Client Education and Discharge Planning

Client Education and
Discharge Planning
LEARNING OBJECTIVES
1. Define the process of client education. 9. Discuss the application of Adult Learning Principles
2. Discuss the meaning of the term learning theory. (Knowles) to client education.
3. Outline the process of collecting client data to determine 10. Identify one strategy to determine readability level of
learning needs. written material.
4. Explain the application of the nursing process to client 11. Describe how to develop an evaluation tool.
education. 12. Discuss the meaning of the term discharge planning.
5. List two factors to consider when determining an 13. List three risk factors that require discharge planning.
appropriate teaching strategy. 14. Identify the steps necessary to complete a discharge
6. List and describe two specific teaching strategies summary.
appropriate for clients and families. 15. Describe documents required to accompany client to
7. Define cultural competence. home.
8. Identify assessments to determine readiness to learn. 16. Identify appropriate referral for Home Health Team.
CHAPTER OUTLINE
Theoretical Concepts Management Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Client Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Delegation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communication Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adaptation to Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Critical Thinking Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
UNIT 1 Client Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scenario 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
UNIT 2 Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . .
Gerontologic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . .
Scenario 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NCLEX® Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . .
UNIT • Client Education

1
Nursing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Implementing the Teaching Strategy . . . . . . . . . . . . . . . . . . . . .
Evaluating Teaching/Learning Outcomes . . . . . . . . . . . . . . . . .
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Collecting Data and Establishing Rapport . . . . . . . . . . . . . . . .
UNIT • Discharge Planning
2
Nursing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Determining Readiness to Learn . . . . . . . . . . . . . . . . . . . . . . . . . Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Assessing Learning Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preparing a Client for Discharge . . . . . . . . . . . . . . . . . . . . . . . . .
Determining Appropriate Teaching Strategy . . . . . . . . . . . . . Completing a Discharge Summary . . . . . . . . . . . . . . . . . . . . . . .
Selecting the Educational Setting . . . . . . . . . . . . . . . . . . . . . . .
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Client Education and Discharge Planning
TERMINOLOGY
Assessment the first step in identifying client’s knowledge base Home care assistance nursing care provided by licensed and
is to set meaningful learning goals and strategies. unlicensed personnel in the client’s home setting.
Client education the process of influencing behavior and Learning The process of conceptual change, within the frame-
teaching the client self-care techniques so that he or she work of the client’s perceptions, that leads to modifications
can resume responsibility for certain aspects of health care in behavior.
following discharge from the health facility. Maladaptive inability to, or faulty adjustment or adaptation.
Compliance follow-through on advice and direction by med- Readiness to learn a component of the learning process; refer-
ical personnel to promote wellness and rehabilitation. ring to the psychologic state of being open and accepting
Comprehensive health care a total system of health care that of new information and the learning process.
takes the whole person into account. Relationship an interaction of individuals over time.
Counseling giving support or providing guidance. Resistance inability to listen and participate in discussion of
Culture a way of living, thinking, and behaving. It is learned health behavioral changes.
within the family and guides the way we solve problems in Support to lend strength or give assistance to.
our daily lives.
Termination the end of something; a limit or boundary; con-
Cultural competence a set of congruent behaviors,
clusion or cessation.
attitudes, and policies that enables nurses and other
healthcare workers to work effectively in a cross- Therapeutic having medicinal or healing properties; a healing
cultural situation. agent.
Diagnosis-related groups (DRGs) categorization of disease Transfer to convey or shift from one person or place to another.
diagnoses that standardizes the reimbursement of govern- Transition the process or an instance of changing from one
ment funds for number of days in the hospital. form, state, activity, or place to another.
Discharge to release from care; done by a physician, nurse, or Transitional care the process of facilitating the transition or
medical care facility. move between hospital and home to maintain continuity
Discharge planning systematic process of planning for client of health care.
care following discharge; includes client needs, goals of Understanding to perceive and comprehend the nature and
care, and strategies for implementation. significance of, to know.
Evaluation tool a test, questionnaire, or direct observation Validate to substantiate or verify.
that evaluates the effectiveness of the teaching.
Helping relationship an interaction of individuals that sets the
climate for movement of the participants toward common
goals.
CLIENT EDUCATION
Challenges to Providing Client Education
Historically, client education has been one of the most impor-
tant responsibilities of the professional nurse. With advances • Various cultures
in medical science and an increasing number of clients with • Various languages
progressive chronic illness, the role of client education can • Lack of time
directly affect the client’s health, adaptation to illness, and • Lack of reimbursement
recovery. While a segment of healthcare consumers are more • Lack of appropriate readable materials
informed and active in making healthcare decisions, there • Lack of literacy appropriate materials
still remain those who lack “health literacy,” or lack the abil- • Lack of training in providing client education and/or
ity to read, comprehend, and act on medical information. the development of materials
These factors contribute to the increasingly difficult task of
providing appropriate and comprehensive client education. In
addition, the influx of clients from various diverse cultures,
different languages, availability of educational materials writ- to know about their illness, medications, and any procedures
ten at appropriate readability levels and/or languages, lack of being performed. Client education is an expected standard for
time, and shorter hospital stays present challenges for nursing. nursing practice.
The purpose of client and family education is for them to The Joint Commission (formerly JCAHO) has mandated
gain knowledge, skills, and behavior changes necessary to meet that client and family education be part of comprehensive care
the client’s healthcare needs. Client education should be indi- and devised Patient and Family Education (PFE) Standards for
vidualized, specific, and understandable. Clients have a right accredited agencies.
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The Joint Commission set the following goals for client and The client education plan is a component of the total nurs-
family teaching: ing care plan, which is part of the nursing process. Thus the
same principles of the nursing process apply to client education:
• Client participation and decision making about health care
assess the learning needs, and plan appropriate teaching, imple-
options
mentation, and evaluation. Client education, when viewed as a
• Increased potential to follow the healthcare plans process rather than the simple action of imparting information,
• Development of self-care skills helps the client to actively participate in his or her health plan
• Improved client/family coping for wellness. Individualized to the specific client needs and in-
• Increased participation in continuing care cluded as part of a total care plan, client education contributes
• Adopting a healthy lifestyle to continuity of care following discharge.
The Joint Commission reviews for evidence of three major Principles of Client Education
processes involved in client education: the hospital’s internal Malcolm Knowles, author of The Modern Practice of Adult
focus on education, direct education of the client and family, Education, discusses strategies for adult learning. He suggests
and evaluation of how well the education program achieves the that adult learning and readiness to learn are influenced by de-
identified goals. The Joint Commission stresses the need for a velopmental tasks. Knowles formulated what he called the
multidisciplinary approach to planning and implementing client “Adult Learning Principles,” which include the following:
education. Because nurses are the principal providers of care and
have legal responsibility for client education, as outlined in each • Adults learn best when there is a perceived need. In order
state’s Nurse Practice Act and emphasized in documents pub- for learning to occur, the client must understand why they
lished by the American Nurses Association and many specialty need to know about a subject. Therefore, the nurse must
associations, they usually provide the leadership role in directing ensure that the client understands the underlying health
the educational plan for the client and family. Nurses provide issue that is to be prevented or the illness that is to be re-
the communication link between the multidisciplinary team solved before teaching.
members to ensure the client’s goals are met in a timely manner.
• Teaching plan is considered part of client care plan.
The cultural beliefs and practices of the client have a major in-
fluence on healthcare behaviors, beliefs, and willingness to learn. • Teaching of adults should progress from the known to the
Client education must be sensitive to these beliefs. For example, if unknown. Assess what they already know; don’t reteach the
things they already know.
teaching a Chinese diabetic, the nurse must consider the food the
client likes to eat, as well as the social values. Eating may not be • Teaching of adults should progress from the simpler concepts
merely for nutrients, but also a gesture of politeness and social in- to more complex topics.
teraction. It is important that nurses gain an awareness of the var- • Adults learn best using active participation. Asking the
ious cultures in order to provide culturally competent care. client to restate what has been discussed will encourage
The goal of client and family education is to promote opti- learning and provide for clarification.
mal client health. To achieve this goal, clients and families • Adults require opportunities to practice new skills. When
must learn in a way that is meaningful and acceptable to their acquiring new manual skills, such as drawing up or injecting
concept of self and in relationship to the illness. Thus learning insulin, it is essential that the client be allowed to practice
is a process of conceptual change within the framework of the the skill. It is important to observe a return demonstration
client’s perceptions that leads to behavioral change. in order to evaluate the effectiveness of the teaching.
To be effective and facilitate the teaching/learning process, • Adults need behavior reinforced. An example of reinforc-
the nurse must utilize excellent listening and communication ing behavior would be to allow the client to draw up and
skills to establish rapport. Determining learning needs, pre- give their insulin each time it is required.
ferred learning style, and learning readiness are all require- • Immediate feedback and correction of misconceptions
ments included in the The Joint Commission’s Standards for increases learning.
Patient & Family Education. Once a client has received a new
diagnosis or new information about his/her condition, the Similar to Knowles’s principles of adult learning, simplicity
nurse must assess three areas: (1) what they already know, (2) and reinforcement are essential in providing client education.
what they need to know and, (3) how best to assist with learn- An understanding of these principles is essential for individu-
ing. Clients need to be able to identify and understand what als who teach adults in the healthcare setting.
the illness is, effects of the treatment, whether it is acute or
chronic, and short- and long-term care needs and outcomes.
Discussing possible outcomes of the illness will help the client Resistance to Change
accept the condition, be open for new ideas or teaching, and Most nurses recognize that the client may resist learning and
be motivated to learn and make appropriate health behavior cannot be forced to learn; the nurse can only assist the client,
changes. The client must recognize any gaps in knowledge and encourage him or her, and facilitate learning. To master informa-
misconceptions and then assimilate new information for possi- tion, the client must have internalized some form of motivation
ble actions. When the client and family assist in goal setting to learn; for example, the client realizes that to adequately
and the information is presented based on their preferences, control diabetes and feel better, he or she must understand the
learning becomes more meaningful. relationship of insulin and food to body needs.
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Client education is more than imparting information to a

Tips to Facilitate Client-Focused Education client; it is the process of influencing behavior. As such, it
• Get to know the client, his/her knowledge level, needs to be directed toward the client’s thinking to facilitate
perception, current practices, and preferences. meaningful behavioral changes. When goals are mutually
• Determine client’s goals and readiness to learn, and agreed on and clearly stated, the learner understands what is
individualize ways to achieve goals. expected, the nurse understands his or her role and can evalu-
• Take into account client’s goals, learning style, special ate it, and the results can more easily be measured. Because of
skills, cultural beliefs, and developmental level. the need to control costs and the current practice of discharg-
• Utilize simple language and interact at client’s level ing clients earlier, a more extensive teaching plan must be
with empathy and concern. developed and implemented.
• Utilize a variety of materials and methods that
encourage active learning and participation. Readiness to Learn
• Plan for right time and right place to maximize client Assessing the client’s readiness to learn is an essential component
and family learning. of client education. Readiness to learn can be limited by physical
• Follow up at another time to clarify information and and psychosocial demands caused by illness, such as pain and
reassess learning. fatigue. For many clients, the post-acute or recovery phase and
desire to return to normalcy act as an incentive to learning.
Many clients appear to resist change, even when changing Methods of Teaching
would result in a positive outcome. When this occurs, the process The methods of client teaching may include:
of learning is blocked. As a nurse educator, you are functioning as
an agent of change, and dealing with resistance to change is a • One-to-one education: most common methodology used in
necessary task. There are several reasons underlying resistance; hospitals, clinics, and physician offices.
one of the most common is that change is frightening, even • Group teaching: most often utilizes videotapes or similar
when a person consciously wishes to alter his or her behavior. If a technology, such as CDs or DVDs.
person perceives change as a possible threat, he or she may resist. • Computer-aided instruction: used in clinics, hospitals, and
Another cause of resistance is inaccurately perceiving the reason physician offices or for client to learn at home.
for or effect of change. Other sources of resistance include psy- • Internet: can increase client’s understanding of symptoms,
chologic inflexibility, cultural practices, inability to tolerate conditions, and treatments—key to Internet use is choosing
change, and not believing that change will have a positive effect. appropriate health Web sites.
The nurse is both an educator and an agent of change. If the
client resists change (the teaching process), attempting to Regardless of the methodology chosen, selection of educational
identify the reason for that resistance and altering the teaching materials and resources should be appropriate for age, develop-
approach accordingly may assist the nurse to accomplish the mental level, cognitive level, culture, and language.
goals of client education.
Barriers to Change Nursing Approaches DISCHARGE PLANNING

Recent changes in healthcare delivery systems, as an
Perceived threat or Identify specific fears or threats and
fear of change impart accurate information that attempt to contain rapidly rising costs, have altered client care.
may reduce fears. Focus on the The number of hospital days for clients in acute care hospitals
positive outcome of change. has decreased; frequently, these clients are discharged still re-
quiring care; and this care is frequently delivered in the home
Inaccurate perceptions Clarify client perceptions. Impart
of effect of change accurate information, and discuss setting. Most clients, especially those who are high risk, bene-
results of behavior change. fit from the process of discharge planning. Discharge planning
is defined as the systematic process of planning for client care
Disagreement that Work to agree on mutual goals and after discharge from the hospital. The emphasis and goal of dis-
change is positive demonstrate positive outcomes so
charge planning are to meet client needs through continuity of
client views change as positive
care—from an acute care setting to a discharge facility.
rather than negative.
To comply with The Joint Commission requirements re-
Psychologic resistance Focus on discussion of client’s lated to discharge planning, initial assessment at admission,
or perceived loss of perceived loss of freedom and ongoing assessments, and referrals must be documented.
freedoms or behaviors demonstrate willingness to alter When the client is admitted and the care plan formu-
plan or adapt to client’s needs. lated, discharge planning should be initiated. The process
Inability to tolerate Recognize that low tolerance is includes an assessment of the client and family’s anticipated
change often caused by fear—allaying fear needs; physical, emotional, and psychosocial status; home
through developing trust, being environment; and family and community resources. Two
supportive when client attempts to common assessment instruments measuring physical and
change, and giving positive
cognitive function are frequently given to at-risk clients at
feedback decreases fear of change.
the time of admission. The Lawton IADL and Katz ADL
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scales provide information useful when developing the dis-

charge plans. Discharge Planning: High-Risk Clients
Comparison of the two scales: • Elderly
• Multisystem disease process
Instrumental Activities • Major surgical procedure
Activities of Daily Living of Daily Living
• Chronic or terminal illness
(Katz ADL) (Lawton IADL) • Emotional or mental instability
Feeding Using the telephone • Inadequate or inappropriate living arrangement
Continence Shopping • Lack of transportation
Transferring Preparing food • Financial insecurity
• Unsafe features in the home
Toileting Housekeeping
Dressing Doing laundry
Bathing Using transportation
Successful discharge planning includes:
Handling medications
Handling finances
1. A transitional plan of care from the acute care setting to
home or another healthcare facility.
Source: Graf, C. (2008, April). The Lawton instrumental activities of daily living 2. Appropriate teaching for family and client in self-care.
scale. American Journal of Nursing, 108(4), 52–62.
3. Knowledge and skills necessary for self-care and emer-
gency procedures.
Discharge planning requires a multidisciplinary approach
4. Appropriate agencies involved in transition to the home
with participation by all members of the healthcare team, in-
care setting.
cluding the client and family. Many of the larger hospitals have
discharge planners or coordinators, who orchestrate the dis- A new approach to discharge planning is transitional care
charge planning. This is especially important when the client is using transition specialists. This category of practitioner was
considered high risk. The nursing staff still play a major role in implemented to facilitate the transition from hospital (where
assessing discharge needs and preparing the client and caregivers discharge planning is initiated) to recovery (in the home). The
to assume responsibility for care after hospital discharge. With transition specialist meets with the family and client in the
the assistance of social workers or community-based nurses, the acute setting, begins discharge planning, and usually makes a
nurse identifies and anticipates client needs and formulates a home visit before the client is discharged. After discharge to
plan for meeting these needs after discharge from the hospital. the home, this specialist is available to the client and family.
The Joint Commission Standards for Client Education

• Hospital plans for and supports the provision and • Client is educated about pain and managing pain as
coordination of client education activities. part of treatment, as appropriate.
• Hospital identifies and provides the resources • Client is educated about habilitation or rehabilitation
necessary for achieving educational objectives. techniques to help him or her become more
• Education process is coordinated among appropriate functionally independent, as appropriate.
staff or disciplines who are providing care or services. • Client is educated about other available resources,
• Client receives education and training specific to the and when necessary, how to obtain further care,
client’s assessed needs, abilities, learning preferences, services, or treatment to meet his or her identified
and readiness to learn as appropriate to the care and needs.
services provided by the hospital.
• Education includes information about client’s
• Client is educated, based on assessed needs, about responsibilities in his or her care.
how to safely and effectively use medications
according to law and regulation and the hospital’s • Education includes self-care activities, as
scope of services, as appropriate. appropriate.
• Client is educated about nutrition interventions, • Discharge instructions are given to client and those
modified diets, or oral health, when applicable. responsible for providing continuing care.
• Hospital ensures client is educated about how to • Academic education is provided for a hospitalized
safely and effectively use medical equipment or child or adolescent, either directly by the hospital
supplies, as appropriate. or through other arrangements, when appropriate.
Source: Adapted from Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Comprehensive Accreditation Manual for Hospital: The Official Handbook.
JCAHO Patient and Family Education (PFE 2001) Standards. Oakbrook Terrace, IL.
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members or friends is only permitted if it directly affects them

Federal Requirements for Discharge and the client agrees. The information reflecting client approval
Planning Process needs to be documented in the client’s record. Family members
• Hospitals must identify at an early stage of involved in discharge planning are helpful, as they can inform
hospitalization all Medicare clients who are likely to the healthcare team about cultural traditions, financial issues, un-
suffer adverse health consequences on discharge if safe living conditions, and support for the client at home. The
there is no planning. nurse establishes a dialogue between these various people and co-
• The hospital must provide a discharge planning ordinates the discharge plan before the client leaves the hospital.
evaluation. When referrals to other agencies are necessary, these are initiated
• A registered nurse, social worker, or other qualified before the client is discharged. The nurse, if there is no discharge
person must develop or supervise development of the planner available, is responsible for coordinating such referrals—
evaluation. including signed physician’s orders for specific care, treatments,
• Discharge planning must include an evaluation of the or medications.
likelihood of needing posthospital services and of the
availability of the services.
• The evaluation must include the client’s capacity for ADAPTATION TO HOME CARE
self-care or the possibility of the client being cared for
in the environment from which the client entered the Home Care Definition
hospital. The term home health care refers to all services that promote,
• The evaluation must be completed on a timely basis maintain, or restore physical, social, or emotional health to
so that appropriate arrangements for posthospital clients in the home setting. Home care is provided in the indi-
care are made before discharge. vidual’s residence. For a smooth transition from hospital to
• The discharge planning evaluation must be in the home, the home care coordinator communicates with the
client’s medical record. family members and the home health nurse. Home care is also
provided to clients in long-term care or residential care facili-
ties in which there are no or limited staff members.
This type of transitional care and coordination has proven to A variety of health workers are needed to provide comprehen-
be cost-effective and has improved the quality of client care. sive home care services to clients and families. Table 1 presents
Communication between the client, family, and healthcare an overview of healthcare providers and their major responsibili-
agencies is essential for effective discharge planning. According ties. The list and responsibilities are not inclusive; consult an
to HIPAA, discussing client information with the family additional home care reference for more detailed information.
TABLE 1 Home Health Team

Healthcare Provider Major Responsibilities
Registered Nurse Performs as a case manager. Initiates physician-ordered plan of care; performs assessment,
planning, and interventions for needed home care skills and teaching. Assists in evaluating
treatment regimens for all services.
Home Care Aide Performs hygienic care, skin care, exercise, ambulation, dressing, and elimination skills.
Some may prepare and serve meals. Assists in maintaining a clean, safe, client environment
(e.g., client’s bedroom).
Homemaker Maintains the home environment, shops for and prepares meals, transports client, and runs errands.
Social Worker Assists in planning for home care needs, instructs in use of social and community services and
resources. Provides information relative to long-term planning and respite care in the home.
Physical Therapist Evaluates environment in preparation for client’s return home. Assists with safety adaptations for
the home, instructs in exercise program, gait training, and use of special adaptive equipment.
Occupational Therapist Instructs in activities of daily living, grooming, upper extremity strengthening, function activities,
and use of adaptive equipment.
Speech Therapist Evaluates swallowing and chewing ability; memory; assists with increasing communication
techniques for client, family, and healthcare provider; and provides speech reeducation program.
Registered Dietician Evaluates and provides for nutritional needs of client. Plans and instructs in appropriate diet.
Physician Prescribes medical plan of treatment. Writes specific prescriptions for medications, diet,
supplies, nursing interventions, and therapist parameters.
Licensed Vocational Nurse Provides skilled nursing care similar to a Home Care Aide under RN supervision. They are
not used by all agencies because of limited independent activities allowed.
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Referral to Home Care client at discharge should be provided; include physical assess-
It is necessary for nurses in all settings to be aware of the referral ment findings, ability to assist in ADLs, adaptive devices needed
process and the type of client who should be referred for home for care, and a brief summary of hospitalization. These data
care services. Although most home care clients have been hospi- greatly assist in the transition from hospital to home.
talized, it is not a prerequisite for service. Physicians, individual
clients, families, residential care administrators, and friends may Home Health Care Changes
refer a client by calling a home health agency and requesting Home health care, a rapidly growing field of health care, has
service. A physician’s approval is needed for reimbursement. An developed in response to recent changes in political and social
evaluation visit is made by the RN or PT, who act as case man- forces in the United States. These changes have demanded
agers, to determine if service is needed, and if so, an appropriate that nurses expand their knowledge about home care and
plan of care is established. Speech therapists are not allowed to acquire skills needed to provide safe, competent care to clients
do initial evaluations in California and in most other states. in the home setting.
Most hospitals have a designated protocol for making refer- Several factors have contributed to the emergence of home
rals, which is described in the hospital policy manual. In most health care as a primary delivery system. The fastest growing seg-
hospitals it is the discharge planner, case manager, or social ment of the American population is 85 years of age or older. The
worker who makes the referral. The nurse may alert the appropri- elderly constitute the largest proportion of population currently
ate person to the client’s need for home care. It is essential that using home healthcare services. Nine percent of those 65 to
the nurse provide complete and thorough information about the 74 years of age and 25% of those 75 years and older require some
client’s condition, including physical and psychosocial needs. type of home care service. Many younger clients are receiving
This information is documented on a standard referral form or on home care visits as a direct result of early discharge from hospi-
an official form from the Department of Health and Human tals. Home care visits are funded by private insurance companies
Services and sent to the home health agency. Accurate informa- and are a cost-effective measure for providing nursing care.
tion and orders are needed to facilitate a smooth transition from Another factor is the changing structure and role of the
hospital to home. Incomplete or inadequate communication American family. Traditionally, women have provided health
could mean a lapse in service and inadequate care for the client. care for the family members at home. With more women work-
All age groups use home health services. The criteria for ing outside the home, the demand for home health services has
referral depends on various factors, such as client need, agency increased.
protocol, and insurance criteria. Since the elderly on Medicare Political factors have had an effect on healthcare delivery
represent the largest segment of the population using home care patterns. A cost-containment measure initiated by the federal
services, it is important that all nurses know Medicare eligibility government in 1983 to curb rising costs of hospitalized Medicare
criteria for home visits. This ensures that accurate information is clients drastically altered the extent of care administered in the
given to the client and family. In addition to eligibility criteria, hospital setting. A prospective payment system (DRGs), rather
many regulations govern the type and frequency of care. Since than a retrospective payment system, was implemented. This
these regulations are subject to change and interpretation by the resulted in shorter hospital stays for Medicare clients. With the
fiscal intermediaries who administer Medicare insurance, fre- shorter stays came a dramatic increase in the need for profes-
quent review of Medicare regulations should be done. Eligibility sional services to care for high-acuity clients in the home.
for another funding agency, Medicaid, differs from state to state. Additional types of services have also had to be added to the
It is the nurse’s responsibility to be familiar with these policies. home care system to meet the needs of these clients. Even more
Each individual insurance company reimburses for services at changes occurred with healthcare reform in the 1990s. Health
different rates and for different levels of service. Each insurance maintenance organizations (HMOs) and reimbursement poli-
plan needs to be reviewed to determine reimbursement. cies directly affected the home healthcare agencies.
Documentation using Outcome and Assessment Information
Transition From Hospital to Home Set (OASIS) is regulated by the Health Care Financing
Administration. The OASIS system was developed by The
A smooth transition from hospital to home depends on an Center for Health Policy Research in Denver, Colorado. Oasis C
appropriate discharge plan. The shorter duration in hospital stay has added 30 process meaures that will affect outcomes. The new
requires a thorough, efficient discharge plan that must be initi- client assessment information was also used to develop
ated at the time of hospital admission. Identifying the client’s a prospective payment system for home health agencies, which
needs and resources before planning for discharge results in a went into effect October 2000. Home visits for maternity clients
realistic plan. Since any illness causes additional stress in the and children under 18 do not require completion of these forms.
family and necessitates an adaptive coping response, the needs
of the family or significant other must be included in the teach-
ing and discharge plan. Discharge planning is completed during Client Teaching
meetings of the interdisciplinary healthcare team. A representa- Client teaching is an essential component of both hospital and
tive member of each discipline discusses the client’s progress and home care. Since clients are discharged earlier and with a
individual needs for discharge. In addition, accurate and com- higher acuity level, the client and his or her family are expected
prehensive documentation must accompany the physician’s plan to accept more responsibility for follow-up care. It is essential
of treatment to ensure a smooth transition. A description of the for client teaching to begin in the hospital and provide a
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description of the disease or condition and the treatment regi- CULTURAL AWARENESS
men. The client and family should be instructed in skills and
The Developmental Disabilities and Bill of Rights Act of 2000
treatments necessary to restore health and prevent other ill-
defined culturally competent services as services that are
ness or complications. The home health nurse builds on the
(a) provided in a manner responsive to the beliefs, interper-
teaching plan, with the main emphasis on adapting care in the
sonal styles, attitudes, language, and behaviors of individuals;
home environment. Continuity of care depends on compre-
and (b) provided in a manner that demonstrates respect for
hensive communication between the discharging and home
individual dignity, personal preference, and cultural differences.
care agencies.
It is essential to remember that all client teaching plans and
strategies must consider cultural aspects in the planning phase.
Adapting Care to the Home Setting Cultural differences affect client’s open-mindedness to client
The client is often a passive recipient of care in the hospital. In education and their willingness to listen to the teaching and
the home setting, on the other hand, the client is in control— then be compliant with the changes that need to occur.
it is his or her environment. That is, the environment is deter- Cultural differences affect client’s attitudes about illness,
mined by the client and family according to their needs, desires, healthcare workers, and treatment modalities. The Joint
values, and resources. The nurse is a guest in this environment, Commission has mandated that there must be greater aware-
which requires flexibility in adapting to a variety of situations. ness of diversity, attention to the needs of special populations,
In the hospital, equipment is readily available. Nurses perform and staff training to meet their needs.
procedures or treatments and provide 24-hour-a-day coverage of When taking cultural competence into account, nurses should
nursing care. In the home, equipment must be ordered or impro- consider the following to make client teaching more effective:
vised, and the emphasis is on teaching the client or caregiver self- • Be aware of own cultural biases and prejudices.
care activities. The home care nurse must become very creative • Become familiar with the core cultural values of client groups.
in adapting and improvising equipment and techniques.
• Whenever possible, use a translator to convey information.
When a client referral is received by a home health
agency, a nurse or physical therapist makes an initial admis- All cultures have health beliefs about illness: what causes it
sion visit. This visit includes a thorough assessment of the and what cures it, as well as who they will allow to treat them.
client, family, and home environment. The home environ- It is important for nurses to understand each culture’s differ-
ment is evaluated for safety, and the client and family are as- ences, as it will impact the client teaching process. Table 2
sessed for knowledge of safety and emergency procedures. summarizes cultural beliefs that may have an effect on health
Assessment of the client includes physical, emotional, psy- care and client teaching.
chologic, and economic status. The home is assessed for any Included in the discharge plan is a discharge summary. This
adaptations that must be made to enable the client to func- summary includes an overall review of hospitalization activities
tion optimally in his or her environment. Family members and the client’s learning needs. There is a statement indicating
are assessed for understanding of the client’s illness or needs; how well the learning needs have been met, the client teaching
cultural, ethnic, and health beliefs and values; ability to cope completed, short- and long-term goals of care, referrals made,
with the current situation; the physical, emotional, and spiri- and coordinated care plan to be implemented after discharge.
tual needs of family members; financial resources; and knowl- Since 1988, hospitals have been mandated by federal
edge of how to use community resources. A complete list of requirements to provide a discharge planning process for all
assessment parameters for each of these areas is included on Medicare clients. These same requirements now apply to all
the initial assessment form. clients within hospitals in the United States.
TABLE 2 Cultural Beliefs Affecting Client Teaching

Ethnic Group Cultural Beliefs
Asian/Pacific Islander Extended family has large influence on client.
Older family members are honored and respected, and their authority is unquestioned.
Oldest male is decision maker and spokesman.
Strong emphasis on avoiding conflict and direct confrontation.
Respect authority and do not disagree with healthcare recommendations—but they may not
follow recommendations.
Chinese Chinese clients will not discuss symptoms of mental illness or depression because they believe
this behavior reflects on family; therefore, it may produce shame and guilt.
Use herbalists, spiritual healers, and physicians for care.
Japanese Believe physical contact with blood, skin diseases, and corpses will cause illness.
Believe improper care of the body, including poor diet and lack of sleep, causes illness.
(Continued)
127
TABLE 2 Cultural Beliefs Affecting Client Teaching (Continued)

Ethnic Group Cultural Beliefs
Believe in healers, herbalists, and physicians for healing, and energy can be restored with
acupuncture and acupressure.
Use group decision making for health concerns.
Hindu and Muslim Indians and Pakistanis do not acknowledge a diagnosis of severe emotional illness or mental
retardation because it reduces the chance of other family members getting married.
Vietnamese Vietnamese accept mental health counseling and interventions, particularly when they have
established trust with the healthcare worker.
Hispanic Older family members are consulted on issues involving health and illness.
Patriarchal family—men make decisions for family.
Illness is viewed as God’s will or divine punishment resulting from sinful behavior.
Prefer to use home remedies and consult folk healers known as curanderos rather than
traditional Western healthcare providers.
African American Family and church oriented.
Extensive extended family bonds.
Key family member is consulted for important health-related decisions.
Illness is a punishment from God for wrongdoing, or is due to voodoo, spirits, or demons.
Health prevention is through good diet, herbs, rest, cleanliness, and laxatives to clean the system.
Wear copper and silver bracelets to prevent illness.
Native American Oriented to the present.
Value cooperation.
Value family and spiritual beliefs.
Strong ties to family and tribe.
Believe state of health exists when client lives in total harmony with nature.
Illness is viewed as an imbalance between the ill person and natural or supernatural forces.
Use medicine man or woman known as a shaman.
Illness is prevented through elaborate religious rituals.
NURSING DIAGNOSES
The following nursing diagnoses are appropriate to include in a client care plan when the components are related to establishing and
maintaining a client teaching and discharge planning.
NURSING DIAGNOSIS RELATED FACTORS
Impaired Communication Verbal Cognitive impairment, auditory impairment, language barrier

Denial Attempt to disavow need to alter lifestyle by avoiding client teaching
Ineffective Health Maintenance Cultural and religious beliefs, information misinterpretation, lack of education,
lack of motivation, inadequate healthcare services
Deficient Knowledge Inadequate understanding of condition, misinformation, language differences
Noncompliance Impaired ability to perform tasks, poor self-esteem, lack of motivation
Relocation Stress Syndrome Changes associated with transfer between facilities or facility and home, effects
of losses associated with moving, stress in family members
Ineffective Role Performance Change in self-perception of role; change in others’ perception of role as a result
of an altered health status, which leads to denial of learning need
CLEANSE HANDS The single most important nursing action to decrease the incidence of hospital-based infections is hand hygiene.
Remember to wash your hands or use antibacterial gel before and after each and every client contact.
IDENTIFY CLIENT Before every procedure, check two forms of client identification, not including room number. These actions prevent errors
and conform to The Joint Commission standards.
128
UNIT • 1
Client Education
Nursing Process Data

ASSESSMENT Data Base IMPLEMENTATION Procedures
• Assess high-risk criteria for client education. • Collecting Data and Establishing Rapport . . . . . . . . . . . . . . .
• Determine the need for client teaching program. • Determining Readiness to Learn . . . . . . . . . . . . . . . . . . . . . . . .
• Identify client learning style and preferences. • Assessing Learning Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Assess knowledge and skill level of client. • Determining Appropriate Teaching Strategy . . . . . . . . . . . .
• Assess motivation to learn. • Selecting the Educational Setting . . . . . . . . . . . . . . . . . . . . . . .
• Assess readiness to learn. • Implementing the Teaching Strategy . . . . . . . . . . . . . . . . . . . .
• Identify physical or emotional barriers that may affect • Evaluating Teaching/Learning Outcomes . . . . . . . . . . . . . . . .
client’s ability to participate in teaching plan.
• Identify health beliefs and practices. EVALUATION Expected Outcomes
• Assess developmental and educational level of client.
• Client’s knowledge regarding his or her health status has
• Determine appropriate methodology for client teaching
increased.
sessions.
• Client’s ability to make informed and effective health-
• Identify appropriate adjunctive materials, such as
related decisions, based on accurate information and
audiovisual aids, to enhance learning process.
awareness of self, has improved.
• Assess appropriate setting for the individual client.
• Effective use of the healthcare delivery system has been
• Determine family members or significant others who will be promoted.
involved in client education.
• Continuity of care and information exchange has occurred
between health agencies or between the hospital and
PLANNING Objectives client’s home and family.
• To develop a plan using the nursing process framework and • The nurse has evaluated his or her teaching effectiveness
adult learning principles and revised the plan, teaching style, and content as
necessary.
• To determine learning needs and establish learning objectives
• Increased compliance to medical regimen as demonstrated
• To select appropriate teaching strategies
by client’s ability to manage condition/disease process.
• To increase client’s knowledge to promote compliance
with health regimen
Critical Thinking Application . . . . . . . . . . . . . . . . . . . . .
• To encourage client participation in goal selection and
implementation program • Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To encourage client to acknowledge individual • Unexpected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
responsibility for health behaviors and health status • Alternative Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To improve client’s ability to make informed decisions
affecting health status
Pearson Nursing Student Resources
• To facilitate behavioral changes that are conducive to
optimum health status Find additional review materials at
• To provide continuity of care when the client is moving nursing.pearsonhighered.com
from one healthcare setting to another Prepare for success with NCLEX®-style practice questions
and Skill Checklists
129
Collecting Data and Establishing Rapport

Equipment d. Use assessment (observation) skills. Rationale: To
Client teaching plan establish a baseline for client teaching.
Room or suitable setting to complete assessment e. Request demonstration of a skill previously learned
or currently used (e.g., giving self an insulin injec-
Adjunct materials, such as audiovisual equipment, charts,
tion). Rationale: Client’s ability to demonstrate
and illustrations
skill assists you to evaluate ability to perform, as well
Written materials, such as outlines or other as mastery of previous teaching principles.
handouts
2. Develop an evaluation plan that determines extent of
Equipment for demonstration and return demonstration client learning goals.
Documentation forms: Kardex, client’s chart,
electronic forms Procedure
1. Identify personal characteristics.
Preparation
a. Age, sex, developmental level.
1. Develop a client teaching plan utilizing the following b. Educational level.
information: assessment findings, expected learning c. Marital status.
outcomes, teaching strategies, teaching materials, d. Family composition and living situation.
education methods. e. Ethnic group and cultural practices pertinent to
a. Use adult (and/or age-appropriate) learning principles. language skill and preference.
b. Use communication and interpersonal relationship 2. Identify resources available; both personal and
skills. Rationale: To encourage client’s participa- community.
tion in the plan.
3. Identify values and attitudes toward self and others hav-
c. Use a nonjudgmental approach. Rationale: A non-
ing his or her particular disease or condition.
judgmental attitude assists client to be honest with
feelings. 4. Assess baseline knowledge—anatomy and physiology
(normal and disease-related) and the disease process—
1. Use “how” questions to facilitate communication. by asking specific questions.
Rationale: “How” is more effective than “why”
5. Assess current knowledge and ability to perform specific
in a question, as “why” tends to set up a defensive skills.
reaction to the question.
6. Assess patterns of coping.
2. Use verbal and nonverbal behavior and congru-
a. Past experiences of self and others in relation to the
ency of behavior to build relationship with the
disease.
client.
b. Perception by client of how ill he or she is at
this time.
c. Reactions to stress and ways of managing anxiety.
d. Current level of self-management.
e. Willingness of client to change behavior.
When collecting data to determine learning needs and Obtain data from Client Profile to prepare teaching plan.
strategies, use age-appropriate materials.
130
Determining Readiness to Learn

Procedure a. Determine willingness to participate in actual hospi-
1. Determine client’s physiologic readiness. tal instruction.
a. Degree of physical comfort of client (level of b. Determine cognitive ability to understand
pain), level of alertness, ability to concentrate, instruction.
degree of interest. c. Evaluate the extent of time and active participation
b. Acuteness of the illness and its influence on client’s of the family during instruction.
ability to learn. d. Assess the interaction of the client and family during
c. Environmental factors that may affect client’s degree client teaching. Rationale: This will provide data
of readiness. on potential compliance and noncompliance issues
d. Safety issues and need for supervision. related to the teaching plan.
2. Evaluate client’s psychologic readiness. 5. Assess the extent of support and actual care the family
members will provide for the client at home.
a. State of client’s feelings and their influence on recep-
Rationale: This will determine the extent of the instruc-
tivity to learning. Rationale: An angry and hostile
tion necessary for the family.
client is not going to absorb information until his or
her anger is acknowledged or worked through.
b. Psychologic barriers (for example, the presence of
denial) and their influence on the learning process. Clinical Alert
c. Client’s intellectual capacity and level of comprehension. The Joint Commission’s Standards for Patient and
3. Assess client’s willingness to make changes and be com- Family Education require that client’s learning needs,
preferred learning styles, literacy level, educational
pliant with the teaching plan.
level, language spoken and understood, and learning
4. Assess family’s ability and willingness to participate in readiness are assessed.
teaching.
Assessing Learning Needs

Procedure 2. Interview client to determine what his/her daily life is
1. Assess if client has learning needs related to diagnosis, like. Rationale: The information will assist you in
hospitalization, surgical procedures, or treatments. determining impact of changes in client’s lifestyle
a. Ask specific questions relative to what physician has brought on by illness or condition. This will help you
told client related to specific learning need(s). determine how to approach the teaching plan.
b. Ask client what he/she is most interested in learning a. Ask client to describe his/her usual daily routine.
about specific learning need(s). b. Determine whether anything has changed with this
c. Ask client to tell you in his/her own words what they pattern since illness began.
know about specific learning need(s). c. Describe hobbies or sports activities in which client
participates.
d. Describe normal workday and what activities are
involved with employment, if still working.
e. Discuss usual family responsibilities. Will the family
be involved with his/her care?
3. Determine client’s age and developmental level.
Rationale: Knowing client’s developmental level is nec-
essary to provide the most effective teaching strategies.

4. Determine client’s learning style. Rationale: This will
assist in matching the most appropriate teaching strat-
egy for client education.
a. Ask questions related to what time of day he/she
learns best.
b. Determine whether he/she learns best by reading,
listening, hands-on learning, or a combination of
Include family in teaching, particularly if they will play a role in styles.
caring for client. c. Use a commercial learning style inventory, if available.
131
5. Complete a cultural assessment. Rationale: To develop a 8. Use assessment data and assessment instrument to
culturally responsive teaching plan based on client’s beliefs. jointly determine client’s learning needs: educational,
a. Determine client’s belief about illness. physical, psychosocial, and financial needs.
b. Determine how strong the client’s belief system is rel- 9. Formulate needs as goals.
ative to his/her traditional culture. 10. Prioritize learning needs or goals.
c. Determine whether he/she uses folk medicine prac- 11. Review with client alternative resources available to ac-
tices and uses a traditional healer. Clients from Asia, complish goals.
Africa, and South America are more likely to main-
12. Determine ability of facility, family, staff, or multidisci-
tain this cultural component of their former country.
plinary team to meet goals or learning needs.
d. Identify whether traditional dietary habits are prac-
ticed in the home. If so, these should be included in 13. Identify potential barriers to learning.
the teaching plan, particularly nutritional counseling. a. Physical: visual or auditory, pain level, literacy level,
6. Determine client’s educational and literacy levels. reading level.
Rationale: Clients may seem disinterested in learning b. Emotional barriers: stress or anxiety, inability to
when in fact they do not understand what is being said focus on information.
and are embarrassed to ask. This can lead to missed c. Language or culture: ability to understand and speak
physician appointments, noncompliance with treatment English, beliefs about health, folk practices, or com-
or medication usage, and even disability. munication style differences.
a. Determine client’s reading level by measuring his/her 14. Obtain verbal or written contract with client for educa-
reading and comprehension skills. tional program.
b. Use a test of reading and comprehension to obtain a 15. Refer client to other resources or agencies when
client profile before beginning teaching process. appropriate.
Rationale: To determine most appropriate written
material for client.

7. Assess client’s ability to speak and read English. Clinical Alert
a. Determine whether client requires an interpreter dur- Agencies contract with telephone language lines to
ing assessment of learning needs and teaching process. provide interpreter services. These services are
b. Ensure that words you use in client’s language are available through AT&T Language Line Services and
correct for the situation. Pacific Interpreters Inc. on a 24-hour basis and in
c. Do not use slang that could be misunderstood. over 140 languages.
d. Use simple words and phrases to allow interpreter to
relate the intent of your statement.
Determining Reading Grade Level
Family Assessment is an integral part of planning an
effective teaching plan if family members will be af- Readability Formulas
fected by, or part of, the care of the client. Include The Fry Formula assesses three samples of 100 words
the following information in the assessment: from different parts of a written handout and is useful
• Which family members will be involved with care to determine client’s reading grade level. The
of client? Simplified Measure of Gobbledygook (SMOG) for-
mula is very similar. The Fry Formula plots the aver-
• Has client approved that family members be
age number of syllables and average number of sen-
given confidential medical information?
tences on a graph that then shows grade level. The
• Can family members provide necessary care or SMOG formula also measures the number of sylla-
will additional support be necessary? bles in a particular sample of written material, which
• Does home environment support client’s care is then converted by a chart that determines reading
needs? grade level.
• Are any changes to home necessary to provide a The Rapid Estimation of Adult Literacy in Medicine
safe environment? (REALM) reading test can be easily administered in a
• Do family members speak English and have basic few minutes. This test provides the reading grade
literacy skills? level for clients who read below ninth-grade level.
• Are there any cultural belief conflicts that could Words the client reads are all common health terms.
inhibit adequate care in home? The client reads as many words as he/she can cor-
• Do family members interact in a supportive rectly pronounce. A chart is used to convert raw
manner with the client? scores obtained from word reading into a reading
grade estimate.
• What do family members know about the client’s
condition? Do they need additional teaching?
Source: REALM, Department of Internal Medicine, Louisiana State University,
Baton Rouge, LA.
132
Determining Appropriate Teaching Strategy

Procedure e. Make sentences 10 words or less and written in ac-
1. Consider the following factors when determining appro- tive voice.
priate strategy: f. Make paragraphs short with one focus.
a. Input from client about how he or she learns best. g. Use large type (fonts) and lowercase letters.
Rationale: Large font size is easier for clients with
b. Specific task or nature of the content to be transmit-
ted and how it is best learned. visual impairments or elderly clients, and lowercase
c. Client attention span and retention ability. letters are easier to read.
d. Reading level of client. h. Use diagrams and photos whenever possible to make
e. Teaching materials and resources available. Electronic a point.
material is available for client education; it is used i. Set realistic goals and only one or two objectives for
particularly for medications, diagnostic tests, and each teaching session. Rationale: Overloading
diagnoses. client with information will not allow him/her to
f. Time, availability, skills, and abilities of staff; master information necessary for compliance.
appropriate use of paraprofessional and professional j. Ensure client completes a return demonstration, if
staff. appropriate. Rationale: This assists you to deter-
g. Participation by members of other healthcare disci- mine the extent to which client understands infor-
plines as part of a team. mation presented. The greater the understanding and
h. Determination of most appropriate time for ability to perform a particular skill, the greater the
teaching. compliance to treatment.
2. Use appropriate reading material for individual 3. Determine which type of teaching strategy will be effec-
client. tive in a given situation.
a. Determine reading level of written material. a. Group process: use of principles from group dynam-
b. Use a readability formula to determine most appro- ics, mental health, or other related fields to en-
priate written information for client. hance learning or behavior changes in a small
c. Use brochures, handouts, and written material writ- group setting.
ten at a sixth-grade level if client has low literacy b. Lecture–discussion: presentation of content in a
skills. didactic fashion with opportunity for questions
Rationale: Seventy-five percent of the adults in the
and interaction during or at the conclusion of the
United States should be able to read the material. presentation.
d. Use short, common words in written material. c. Demonstration–return demonstration: demonstration
Rationale: Medical terminology may be
(videotape) by the instructor with practice by the
misunderstood. learner and return demonstration of mastery of the
skill.
d. Role playing: assumption of roles by various partici-
pants or learners for the purpose of clarifying various
aspects of a situation.
e. Games: structured (age-appropriate) game situation
with rules designed for the learner to accomplish
specific educational objectives.
Components of a Teaching Plan

• Client learning needs
• Expected learning outcomes
• Teaching content organized from simple to
complex
• Teaching methods and tools
• Barriers to learning and readiness to learn
• Evaluation tools
Determine which teaching strategy will be most effective for client.
133
EVIDENCE-BASED PRACTICE
Silent Clients
A qualitative study in Finland (N = 38 patients, N = 19 nurses)
found that 18 clients who were identified as aloof or silent spoke
little about themselves and followed the lead of the nurse. The
nurse often used communication techniques that did not facilitate
communication and were nontherapeutic. The study concluded
that client’s quietness or silence in client education settings “was
complex, supported by the hospital’s institutional standard,
nurses’ lack of expertise, and client’s restrictive and face-saving
speech.” This underscores the necessity that client education be
client focused, based on client’s knowledge, experience, and pref-
erences, rather than comply to a preset standardized, structured
format.
Source: Kettunen, T., Poskiparta, M., Liimatainen, L., Sjögren, A., & Karhila, P.
(2001, May). Taciturn patients in health counseling at a hospital: passive recipi- Client education using computerized program assists nurse in
ents or active participators? Qualitative Health Research, 11(3), 399–422. From providing information that is relevant to client’s needs.
Mynatt, S. (2002, January). Patient taciturnity in health counselling was under-
stood in terms of 4 participation frames. Evidence-Based Nursing, 5(1), 30.
a. Videotape or videocassette programs.
4. Select appropriate teaching adjuncts based on develop- b. Films; slide and tape presentations.
mental level, learning style, and reading literacy. c. Diagrams, charts, and illustrations.
d. Programmed instruction materials, i.e., computer/
Internet.
e. Books.
f. Pamphlets and other written handouts.
5. Provide language-specific material for non–English-
speaking clients.
a. Photos.
b. Models of specific body parts.
c. Audio tapes in specific language.
After selecting the

appropriate setting, choose
the teaching adjuncts.
Selecting the Educational Setting

Procedure
1. Choose an appropriate setting based on selected teach-
ing strategy and available facility space.
2. Evaluate types of setting most appropriate to individual
client and family learning needs.
3. Consider an informal setting.
a. Spontaneous teaching interactions between nurse
and client can occur at any time in any setting.
b. Usually no formal plan or evaluation tool is used.
4. Consider a formal setting.
a. Teaching is carried out in a specified area of the facil-
ity such as an in-service classroom.
b. Teaching can occur independently, such as with
Preoperative teaching using computerized module.
audiovisual programmed instruction modules, or in a
group setting.
c. Formal plan for the teaching program includes writ-
ten goals, objectives, teaching strategies, content,
and evaluation method.
134
Implementing the Teaching Strategy

Procedure how client is understanding content and allows for
1. Gather teaching materials appropriate for client’s learn- modification as indicated.
ing needs and teaching strategy. 9. Plan for short teaching sessions on a frequent basis.
2. Sit with client in designated setting, and establish a 10. Adhere to agreed-upon starting and ending times; nego-
warm and accepting relationship. Rationale: This is tiate any changes. Rationale: This encourages client
conducive to teaching and assists client in learning. to trust you.
3. Specify previously established mutual goals and behav- 11. Provide closure to teaching situation by summarizing
ioral objectives of the program. Rationale: Mutually and reiterating agreements made, actions to be taken, or
agreed-on goals promote acceptance of teaching strategy subsequent events to follow.
by the client. 12. Provide positive reinforcement if not done previously.
4. Clarify or reclarify contract, agreements, or expected Rationale: This approach increases self-esteem and
outcomes with individual or group. Rationale: encourages learning in client.

Beginning at the level of understanding of person or 13. Terminate teaching session by establishing time for next
group facilitates the process. client contact.
5. Assess teaching situation for any modifications needed 14. Do post-assessment of your own participation, and plan
and adjust plans accordingly. for corrections and improvements in presentation.
6. Teach content or components of the plan to client. Rationale: Ongoing evaluation assists in final step of
Rationale: Sticking to the plan and not deviating or nursing process evaluation.
going off on a tangent reinforces your commitment to 15. Reinforce teaching throughout hospitalization.
help client master the content. a. Use return demonstration of skills frequently
7. Use appropriate communication skills throughout ses- throughout hospital stay.
sion. Rationale: Therapeutic communication tech- b. Review teaching content through use of videotapes
niques enhance learning environment. and reading material.
8. Request feedback (evaluation interchange) during c. Provide positive reinforcement for changes in
teaching process. Rationale: Feedback lets you know behavior.
d. Discuss teaching content and written information by
asking pertinent questions and providing answers to
client’s questions.
16. Send teaching plan and written materials home with
client and family. Computer-generated written mate-
rial (medications, tests, diagnosis, etc.) should be
discussed verbally, in addition to providing written
material.
17. Place copy of written instructions in chart for documen-
tation. Instructions must be signed by client. This stays
in chart.
18. Provide copy of teaching plan and written material to
home health agency if referral has been made for visit-
ing nurse. Rationale: This promotes consistency in
information dissemination and reinforces teaching
provided to client while hospitalized.
19. Document your teaching on specific client teaching
forms, or electronic forms.
Documentation should include:
a. Educational assessment/comprehension level.
b. Knowledge and skill level of learning need(s).
c. Motivational level (interaction during teaching
session).
d. Learning barriers (language, speech, vision, hearing).
Demonstration is an important component of teaching strategy. e. Overall goal achievement.
135
EVIDENCE-BASED PRACTICE
Computer-Generated Client Education
Computer-generated client education has been studied sev- Baker et al. surveyed 4,764 individuals, and the results indi-
eral times. Leaffer and Gonda found that clients taught how cated that 40% stated they had used the Internet for information
to use the Internet to retrieve health information were still or advice about health or health care during the last year. Sixty-
using it 90 days later, and 66% of them were taking the infor- seven percent stated that using the Internet improved their
mation they found on the Internet to their healthcare understanding of symptoms, conditions, or treatments.
providers when they had a scheduled visit. More than 50% of Source: Baker, L., Wagner, T. H., Singer, S., & Bundorf, M. K. (2003). Use of the
the clients stated that using the Internet made them feel Internet and e-mail for health care information: results from a national survey.
more knowledgeable, and thus they were more satisfied with JAMA, 289(18), 2400–2406.
the treatment they received.
Source: Leaffer, T., & Gonda, B. (2000). The Internet: An underutilized tool in
patient education. Computer Nursing, 18, 47–52. http:///www.medscape.com/
viewarticle/478283_print
Evaluating Teaching/Learning Outcomes

Procedure COMMUNITY Client Information
1. After demonstrating skill(s), ask client to complete a re- HOSPITAL
turn demonstration. Evaluate client’s ability to perform
MULTIDISCIPLINARY TEACHING RECORD
tasks. INITIAL ASSESSMENT: Interested in health instruction? Yes No Can patient read? Yes No
Language used: English Other Glasses: Y / N Blind: Y / N Hearing Aid: Y / N Deaf: Y/N
2. Ask client and/or family to explain demonstration using Other Signature Date
BARRIERS TO NEEDS
own words. N=
LEARNING CODES
None 1=
CODES
Knows well A=
TEACHING METHOD CODES
Audiovisual
EVALUATION CODES
Patient/Significant Other
C= Cognitive Limitations 2= Needs review D= Demonstration 1= Able to repeat information in own words and/or perform
3. Ask client and/or family specific questions regarding E=

F=
L=
Emotional
Financial
Language
3=
* =
New material
See Comments
P=
MIS =
MM =
Printed Materials
Medication Information Sheet
Material Mailed
2=
3=
return demonstration. (Education Completed)
Needs further instructions (Requires entry in Comments)
Unable to retain information or perform return
information provided. Rationale: To determine neces- M=

P=
R=
Motivation/desire
Physical Limitations
Religious/Cultural
T=
V=
* =
Telephone Call
Verbal Instructions
See Comments
4=
* =
demonstration (Requires entry in Comments)
Not ready to learn (Requires entry in Comments)
See Comments
sity of reinforcing or reteaching information.

* = See Comments
TOPIC ASSESSMENT PATIENT EDUCATION / EVALUATION
Person Teaching
4. Develop a simple pre- and posttest to determine client’s DISEASE PROCESS
(Specify)
Barrier
Code
Needs
Code
Taught
Pt/Other
Method
Codes
INSTRUCTION
Evalution
Code
DATE/
INITIALS
knowledge base. Cause/effect of Disease Process

Methods of Control
Common Signs/Symptoms to Report
Risk Factors to Modify:
5. Develop hypothetical situations for client to problem Smoking Cessation
solve. Rationale: This will help determine client’s ABILITY TO COPE

WITH ILLNESS
Coping Methods and Relaxation Techniques
Spiritual and Emotional Support Provided
Referral If Indicated
understanding of disease or condition. DISCHARGE

PLANNING/CONTINUING
CARE NEEDS
Community Resources
Home Health / SNF Referral
See UM/Social Service Section
6. Use an evaluation tool, if appropriate. Rationale: MEDICATIONS

Indications, Dosage, Route, Precautions
Drug/Food Interactions
Adverse Drug Effects
Evaluating with a specific tool focuses the evaluation Insulin Injection Technique
Wound Care
MDI Inhaler
Dressing Change
phase better. WOUND CARE Signs/Symptoms of Infection

Importance of Hand Washing
Activity Level Restrictions/Limitations

ACTIVITY LEVEL
Prescribed diet
NUTRITION/DIET
Hospital Phone # Given for Dietician Referral
OTHER EDUCATION
Comments (Include Date/Time and Initials):
INITIALS SIGNATURE/TITLE DEPT. INITIALS SIGNATURE/TITLE DEPT.
Multidisciplinary teaching record.
a. Evaluate forms, format, and types of tools available

for evaluation.
1. Pretest–posttest: measures changes in areas such as
knowledge level, attitudes, and values.
2. Questionnaire: completed by client to report atti-
tudes, certain behaviors, and, most frequently,
level of satisfaction with the teaching program.
3. Physiologic tracers: determined before teaching
Request a return demonstration to evaluate client understanding. episode to be the criterion of measurement of success
136
(e.g., changes in blood pressure values after teaching b. Choose an evaluative tool based on goals and objec-
program for hypertensive clients). tives of the teaching program. Rationale: The pur-
4. Direct observation of behavior changes: report of pose is to achieve goals, thus evaluative tool should
level of performance during return demonstrations. be based on goals.
DOCUMENTATION for Client Education

• Client’s learning needs • Client’s reading level
• Client’s learning objectives and goals set by client and staff • Client’s learning style preference
• Topics or subjects covered as a part of client education • Progress in meeting the expected outcomes of teaching
process, such as medications, procedures, dietary plan, • Client’s emotional response to the learning process
activity restrictions, or follow-up care • Information or equipment sent home with client
• Teaching strategies used • Client’s developmental level
• Degree of client’s participation in the teaching activity
CRITICAL THINKING Application

Expected Outcomes • Continuity of care and information exchange has occurred
• Client’s knowledge regarding his or her health status has between health agencies or between the hospital and
increased. client’s home and family.
• Client’s ability to make informed and effective health- • The nurse has evaluated his or her teaching effectiveness
related decisions, based on accurate information and and revised the plan, teaching style, and content as
awareness of self, has improved. necessary.
• Effective use of the healthcare delivery system has been • Increased compliance to medical regimen as demonstrated
promoted. by client’s ability to manage condition/disease process.
Unexpected Outcomes Alternative Actions

Client’s health status or treatment compliance has not improved • Reevaluate nursing care plan according to the nursing process.
as a result of the teaching program. • Reassess client for barriers to learning.
• Assess client’s reading and developmental levels.
• Reevaluate testing tool.
• Review client’s learning style preference.
• Determine readability level of written material.
• Problem solve with client as to next step to take.
• Request assistance from in-service consultant for determining
which aspects of the teaching program were not successful
and why.
• Assist in revising parts of the program and restructure for
individual client needs.
Client is hostile to teaching program. • Attempt to determine underlying reason for hostility.
• Terminate this session of teaching program, but tell client you
will return tomorrow or at a later time.
• Bring another nurse along to assist you in teaching as well as
to help you evaluate reason for hostility.
Client’s ability to make informed and effective health-related • Assist client to take realistic responsibility for ineffective
decisions, based on accurate information and awareness of self, decisions without guilt and shame attached.
has not improved. • Assist client to identify those areas in which he or she is willing
to make changes and support development of a plan of action.
• Refer to other resources such as groups with like conditions
(e.g., cancer, diabetes).
(Continued)
137

Client is unable to understand client teaching due to language • Identify a volunteer or family member who can be used as an
barrier. interpreter.
• Use the AT&T Language Line.
• Obtain teaching material in client’s native language.
• Use photos or models, or make drawings that depict task
to be performed.
138
UNIT • 2
Discharge Planning
Nursing Process Data

ASSESSMENT Data Base IMPLEMENTATION Procedures
• Determine client discharge planning needs. • Preparing a Client for Discharge . . . . . . . . . . . . . . . . . . . . . .
• Determine if client is in a high-risk category. • Completing a Discharge Summary . . . . . . . . . . . . . . . . . . . .
• Assess special needs of client for individualized planning.
• Assess need for multidisciplinary healthcare workers. EVALUATION Expected Outcomes
• Determine information needed for compiling discharge
• Client’s discharge plan is initiated upon admission.
summary.
• Client’s discharge teaching is completed before
discharge.
PLANNING Objectives • Client’s plan for discharge is based on identified
• To complete a discharge risk factor assessment when long-term goals.
admitting a client
Critical Thinking Application . . . . . . . . . . . . . . . . . . . .
• To determine healthcare workers needed for discharge
planning • Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To make appropriate referrals for client discharge • Unexpected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To complete discharge teaching • Alternative Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To develop a discharge plan
• To complete a discharge summary Pearson Nursing Student Resources
Find additional review materials at
nursing.pearsonhighered.com
Prepare for success with NCLEX®-style practice questions
and Skill Checklists
139
Preparing a Client for Discharge

Procedure
1. Obtain admission history, physical, and hospital
progress notes.
2. Determine risk factors for discharge planning at time
of admission.
3. Refer high-risk clients to discharge coordinator or
social service department, if appropriate.
4. Develop discharge plan (if not already completed)
including short- and long-term goals in conjunction
with physician and client. Plan components should
include:
a. Diet.
b. Medications.
c. Treatmnts.
d. Physical activity limitations. Discharge teaching is an important component of the discharge plan.
e. Signs and symptoms to report.
f. Follow-up medical care.
g. Equipment.
h. Appropriate community resources.
5. Evaluate degree to which client education plan was
implemented; reinforce aspects that were incom-
plete or refer to home agency.
6. Identify need for follow-up care after discharge in
conjunction with physician.
7. Make appropriate agency referrals.
8. Complete a discharge referral form, and communi-
cate directly with referral agency about client.
NOTE: Healthcare agency may prefer their own discharge
form to be completed rather than documentation in the
nurses’ notes.
9. Develop written discharge instructions for client
and family, including medication administration
times, dose, and side effects; treatments to be carried
out at home for in a facility, potential side effects or
complications from treatments or surgery; when to
notify physician regarding symptoms; etc.
10. Update client care plan, and send copy to referral
agency.
11. Send client teaching plan and materials to referral
agency. Rationale: To maintain consistency in
client teaching.
12. Document discharge summary.
Sample discharge plan form.
140
Completing a Discharge Summary

Procedure
1. Document a complete physical and psychosocial
assessment at time of discharge.
2. Review vital sign ranges, and state latest vital signs.
3. Identify activity level of client.
4. Describe use of adaptive devices or equipment needs.
5. Review client teaching plan. Provide explanation of
areas where teaching was adequate and where addi-
tional reinforcement is required.
6. Identify prescribed medications, dosage, and administra-
tion times. Provide information on client’s knowledge of
medication.
7. Describe goal achievement based on client care plan. Computer programs provide discharge teaching that is accu-
Describe action taken if goal not achieved. rate and inclusive.
8. Identify referral agencies contacted. 12. Describe method of discharge (e.g., wheelchair) and
9. Provide information regarding instructions on physician person accompanying client at discharge.
office visits, appointments to healthcare agencies, or 13. State means of discharge transportation (e.g., private
support services. car, ambulance).
10. Describe client’s condition at time of discharge. 14. Specify discharge facility where client is going.
11. Document discharge instructions provided to client NOTE: Many facilities have developed forms that combine dis-
and family. charge summaries and client instructions.
DOCUMENTATION for Discharge Planning

• Discharge teaching completed, and additional teaching • Referral agencies contacted
need(s) necessary after discharge • Discharge summary form completed; discharge instructions
• Discharge plan completed, including risk factors, short- and including medications, treatments, etc.
long-term goals, and degree to which plan was implemented • Client’s condition at time of discharge
• Summary of client care during hospitalization, client inter- • Date, time, location, and mode of discharge
ventions provided
• Need for follow-up after discharge
Legal Considerations
Lawsuit Regarding Follow-Up Discharge Teaching: Roberts v. Sisters of St. Francis Health Services (1990)
A 3-year-old presented to the emergency room with an for symptoms of meningitis. The court found in favor of the
upper respiratory infection. The child was discharged nurse stating she was not negligent and that she provided
home in the care of her mother. The nurse gave both written instructions for fever treatment and other instruc-
verbal and written instructions, including a pretyped in- tions. The court held that the mother was negligent for not
struction, for treating a fever. The child’s condition wors- seeking help when the child needed additional care.
ened a few days later and the mother brought the child Based on this court ruling, remember to give both
to another hospital, where the child subsequently died written instructions and verbal explanations. Written
from meningitis. client teaching sheets should be used to reinforce,
The mother brought a lawsuit against the first hospi- not replace, discharge teaching. It is recommended
tal for failure to provide adequate instructions upon dis- that this type of information (teaching sheets) should
charge. The suit contended the nurse was negligent for be written at the sixth-grade reading level. Non–English-
not providing written follow-up instructions to see an- speaking clients should have instructions translated
other physician and not warning the mother to observe into the client’s primary language.
141
CRITICAL THINKING Application

Expected Outcomes • Client’s plan for discharge is based on identified long-term
• Client’s discharge plan is initiated upon admission. goals.
• Client’s discharge teaching is completed before discharge.

Client is discharged before discharge plan is completed. • Continue to complete discharge plan, and send to referral agency.
• Verbally communicate to referral agency and discuss discharge
needs of client.
Discharge plan does not contain adequate data. • Reassess parameters of a discharge plan, and revise accordingly.
• Elicit assistance from another nurse or supervisor to revise
discharge plan.
Goals of discharge plan were not accomplished. • Attempt to assess reason goals were not met.
• Reformulate or revise goals so that they are mutually agreed on
and more realistic.
• Request assistance from expert healthcare workers or in-
service consultant.
Discharge referral plan is not implemented and client • Attempt to contact other referral agencies to provide
receives no referral notice before discharge. continuity of care for client.
• Notify physician and discharge coordinator (if available) of
necessity of providing follow-through care after discharge.
GERONTOLOGIC Considerations
Teaching Strategies • Avoid totally dark room for audiovisual presentations.
Memory changes occur with the elderly population. • Increase time allowed for psychomotor skills, and allow
• There is better short-term memory with auditory rather time for repetition.
than visual presentation of information. • Slow the pace of presentation.
• Structure should be brief and simple. • Give small amounts of information at one time.
• Repetition is important. • Use analogies and examples to explain information.
• Older clients learn better by doing, using multiple senses, Mnemonic devices are helpful to compensate for imperfect
than by reading instructions. memory.
• Memory is better for things considered important. • Establish attainable short-term goals.
• Clients remember best what is told first. • Encourage participation in goal setting and planning.
• Declining mentation is not inevitable with aging, but some • Integrate new behaviors with previously learned ones.
memory loss is usual. • Focus on problem solving, not just delivery of facts.
Retention facts that underlie teaching strategies. People remember: • Apply teaching to present situation.
• 5% to 10% of what they read. • Bolster self-esteem and self-confidence in self-care.
• 10% to 20% of what they hear. • Stress the “why” of what is presented.
• 30% to 50% of what they hear and verbalize. • Recognize that the elderly client may prefer to be alone
• 70% of what they verbalize and write. when learning.
• 90% of what they say as they perform a task. • Make follow-up phone calls, if indicated, to check on the
Interventions for teaching the elderly client, reinforce teaching, or to clarify any misunderstanding.
• Speak distinctly and sit close to learner.
Discharge Planning
• Face the learner so that lip reading can supplement hearing.
A discharge plan for the elderly contains some of the same
• Use visual aids and verbal teaching.
components as a plan for a younger adult; at every step in the
• Decrease extraneous noise. plan, however, the coordinator must remember that this is an
• Use printed materials with large type and high contrast. elderly person and he or she must be evaluated for the ability
• Limit use of blue, green, and violet illustrations. Use red. and resources to manage at home. Include family and/or
142
caregiver in discharge planning. This is especially so if the • Special considerations the discharge planner must take
elderly person lives alone or with another elderly person. into account when coordinating a plan for an elderly indi-
Following are several issues that the discharge planner must vidual. For example:
consider when formulating the plan: 1. Does the person have a hearing or visual impairment
• Was the person functioning independently at home before that interferes with learning?
hospitalization, and is it realistic to expect him/her to do so 2. Does the teaching need to be done in written form (not
again? just verbal)?
• Does this person have capable family or friend resources to 3. Would a return demonstration of care procedures by the
assist with functioning in the home (in addition to the home health nurse be beneficial after the client has
necessary professional resources)? returned home?
• What is the baseline health status of the person (assuming 4. Will the anxiety level of the client to be discharged
he/she recovers from the current hospitalization), and does interfere with understanding and learning?
this status allow for independent functioning after hospi- 5. Is the health status of the client a way of gaining atten-
talization? tion? If so, this need should be separated from the needs
• What are the long-term financial resources of the elderly of self-care after discharge. It is important to convey this
person and do special measures need to be initiated for need to the follow-up caregiver.
coverage?
• If the elderly person cannot return to the facility he or she
was in before hospitalization, what special arrangements
need to be made?
MANAGEMENT Guidelines
Each state legislates a Nurse Practice Act for RNs and Communication Matrix
LVN/LPNs. Healthcare facilities are responsible for establish- • The teaching plan should be developed in concert with the
ing and implementing policies and procedures that conform client and family. Mutually acceptable goals should be es-
to their state’s regulations. Verify the regulations and role tablished with realistic time frames.
parameters for each healthcare worker in your facility. • The teaching plan is initiated early in the hospitalization.
Delegation It must be written because it is a permanent part of the
client record. It is updated as goals are achieved.
• RNs must develop the teaching and discharge plans based
• Team members are kept apprised of the progress toward
on the assessment of client needs. The Nurse Practice Act
meeting the teaching goals by updates during shift report.
sets the standards for who assesses and plans client care.
Multidisciplinary team input is critical and a major compo- • Client information is disseminated between referral agen-
nent of both plans. The nurse is usually the coordinator of cies and the hospital through a written discharge summary
most client care plans and teaching plans. and/or referral sheet. The data in the summary includes
pertinent information on the hospitalization and the con-
• Once the teaching and discharge plans have been devel-
dition at discharge, the medications and treatments the
oped, other members of the healthcare team may partici-
client is to continue to take, and specific equipment re-
pate in implementing them.
quired for client care.
• LVN/LPNs follow the guidelines established in the teach-
ing plans. They can assist with the discharge plans; how-
ever, an RN must write the discharge referral summary and
communicate with the referring agency.
CRITICAL THINKING Strategies

Scenario 1
Mr. John Johanson, age 58, was admitted to the medical unit and irregular, R 36. He has bibasilar rales and a 3+ pitting
with a diagnosis of heart failure. He is African American, 5'7⬙, edema of the lower extremities. His point of maximal impulse
and weighs 260 pounds. He is a cross-country truck driver. He (PMI) is at the sixth intercostal space (ICS), midaxillary line.
lives alone when not working. He usually watches TV and eats He states he is short of breath and has had difficulty ambulating
fast foods or frozen dinners. This is his second hospital admis- the last few days. He states he has tried to lose weight but even
sion in the last month. His vital signs are BP 230/108, P 108 after dieting he gains more weight back. When asked about his
143
smoking habits, he states he knows he is not supposed to smoke The child is assessed by the pediatrician and the child is ad-
and he has tried to stop, but with his work it is too difficult be- mitted for further testing. The pediatrician’s admitting diag-
cause he is alone so much. He states he is on blood pressure nosis is failure to thrive. The child’s weight is only 5 pounds
drugs, but unsure of the name. over what it was at birth (7lb 2 oz), and the child is still not
turning over from back to front. As the admitting nurse, you
1. Identify the current nursing diagnoses by priority and pro-
need to begin the discharge plan and the teaching plan. Based
vide rationale for answers.
on the limited information from the physician and the admit-
2. From these data, identify the teaching needs by priority ting diagnosis, complete the following scenario.
and develop a teaching plan for Mr. Johanson.
3. Are there any cultural considerations that need to be 1. What information will you need to obtain before you can
taken into account when considering his teaching plan? plan for discharge?
If so, identify actions you will take relative to the cultural 2. What information is necessary to obtain before you can
considerations. develop a teaching plan?
4. Briefly outline how you will determine when it is appro- 3. What approach will you take with the mother in order to
priate to initiate the teaching plan. obtain the necessary information for both the discharge
5. Describe the discharge plan you might develop for and teaching plan?
Mr. Johanson. 4. Describe the nurse’s role in client teaching for this
mother.
Scenario 2
A very young mother brings a 6-month-old child to the emer-
gency room and tells the triage nurse that she doesn’t know
what is wrong her child, but she doesn’t seem to be “normal.”
NCLEX® Review Questions

Unless otherwise specified, choose only one (1) answer. 3. Evaluate extent of time and active participation of
family during instruction.
1. The healthcare team member (HCT) who assumes the
leadership role in directing the educational plan for the 4. Evaluate interactions between client and family.
client and/or family is usually the 5. You have been assigned to develop a teaching plan for a
1. Physician. client being discharged after a laparoscopic procedure for
2. HCT member whose role represents the greatest gallbladder removal. Your priority intervention is to
teaching need requiring education. 1. Assess the home environment for specialized
3. Discharge planner. equipment needs.
4. Nurse. 2. Determine when the client plans to return to work.
3. Determine who will be at home with the client after
2. Clients at high risk for discharge, usually requiring spe-
discharge.
cific instructions, include those who are/have
4. Assess the client’s usual lifestyle and daily activities.
1. Living alone.
2. Multisystem issues. 6. You are developing the strategy for an initial teaching
3. Small children. plan for a 24-year-old client admitted with newly diag-
nosed acute leukemia. Which one of the factors would
4. A job requiring them to return to work immediately.
not be taken into consideration as you develop the initial
3. Data for which one of the personal characteristics below teaching plan?
is least necessary to obtain when planning for client 1. Attention span and retention ability.
teaching? 2. Reading level.
1. Educational level. 3. Input from client on how he/she learns best.
2. Family composition and living situations. 4. Support for client at home.
3. Ethnic group.
7. Nurses evaluate the effectiveness of the teaching
4. Employment/occupation.
strategies by
4. It is imperative the client’s family participate in teaching Select all that apply.
activities. What actions would not be used to determine 1. Asking the client to do a return demonstration of the
their ability and willingness to participate? skill being discussed.
1. Assess cognitive ability to understand instruction. 2. Having the client take a posttest of the teaching
2. Assess how attentive they are to the client and how content.
often they visit.
144
3. Asking pertinent questions relative to the teaching 2. Describe the activity level of the client during hospi-
content. talization.
4. Summarizing the teaching content they presented. 3. Summarize the teaching plan and client’s response to
5. Clarifying misinformation after each teaching session. teaching.
4. Summarize nursing interventions provided during
8. A client becomes very agitated and hostile when you ap-
hospitalization.
proach him to begin client teaching for discharge. Which
one of the actions would not be an appropriate action by 5. Provide intake and output findings during hospitaliza-
the nurse? tion.
1. Begin the teaching and explain you are required to 10. Gerontologic considerations for client education should
complete the teaching. include which one of the following concepts for older
2. Attempt to determine the reason for the agitation and clients? They
hostility. 1. Learn best through reading material.
3. Do not begin the teaching program but explain that 2. Remember 30% to 50% of what they read.
you will return later. 3. Need extraneous noises decreased while teaching is
4. Ask another nurse to assist you in assessing the reason being presented.
why the client is refusing the teaching. 4. Learn best in group settings.
9. Documentation for discharge includes which of the fol-
lowing statements?
Select all that apply.
1. Summarize vital signs during hospitalization and in-
clude latest vital signs.
NCLEX-RN® Answers with Rationale

1. (4) Nurses are the principal providers of care; therefore, they usually take 6. (4) The initial teaching plan will support the client in respect to the di-
the leadership role in directing the educational plan. One of the other agnosis, treatment, medications, and expected outcomes. Teaching is a
health team members may play a major role in the teaching; however, major part of this initial plan. Of course, determining the support system
the nurse usually directs and guides the process. (1) Physicians usually do at home will become more essential as the teaching continues and dis-
not play a major role in education while the client is hospitalized. charge planning is discussed. (1), (2), and (3) are essential components
(3) Discharge planners are pivotal in determining placement of clients for the teaching plan and will be integrated within the plan.
on discharge and in obtaining equipment for the home. 7. (1 2 3) Summarizing the teaching content or clarifying misinformation
2. (2) Clients with multisystem issues usually require education regarding does not evaluate the effectiveness of the teaching strategies. It does
diagnosis, multiple treatments, and medications. (1) Living alone does provide information on retention of information, which can play a role
not necessarily place a client at high risk for discharge. If the client is in how effective the strategies have been. However, you do want to
young, self-sufficient, and has a good support system, the client is not at evaluate the type of strategy utilized in teaching. Basically, what they
high risk. Answers (3) and (4), in and of themselves do not place clients are doing in (4) and (5) is reiterating information. You cannot evaluate
in a high-risk category. whether they are able to utilize the information that was covered in the
3. (4) The first three distractors are essential to determine an appropriate teaching.
educational plan. (1) The educational level determines the level and 8. (1) The client will become more agitated with you if you attempt to
scope of information that can be presented. (2) Family members should continue with the teaching. The other responses are all appropriate for
be included in the educational plan. (3) Ethnic and cultural issues need this situation. It is best to come back at a different time (3). At that
to be taken into account, especially when discussing items such as di- time you may be able to determine why the client is agitated and hos-
etary alterations. The actual employment or occupation in most cases is tile. (4) Frequently, another nurse is able to establish rapport with a
not necessary in developing the teaching plan. client, and it would be best to ask that nurse for assistance with the
4. (2) The amount of time the family spends at the client’s beside may be client.
dependent on their work schedule, family responsibilities at home, etc. 9. (1 2 3) This data is important information for other health care workers
Once the teaching needs are determined, then it is important to evalu- to have in order to develop an appropriate plan of care for the client.
ate their active participation. Nursing interventions and I&O records are not necessary unless there is
5. (4) Knowing the lifestyle and usual daily activity can assist with deter- a specific issue with them. For example, if the client’s urine output has
mining the impact of changes on this activity and the emphasis on the been low and he/she isn’t taking in fluids, that should be included in the
teaching plan. (1) This procedure is not considered a major surgical in- discharge summary.
tervention. Most of the listed procedures are done on an outpatient 10. (3) Older clients frequently have hearing deficits and extraneous noise
basis; therefore, the home environment would not be evaluated. There impairs their hearing. This can lead to perceiving incorrect information
is no need for specialized equipment. (2) All clients having outpatient and directions. (2) Older clients remember about 5% of what they read.
or short-stay surgery must have someone take them home because of the (1) They remember 50–70% of what they hear and verbalize.
anesthesia. It isn’t important to determine who will be staying at home (4) Usually, older clients do not learn best in groups, because it can be
with the client or when they return to work. The physician will give the noisy and disruptive.
client directions on the return-to-work date.
145

Client Education and Discharge Planning

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Client Education and Discharge Planning

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Client Education and

UNIT • Client Education

Client education is more than imparting information to a

Barriers to Change Nursing Approaches DISCHARGE PLANNING

scales provide information useful when developing the dis-

The Joint Commission Standards for Client Education

members or friends is only permitted if it directly affects them

TABLE 1 Home Health Team

TABLE 2 Cultural Beliefs Affecting Client Teaching

TABLE 2 Cultural Beliefs Affecting Client Teaching (Continued)

NURSING DIAGNOSIS RELATED FACTORS

Impaired Communication Verbal Cognitive impairment, auditory impairment, language barrier

Nursing Process Data

Collecting Data and Establishing Rapport

Determining Readiness to Learn

Assessing Learning Needs

essary to provide the most effective teaching strategies.

material for client.

Determining Appropriate Teaching Strategy

Components of a Teaching Plan

After selecting the

Selecting the Educational Setting

Implementing the Teaching Strategy

outcomes with individual or group. Rationale: encourages learning in client.

Evaluating Teaching/Learning Outcomes

3. Ask client and/or family specific questions regarding E=

information provided. Rationale: To determine neces- M=

sity of reinforcing or reteaching information.

TOPIC ASSESSMENT PATIENT EDUCATION / EVALUATION

knowledge base. Cause/effect of Disease Process

5. Develop hypothetical situations for client to problem Smoking Cessation

solve. Rationale: This will help determine client’s ABILITY TO COPE

understanding of disease or condition. DISCHARGE

6. Use an evaluation tool, if appropriate. Rationale: MEDICATIONS

phase better. WOUND CARE Signs/Symptoms of Infection

Activity Level Restrictions/Limitations

Comments (Include Date/Time and Initials):

INITIALS SIGNATURE/TITLE DEPT. INITIALS SIGNATURE/TITLE DEPT.

Multidisciplinary teaching record.

a. Evaluate forms, format, and types of tools available

DOCUMENTATION for Client Education

CRITICAL THINKING Application

Unexpected Outcomes Alternative Actions

Unexpected Outcomes Alternative Actions

Nursing Process Data

Preparing a Client for Discharge

Sample discharge plan form.

Completing a Discharge Summary

DOCUMENTATION for Discharge Planning

CRITICAL THINKING Application

Unexpected Outcomes Alternative Actions

CRITICAL THINKING Strategies

NCLEX® Review Questions

NCLEX-RN® Answers with Rationale

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