do have some best practices regarding timing, abbreviations, what not to document, and what to do if you make an error in your documentation.

Timing

Document immediately after doing something, but not before. Consider: What if you get delayed, or what if you attempt to administer medication and the patient refuses? That's why you don't document beforehand.

However, it's important that it's immediately after—you do not want to put it off until end of shift—then things might get forgotten or missed.

Abbreviations

It's important to use approved abbreviations. Verify with your facility what their approved abbreviations are.

If you'd like to learn more about common abbreviations, check out our Medical Terminology and Abbreviations Flashcards for Nursing Students.

What not to document

When you are chartng, don't use humor or slang. Do not include any kind of negative descriptions of the patient. It's the patient's medical record after all—it would not be appropriate to include these things. Just document the facts!

What if you make an error?

If you are documenting on a written record (something you're physically writing on) you may make errors. It happens. The best practice is to put one single line through the incorrect part. Don't scribble it out (or use whiteout/correction fluid)—make a single line so that the error is still legible.

Then, add your initials, the date, and time.


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.

Drop any comments you have for us.

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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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