POSTOPERATIVE EDUCATION AND TEACHING Meg Beturne, MSN, RN, CPAN, CAPA
OVERVIEW Purpose: The perianesthesia registered nurse (RN) will demonstrate understanding of the teaching/learning process. The perianesthesia RN will show ability to verify patient s readiness for discharge. The perianesthesia RN will demonstrate skills in providing discharge instructions/education to the patient, family, responsible adult or caregiver. The perianesthesia RN will address postanesthesia, postoperative/post procedure learning needs, answer questions related to postanesthesia and postoperative/post procedure care, document all education and pertinent information, and evaluate the teaching plan. Competency Statement: Provide pertinent postanesthesia and post procedural education to the patient and responsible adult or caregiver per surgeon, anesthesia, and/or facility protocol, with a working knowledge of the teaching/learning process. Criteria: 1. Verify patient is ready for discharge according to the facility/unit specific policy/protocol (Phase I, II, and Extended Observation). Evaluation of patient s status for discharge includes, but is not limited to: Return of protective reflexes Return to acceptable level of consciousness Stable respiratory function, and oxygen saturation Stable cardiac and hemodynamic status Stable vital signs Thermoregulation Pain and comfort controlled/manageable Nausea and vomiting controlled/manageable Acceptable level of emotional comfort Free from surgical and procedural site complications Ability to ambulate consistent with baseline/procedural limitations Ability to void if indicated Appropriate child-parent/significant other interactions Patient safety needs met Return of postanesthesia scoring system to baseline level if used Discharge order from both the surgeon and anesthesia provider 2. Reassess patient/family educational needs and review key variables (Phase I, II, and Extended Observation). Elements of reassessment include, but are not limited to: Perception/understanding of plan Role expectations and compliance with prescribed regimen Readiness to learn (willingness/ability) Emotional intelligence (chemical changes) Functional barriers (reading ability, comprehension, language) Cultural or spiritual beliefs Health beliefs and practices Time orientation Geographic isolation Motivation for learning ASPAN 2009 Edition 445
Identified learning styles (visual, auditory, kinesthetic, through smell/taste) Hierarchy of needs Risk of self-care deficit Communication styles (verbal/non-verbal, active/passive listener) Age (chronological and developmental) Pre-existing emotional or behavioral disorders/substance abuse Previous unpleasant experiences Key variables include, but are not limited to: Nurses ability/comfort with teaching process Availability of appropriate resources (human and written) Variability of time frames for teaching which affect length, location, and pace of sessions Accessibility of non-threatening learning environment Complexity of instructions with multiple steps Emerging fears about the development of postoperative complications 3. Review key education strategies/domains and reasons for reinforcement of preoperative teaching plan (Phase I, II and Extended Observation). Teaching strategies include but are not limited to: Explanation (cognitive) One-to-one discussion (affective, cognitive) Answering questions (cognitive) Demonstration (psychomotor) Discovery (cognitive, affective) Group discussions (affective, cognitive) Practice (psychomotor) Printed and audiovisual materials (cognitive) Role-playing (affective, cognitive) Modeling (affective, psychomotor) Computer-assisted learning programs (all types of learning) Five teaching domains: Situational and procedural information (process, roles) Sensation and discomfort information (pain, anxiety) Patient role information (instructions, follow-up) Skills training Psychosocial support (decision making) Reasons for review/reinforcement of preoperative instructions: Supports a positive outcome Allows basics to be grasped before proceeding to variations and adjustments Addresses changes in plan due to operative events Provides another opportunity for patient and caregiver to ask questions Offers chance to explain/clarify purpose and care of equipment Affords time for actual demonstration and return demonstration of skills Enhances learning, builds confidence and facilitates a smooth discharge process Results in improved level of patient satisfaction 446 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
4. Reinforce/Implement Postoperative Education Plan, including patient s responsibility in care. Review plan related to surgical/procedural care. Frequent pulmonary toilet Activity with any limitations (ambulation, exercise, sexual activity) Dietary restrictions (if any) and control of post discharge nausea and vomiting Patterns of elimination (use of laxatives/stool softeners) Adequate fluid/food intake balanced with adequate output Modifications for maintaining proper hygiene Care and observation of operative site Care and observation of dressings, drains and catheters Observation/neurological assessment of extremities (swelling, numbness, and tingling) Frequent hand washing to prevent infection Review plan related to pain control including drug management, and non-pharmacological measures. Use of prophylactic approach Time of next dose clearly verbalized and written Careful reading of labels Purpose, expectation and limitations Dosage, timing and consumption Common side effects Interactions with food and other drugs Interactions with alcohol Adverse signs and symptoms Allergic responses Ineffective response Physician notification of issues Balance of rest and exercise Driving cessation while taking opioids Proper position for comfort/elevation of extremity Application of ice/cold therapy Use of non-pharmacological strategies Review plan related to anesthesia precautions/expectations. Cognitive and psychomotor side effects Interaction of alcohol and recreational drugs Loss of protective pain sensation (sensory blocks) Use of sling until motor and sensory function returns Potential effect of nerve blocks on respiratory system Signs and symptoms of postdural puncture headache Sore throat following intubation Review plan related to the role of the family member/responsible adult; assess their understanding of surgical/invasive procedure and process. Along with patient, receives verbal and written instructions (general and procedural specific) Along with patient, receives precise information related to complications and symptoms Along with patient, provides written acknowledgement that instructions were thoroughly conveyed Obtains post-discharge access information (routine and emergency) Assists patient in dressing, collecting belongings (if necessary) once nurse removes IV catheter, drains and dressings (per unit policy) ASPAN 2009 Edition 447
Transports patient safely home with seat belts on (according to state, accrediting bodies and facility guidelines) after nurse has safely transferred patient to the transportation source Ensures that home environment is clean, comfortable and safe Assists with activities of daily living Complies with prescribed therapeutic/drug regimen Ensures that specialized equipment/services are present Ensures postoperative testing is completed (if indicated) Monitors the patient s progress toward recovery Functions as appropriate support system Accompanies patient to scheduled return visit to clinic or surgeon Time period for caregiver service dependent on surgery, length/type of anesthesia, age, and general health status 5. Document and evaluate Postoperative Education Plan Documentation of the teaching process is essential because it: Provides a legal record that teaching has occurred Provides a record for referral and review with the patient at a later date (i.e., follow up phone call) Validates diagnosed learning needs/objectives, topics taught, client outcomes, need for additional teaching and resources provided Validates specific instructions/requests from the patient for confidentiality that variations from the norm were met Validates verbal and non-verbal responses to the education Validates caregiver s understanding of postoperative instructions Serves as an indicator for quality improvement and bench marking purposes Evaluation of teaching plan is important to improve future education content and process. Evaluation must be ongoing Effectiveness is evaluated by change in behavior, knowledge attained, attitudes and skills development Use of open-ended questions to validate patient s understanding of instructions Use of return demonstration to validate acquisition of skills Methods of evaluation: self-report of patient, family, significant other, direct observation, oral questioning, and feedback from physicians Learning is measured against predetermined objectives Methods of measurement: defined quality indicators that determine patient outcomes, observation, interview, checklist, written/oral testing, patient demonstration of information provided, patient satisfaction surveys, post-procedure contacts 448 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
Bibliography American Society of PeriAnesthesia Nurses. 2008-2010 Standards of Perianesthesia Nursing Practice. Cherry Hill, NJ: ASPAN; 2008. Association of perioperative Registered Nurses. Standards, Recommended Practices and Guidelines 2007. Denver, CO: AORN; 2007. Bastable SB. Nurse as Educator: Principles of Teaching and Learning. Sudbury, MA: Jones and Bartlett; 1997. Burden N, Quinn D, O Brien D, Gregory-Dawes B, eds. Ambulatory Surgical Nursing. 2 nd ed. Philadelphia, PA: WB Saunders; 2000. DeFazio Quinn DM, Schick L, eds. PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St. Louis, MO: Saunders; 2004. Joint Commission on Accreditation of Healthcare Organizations: Standard RI.1.2, RI.1.2.8, TX. 5.4, PF. 3.4, CC. 6.1, Oakbrook Terrace, IL, 2007. Phippen ML, Wells MP. Patient Care during Operative and Invasive Procedures. Philadelphia, PA: WB Saunders; 2004. ASPAN 2009 Edition 449
QUESTIONS: POSTOPERATIVE EDUCATION AND TEACHING COMPETENCY 1. For perianesthesia teaching to be effective it must: a. be tailored to the patient s identified needs b. be presented in a manner in which the patient can understand c. be modified to overcome sensory and language barriers d. use simple phrases, repetition, and return demonstration e. all of the above 2. The best way to encourage patient feedback / participation is to: a. use open-ended questions b. explain everything so that there are no questions c. leave out valuable information so that the patient will ask questions d. a & c 3. Documentation of all teaching, both preoperative and postoperative, serves as a: a. reference for the patient to review b. check list for the nurse to refer to c. legal and chart auditing purposes 4. Postoperative instruction should include the following information: a. prescription information and emergency phone number b. activity, diet, wound care, and pain management c. follow-up appointment, and other special instructions 5. Teaching that focuses on an individual s needs increases: a. comprehension b. compliance c. a positive experience 6. Teaching is most effective when the following techniques are used: a. quiet atmosphere and eye contact b. non-technical language c. repetition and return demonstration 450 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
KEY: POSTOPERATIVE EDUCATION AND TEACHING COMPETENCY QUESTIONS 1. For perianesthesia teaching to be effective it must: a. be tailored to the patient s identified needs b. be presented in a manner in which the patient can understand c. be modified to overcome sensory and language barriers d. use simple phrases, repetition, and return demonstration e. all of the above 2. The best way to encourage patient feedback / participation is to: a. use open-ended questions b. explain everything so that there are no questions c. leave out valuable information so that the patient will ask questions d. a & c 3. Documentation of all teaching, both preoperative and postoperative, serves as a: a. reference for the patient to review b. check list for the nurse to refer to c. legal and chart auditing purposes 4. Postoperative instruction should include the following information: a. prescription information and emergency phone number b. activity, diet, wound care, and pain management c. follow-up appointment, and other special instructions 5. Teaching that focuses on an individual s needs increases: a. comprehension b. compliance c. a positive experience 6. Teaching is most effective when the following techniques are used: a. quiet atmosphere and eye contact b. non-technical language c. repetition and return demonstration 452 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
Competency Based Orientation for the Perianesthesia Nurse Name Date Written Competency Test Pass & Date (90%) POSTOPERATIVE EDUCATION AND TEACHING Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with N/A. Competency Statement Discusses with Preceptor Provide pertinent postanesthesia and post procedural education to the patient and responsible adult or caregiver per surgeon, anesthesia, and/or facility protocol, with a working knowledge of the teaching/learning process. CRITERIA: 1. Verify patient is ready for discharge according to the facility/unit specific policy/protocol (Phase I, II, and Extended Observation). 2. Reassess patient/family educational needs and review key variables (Phase I, II, and Extended Observation). 3. Review key education strategies/domains and reasons for reinforcement of preoperative teaching plan (Phase I, II, and Extended Observation). 4. Reinforce/Implement Postoperative Education Plan, including patient s responsibility in care. 5. Document and evaluate Postoperative Education Plan. Retake & Date Observed Performs with Assistance Independent Meets Criteria Does Not Meet Criteria Re-Validate Meets Criteria Employee Signature Date Preceptor Signature Date ASPAN 2009 Edition 453