Transcript for:
Effective Patient Education and Nursing Documentation

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.  And please subscribe, because you don't  want to miss what's coming next. We have   so much good content for you. And  you want to be the first to know.  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!