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Diagnosed Deep vein thrombosis (DVT)

The purpose of this paper is to outline a teaching plan to provide general comprehensive pre-discharge education for a 64 years old male Indian patient who was newly diagnosed deep vein thrombosis (DVT) and will be starting on warfarin for at least three-month post-discharge. By providing adequate information and clear explanation can help allay anxiety and provide assurance to the patient, resulting in better disease control. The teaching plan aims to cover the assessment of the patient’s current health status as well as his mental and social well-being. The learning aims and outcomes will be planned for the patient, follow by implement suitable teaching strategies after determining the patient’s learning needs and style. The anticipated strengths and limitations will be discussed in the following context, as well as the evaluation plan and a summary conclusion.

As a registered nurse in the adult setting ward of a large Singapore public hospital, it is common to have patients who require a pre-discharged teaching plan. The right setting is crucial as it can affect learning and the quality of delivering education. Unfavorable conditions such as temperature, lighting, noise level, tense atmosphere, and lack of privacy area are examples of environmental factors that can cause a distraction to the patient, resulting in less learning motivation (Krau, 2011). By establishing a trusting and less disturbance learning environment can helps the patient to feel a sense of security in confiding information, believe that his concerns are taken seriously, and feel respected (Bastable, 2017). Therefore, a comfortable day lounge or discharge lounge within the health care facility will be a suitable setting for providing pre-discharge education compared to bedside teaching. 

Deep vein thrombosis is a blockage in the vast and deep veins that often occur in the, which is a common cause of morbidity and mortality, usually treated with the use of anticoagulants to relieve acute symptoms and reduce the risk of recurrent thrombosis or post-thrombotic syndrome (Hasrani et al., 2016). Anticoagulants include warfarin, are ranked first among the therapeutic drugs that have adverse effects related to death, and are among the top five drugs associated with medication errors (Brunetti et al., 2018). According to Popoola et al. (2016), insufficient education on warfarin use leads to many significant bleeding events during the first three months of anticoagulant treatment. Research also stated that incorrect use of warfarin by patients with low knowledge levels are more likely to increase the risk of thromboembolism and bleeding (Baysal & Midilli, 2018).

Therefore, develop a patient-centered approach to educate patients on the DVT and the correct use of warfarin is an essential responsibility for nurse counseling and educational roles, which help to empower a greater involvement in self-care and minimize the life-threatening complications (Baysal & Midilli, 2018). A recent study shows that patients who received proper education on the use of warfarin achieved significantly better International Normalized Ratio (INR) control with fewer adverse events, resulting in a shorter length of stay in hospital and reducing the emergency department visits associated with warfarin (Hawes, 2018). It underlined the importance of patients’ knowledge level in self-management of minor adverse events and the prevention of significant complications after discharge.

According to the developmental stages, the patient who aged 64 with newly diagnosed deep vein thrombosis is currently under his middle-aged adult stage. Based on the concept of adult learning, it emphasized more to the learner-centered way of learning and internally motivated (Zaidi & Nasir,2014). Bastable (2017) stated the patient at middle-aged might experience either a more relaxed lifestyle or higher stress level due to midlife crisis issues which related to the nature of physical, cognitive, and psychosocial changes, which may ultimately affect the readiness to learn. The socio-cultural background should be taken into consideration by assessing the patient’s positive and negative past experiences with learning to identify the motivational level of involvement and the potential obstacles which may influence the educational outcomes (Bastable, 2017). 

The characteristics of middle-aged adulthood also include exploring alternative lifestyles, desires to modify disturbing aspects of life, and reexamining the goals and value (Bastable, 2017). Thus, other than exploring the patient’s emotional, financial, and physical support system, provide information to coincide with life concerns can also facilitate in maintaining independence and reestablishing his standard life patterns (Bastable, 2017). The learning type of patient can be determined under the guidance of the VARK models, which consists of four learning styles, including visual, auditory, written, or kinesthetic (Krau, 2011).

Aim: The goal of pre-discharge education is to give the patient a better understanding of diagnosis, to strengthen the knowledge of possible drug interaction and medication adherence, as well as to learn how to recognize problems and respond appropriately. 

By the end of the education, the patient will be able to-

  • List at least three correct ways of consuming warfarin (Baysal & Midilli, 2018). 
  • Recall at least five of the signs and symptoms of warfarin toxicity (Witt et al., 2016).
  • Name at least five drugs and foods that may cause interaction with warfarin (Popoola et al., 2016).
  • State the importance of adherence to the medication regimen and the scheduled laboratory tests (Armstrong et al., 2011). 

The learning theory that applies to the patient is the cognitive learning theory, which has been widely used in education and focuses on thinking and understanding (Aliakbari et al., 2015). The recommended method is one-to-one instruction, which can adjust to meet the patient’s learning needs and focused on the patient’s specific self-management plan, resulting in a positive effect on patient education and compliance (Bastable, 2017). The patient allows applying the information that he learned at a higher cognitive level. For example, the patient can apply his understanding into different types of scenarios as a rehearsal of a real situation, which helps to prevent such occurrences after discharge.

Given the nature of physical changes in hearing and vision that might affect learning, the well-utilized of visual and written materials such as booklets and pamphlets can make the information permanently and promote the effectiveness of education (Yiu et al., 2020). Inside should contain simple information or clear images on the use of warfarin, including the indication, side effects, laboratory monitoring, drug-drug interaction, and drug-food interaction to simplify reading (Baysal & Midilli, 2018). Studies have shown that pre-discharge verbal and written education for patients who use warfarin facilitate a positive patient’s attitudes with significant improvement in warfarin knowledge (Stafford et al., 2012).

The patient may have difficulty following warfarin dose instructions or miss the scheduled day for laboratory tests due to various possibilities, including aging, poor memory, or work-related factor (Witt et al., 2016). When looking into the condition of the patient, it is clear to see that the cause of deep vein thrombosis is closely related to his lengthy overseas travel. Some of the non-threatening reminders can be explored, such as the use of pillboxes, calendars, diaries, electronic reminders, or written instructions, which can improve drug compliance (Witt et al., 2016). 

Based on the gestalt principle in cognitive learning theory that psychological organization is directed towards balance, regularity, and simplicity (Bastable,2017). With the use of effective patient-provider communication includes limiting the amount of information, organizing information in sequence, using action-oriented messages, and keeping clear instructions, can assist in facilitating the adherence to the teaching plan with a better understanding (Parnell, 2014). Parnell (2014) recommends the use of a “chunking and checking” method that requires the patient to repeat the information in his own words, which ensures the retention of information.

As nurses, effective teaching involves also incorporating cultural and religious beliefs, literacy and educational levels, language skills, and considering the context of communication (Parnell, 2014). Besides, timing is crucial, especially come to pre-discharge education, which prevents the patient from overloading with new information. Thus, the ideal time frame will be approximately 15 minutes to identify and prepare for the session, and 20 minutes to perform the teaching exercise (Piazza et al., 2012).

The advantage of the teaching plan is high flexibility because it conducts face-to-face with the patient. Thus, the pace and content of teaching can be tailored to meet individual needs based on the patient’s condition (Bastable, 2017). Also, it provides a chance for immediate feedback to be shared between the nurse and the patient.

Although one-to-one instruction is the most frequently used method of teaching patients, the expert revealed that learning distributed over multiple sessions leads to better memory than information learned in a single session (Bastable, 2017). If the number of patients on warfarin is high, the educational cost may increase because one-to-one instruction must be offered to each patient, and it is time-consuming (Zaidi & Nasir, 2014). Also, it may burden the nurses who already have a substantial daily workload. Thus, providing standardized programs of instruction via group teaching sessions can be an alternative method.

The Roberta Straessle Abruzzese (RSA) model helps to classify the educational evaluation into five levels include process, content, outcome, impact, and program (Bastable, 2017). The content evaluation can apply immediately after the learning experience to determine how well the patient had learned, which ensuring the persistence of the information (Baysal & Midilli,2018). Extensive use of the teach-back or questioning method provides the patient with an opportunity to participate in the learning process activities, which allow the nurse to evaluate his understanding of information and provide feedback on the progress (Bastable, 2017). The cognitive test can also be one of the evaluation methods to provide data for content evaluation.

In conclusion, sufficient patient education can assist in enhancing prevention and treatment outcomes for patients living with and managing chronic disease. The appropriate learning theory that identifies helps to enhance readiness to learn and the implementation of effective teaching strategies. The evaluation phase is essential to ensure the competence of the patient at the end of the teaching session. The economic burden of treatment costs and recurrent admission can be controlled if well-organized patient education is provided.
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