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 Introduction
            Health seeking behaviors are personal actions that promote optimal wellness, recovery and rehabilitation. Patients know what behaviors are important to their health through education from healthcare providers and through and seeking knowledge on their own. The internet has played a major role in the increase of health seeking behaviors because information is easily accessible. People no longer need to make a face to face appointment with their health care provider, or wait for yearly physicals to discuss ways to prevent illness and disease. “Since 2000, the proportion of American adults reporting that they have looked online for diet, exercise, or fitness information has increased substantially” (Weaver, Mays, Weaver, Hopkins, Eroglu, & Bernhardt, 2010). As nurses, it is our job to educate and assess a patient’s learning needs. Because the elderly are less likely to use the internet to seek knowledge on their own, it is important for nurses to evaluate health behaviors and identify areas that require further teaching. COPD, for example, is a disease that is common among the elderly population. Educating elderly patients diagnosed with COPD can help improve their quality of life and possibly regain independence.

Client Background
            H.H. is a seventy three year old Caucasian man who was admitted to Southern New Hampshire Medical Center on September 7, 2010. H.H. currently lives with his wife in Nashua, New Hampshire. Before his illness prevented him from working, H.H. was a high school graduate and was a construction worker. He has three grown children, two boys and one girl, who now have families of their own. H.H. is very fond of his grandchildren, and values being a part of their life and being able to watch them grow and develop.
            H.H. was admitted with a primary diagnosis of community acquired pneumonia. His past medical history is extensive including emphysema, hypothyroidism, hypercholesterolemia, interstitial lung disease, and osteoarthritis. The primary nursing diagnosis for H.H. is altered respiratory status, related to emphysema, as manifested by shortness of breath upon exertion. Shortness of breath is a major concern for this patient, and this is the chief reason he needs teaching. He is unable to complete activities of daily living because he has inadequate gas exchange. Having conversations is difficult for H.H. because he needs to frequently stop to catch his breath. He requires four liters of oxygen via nasal cannula even while at rest. This issue has also affected his ability to eat. His need for oxygen is so great that eating is completely exhausting. This has resulted in inadequate nutrition.
               Because H.H. is continuously out of breath, he does not ambulate often. His muscles have significantly weakened as his emphysema has progressed. Although it is important for H.H. to ambulate, cough, and deep breathe to assist gas exchange and promote mucus secretion, his anxiety often interferes with these tasks. It is very frightening for H.H. to constantly feel like he cannot breathe. For this reason, he remains in bed. It is important for his health care providers to teach him the importance of trying to remain as active as possible which requires delivering education on how to prevent severe shortness of breath upon ambulation.

Learning Needs
            H.H. has multiple learning needs. It is important to prioritize his needs to focus on what is most essential to improving his physical health status. Currently, his shortness of breath has affected his quality of life, so this issue is a priority nursing concern. While taking care of H.H. I could see that he was barely able to move around in bed, eat, or hold a conversation without losing his breath. He depended on my assistance to get washed up and to order his breakfast. He also had adventitious lung sounds, which improved slightly after nebulizer treatments. A major component of his learning needs will include his medication regiment. Specifically, it is important to focus on his inhaler medications prescribed to treat his emphysema. It is important to understand when to take each medication, the expected response, and the side effects of each drug.
            The need to become more independent was suggested by the patient; however, I explained to him that this learning need was a long term goal, and often times short term, focused goals can help meet long term goals. I then suggested that we may want to focus on learning various ways to control and prevent shortness of breath. H.H. agreed and stated that he wants to be able to play with his grandchildren and not rely on his wife to do everything for him. H.H. is concerned that his condition will continue to deteriorate and that he will continue to develop more and more issues related to his inability to ambulate and complete simple activities of daily living. These concerns supported the learning needs the patient and I chose to focus on. To achieve the above learning needs, I will educate H.H. on the importance of pursed lip breathing, use of incentive spirometry and proper inhaler administration.

Student Knowledge/Learning
            As a student, it is important deliver accurate and appropriate information to the patient. Patients trust their healthcare providers, and although we are students, we are expected to know how to safely care for our patients and address their needs and concerns. When providing patient education to H.H., I need to have good communication skills. Because H.H. is elderly and has trouble hearing, I need to speak clearly and slowly in order to meet his learning needs. In regards to his shortness of breath, I need to be familiar with techniques used to promote air flow and optimize gas exchange. The ability to demonstrate the use of incentive spirometry is important so that I can show the patient the correct way to use the device. When teaching incentive spirometry, I should emphasize that holding his breath after inhaling increases air distribution in the lungs. Explaining how coughing after the exercises helps clear secretions will also be helpful to H.H. (Lezon, 1999). I should also be knowledgeable about various positions that enhance air flow, such as high fowler’s position. It is important for me to know about oxygen supplementation. For example, I should be able to inform the patient that the peek flow meter cannot exceed six liters if using a nasal cannula (ATI, p. 31).
            Lastly, I need to be especially knowledgeable about the medication orders for this patient. It is vital for the patient’s safety to understand and explain the reason, route, dose, desired effects, side effects, contraindications, and important patient information regarding each drug. In regards to the medications ordered for emphysema, I should know the order in which to take each type of inhaler. For example, a beta adrenergic should be taken first, followed by the anti-cholinergic, and finally the corticosteroid. When taking corticosteroids, mouth care is vital. I need to inform the patient that it is important to rinse his mouth after use so that infections, such as thrush, do not develop. Elder clients need age-specific teaching. “Elderly people have been identified as more likely to use poor inhaler techniques” (Abley, 2007). Common errors include failure to hold breath after inhalation, failure to exhale before inhalation, and poor coordination of aerosol administration with the start of inhalation (Abley, 2007). It is, therefore, my responsibility to research and understand how to effectively teach the elderly population. With the above knowledge and skills, addressing the patient’s learning needs will be effective.

Client Learner Assessment
            During patient teaching, it is important to assess the patient’s readiness. It is important to assess physical readiness, such as assuring that the patient is well supplied with oxygen and breathing without difficulty, so that the patient can devote his attention to what I am teaching. If the patient is preoccupied with trying to breathe or trying to get comfortable, he will not be able to absorb and practice the teaching points. Because he develops such anxiety about not being able to breathe, I need to assess H.H.’s emotional readiness. It is important to remind H.H. to stay calm and to take slow deep breaths when ambulating. If the patient demonstrates fear or anxiety, it is important for me to address his fears, suggest relaxation techniques, and reassess before starting the patient teaching. The patient’s anxiety is a barrier to his education because it can prevent him from trying new things, such as pursed lip breathing when ambulating. Assessing H.H.’s readiness will improve the effectiveness of the teaching and will keep the patient safe.
            Another barrier for H.H. is his age. Research suggests that only 18% of patients over 65 are “teachable.” It is possible, however, that a larger percent of the elderly are “teachable” if the teaching program is specifically designed for elderly people and if physical inability is compensated for by providing an aid prior to the teaching (Abley, 2007). With this in mind, it is important to assess his cognitive status as well as his ability to retain and process new information. H.H. still has good cognitive abilities; however, some elderly patients have trouble with memory, such as patients with dementia. These types of illnesses would change how I would deliver the information to the patient. It is also important to ask H.H. if he learns better through communication, visual demonstrations, or written materials. It may be better for H.H. to listen, or watch me demonstrate the information. H.H. stated that he thought he would benefit most from receiving written materials that he can review later once I leave. This will promote independence in practicing the techniques when he is not in an acute care setting.

Goals
            The outcome that is important to achieve is knowing how to better control shortness of breath. This will allow him to feel more comfortable ambulating and trying to complete activities of daily living. This outcome cannot be completed in one teaching session, however, the skills, techniques and information he needs to eventually reach his goal will be provided. The outcome desired, restoring some independence, will take practice and time, but with the proper education, it can eventually be achieved.
            Behavioral objectives for achieving this outcome include demonstrating pursed lip breathing before, during, and after ambulation, using incentive spirometry, and properly using inhalers. Education on inhaler use will include administering them in the right order as well as correctly administering each medication. H.H. should remember to inhale slowly for three seconds, hold his breath for ten seconds, and wait one minute between puffs. He should wait five minutes before inhaling the next medication (Lezon, 1999). This will provide maximum benefit to H.H.’s lungs. For incentive spirometry, the patient’s goal is to reach 1,500mL at least ten times a day. It is beneficial for the patient to document use of the spirometer for the nurse’s evaluation and for the patient to evaluate progress. The patient should mark on the spirometer the highest volume reached. Using the marker on the incentive spirometer serves as a visual goal for future attempts. (Lezon, 1999)  Use of incentive spirometry is especially important for older clients like H.H. because “older adult clients have decreased pulmonary reserves due to normal lung changes including decreased lung elasticity and thickening alveoli” (ATI, p. 116). Lastly, during ambulation and activity, such as bathing, the patient’s oxygen saturation should not drop below 89%. This should be monitored at all times during ambulation using a pulse oximeter.
            Demonstrating pursed lip breathing as well as using incentive spirometry are both psychomotor and affective learning domains. Affective learning is required because the patient must be willing to participate in the activity and willing to learn a new behavior. Psychomotor learning is involved because the patient must physically complete these activities in order to evaluate effectiveness and understanding. Proper use of medications involves a combination of learning domains including cognitive, affective, and psychomotor. Again, the patient must be willing and ready to learn, which requires affective learning. Secondly, the patient must be able to learn new knowledge and develop intellectual skills, requiring the cognitive domain. Finally, psychomotor learning is used when the patient is required to demonstrate the skill of using the inhalers correctly once I am done explaining the procedure (Big Dog & Little Dog ‘s Performance Juxtaposition, 2010).

Teaching Strategies
            The teaching strategy I will use to educate this patient is a demonstration/practice method. This will allow the patient to listen to what should be done, observe me demonstrating the skills, and finally having the patient practice what he learned. Evidence that this approach is effective was that the patient was attentive and not losing focus, as well as demonstrating the ability to properly practice the activities. This teaching strategy is based on cognition, because the patient is learning new information, as well as psychomotor because the patient must demonstrate proper skills.
            Although H.H.’s long term goal is to be able to become more independent, in order to achieve this, he must first learn to efficiently use his respiration ability. I will evaluate whether these short term outcomes were met by observing the patient practice pursed lip breathing and proper use of incentive spirometry. I will also observe the patient’s use of his inhalers. To evaluate quality of teaching, it would be important for the patient to verbally repeat back to me what should be done. If the patient is confused or does not understand the reasons behind certain interventions, I know that I did not successfully educate the patient. I can also ask for patient feedback in order to evaluate quality of teaching. If the patient reports that I went too fast, too slow, or simply did not explain the information clearly, I can determine the effectiveness and value of the education session.
            If the short term outcomes are not met I will alter my teaching strategies. In order to satisfy the patient’s learning needs, I will offer to repeat the education session. I will need to evaluate whether or not the patient wants to continue learning, or whether the patient needs a break. If the patient is tired and unfocused, an immediate second teaching session will not be effective. I can offer written materials if not given the first time, so that the patient can review teaching material in order to better complete the activities next time. It is crucial to reflect on patient teaching in nursing practice. This is because not all teaching sessions will be effective. In the future, when teaching a similar patient need, it will help to know what strategies worked last time and which needed improvement.

Evaluation of Outcomes
            After the teaching session, I felt like I met my teaching objectives for H.H. He understands the importance of and reason behind pursed lip breathing. He showed correct use of the incentive spirometer, and used all three inhalers correctly and in the right order. These were the short term objectives established for H.H. during the teaching session. Controlling and eliminating severe shortness of breath is a long term goal, which cannot be reached after one day. If H.H. continues to practice and focus on breathing techniques, exercising the lungs using incentive spirometry, and using medications to manage his emphysema, his long term goal may be met.
            As I carried out this assignment I thought about a lot of things. Often times, patients are hopeful that they can someday be independent again. This is hard when the illness or disease is progressive or chronic, such as COPD. For this reason, it was important for me to look at his health status and decide on teaching points and goals that H.H. was physically able to learn and utilize in his everyday life. I also had to think about his anxiety and his mental readiness to learn. H.H.’s anxiety was a significant barrier to his willingness to ambulate. It, therefore, was important for me to establish a trusting relationship with H.H. so that he would be willing to address his learning needs. I was concerned that although H.H. had a strong desire to improve his oxygenation and prevent severe shortness of breath upon exertion, he would not be able to overcome the anxiety. His age and the progression of his COPD was also a factor affecting whether or not H.H. would be able to meet the objectives. It was important for me to take my time with H.H. and explain the benefits and precautions to take so that he felt comfortable with the interventions that I was teaching.
            I believe I was successful with this patient. Despite the many barriers and the unstable condition that H.H. was in, I was able to find ways to work with his capabilities. I am glad that I chose the interventions that I did because they are simple yet effective. I also thought I was successful in turning his ultimate goal, regaining independence by controlling shortness of breath, into smaller objectives that he can use to work towards that ultimate goal. To improve my approach next time, I might offer to split the teaching into two different days. The purpose of this would be to talk with H.H. about the various interventions and to discuss any concerns or anxiety he may be having or feeling. I would then have a separate time set up for teaching and having H.H. try the interventions. I think this would be effective because it would give him time to physically and mentally prepare for ambulation, and this would help ease his anxiety.

Conclusion
            Addressing the learning needs of patients and identifying health seeking behaviors are key nursing roles in the healthcare setting. It is important for nurses to realize that although they may address the same interventions, it does not mean that the education delivery will be the same. Patient education needs to be individualized. Nurses should evaluate the patient’s strengths, weaknesses, goals, and barriers, as well as the emotional and physical readiness to learn. Evaluating these various aspects of a patient can help the nurse choose the best teaching strategy for each individual patient because not all patients learn in the same way or at the same pace. Nurses should also reflect on teaching effectiveness to determine whether or not the desired outcome was achieved and make any necessary changes to improve the quality of future teaching.

References

ATI. Adult Medical-Surgical Nursing (7.1 RN Edition).

Abley, C. (1997). Teaching elderly patients how to use inhalers. A study to evaluate an education programme on inhaler technique, for elderly patients. Journal of Advanced Nursing, 25(4), 699-708. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=1997016944&site=ehost-live

Big Dog & Little Dog ‘s Performance Juxtaposition. (2010, July 5). Retrieved October 8, 2010,  from Bloom’s Taxonomy of Learning Domains: The Three Types of Learning:  http://www.nwlink.com/~donclark/hrd/bloom.html

Lezon, K. (1999). Teaching incentive spirometry. Nursing, 29(1), 60-61. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=1999013405&site=ehost-live

Weaver, JB,,III, Mays, D., Weaver, S. S., Hopkins, G. L., Eroglu, D., & Bernhardt, J. M. (2010). Health information–seeking behaviors, health indicators, and health risks. American Journal of Public Health, 100(8), 1520-1525. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010726479&site=ehost-live

 

            

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