Nurses play a key role in reducing hospital overcrowding based on a recent study commissioned by the Agency for Healthcare Research and Quality.  The study published in the February 3, 2009 issue of the Annals of Internal Medicine determined that patients who clearly understood their discharge instructions were less likely to return to the hospital emergency department or need more follow-up care.

While this might appear to be a simple assumption to most in the nursing field, it points out a serious deficit in the way some RNs are implementing a basic component of nursing care, patient education.  Students planning on a nursing career should pay attention to the lessons learned in this study.

Recent episodes and articles here at the Nursing Show have discussed the importance of telemedicine follow-up on patient’s handling of complications, pain management, and other post hospitalization issues.  The journal article above points out the importance of this key nursing intervention.  For student nurses, I think it’s important to review some of the aspects of a good set of discharge instructions based on the tried and true ADPIE model.

Assess

Every nursing intervention begins with an assessment of the patient.  Providing discharge instructions is no different.  Before proceeding, the nurse or student must assess the patient’s ability to understand or comprehend the instructions.  Communication with the patient who has a hearing deficit will be very different from the patient with perfect hearing.  Understanding the individual’s particular communication needs starts with assessing them.

Things to look for include:

• Level of education
• Language barriers
• Visual disturbances
• Hearing deficits
• Cultural differences
• Economic concerns

Diagnose

Once potential problem areas are identified, use your nursing diagnoses to begin to lay out areas of concern.  How is the patient likely to miss part of their discharge instructions.  Planning is the next step, but it should not be rushed into until the nurse understands the patient’s particular needs. By planning based on a nursing diagnosis, the RN can start with a foundation clear patient needs in mind.

Plan

Planning is where the rubber meets the road.  In this stage, a nurse takes the information from their assessment of the patient and puts that together with the nursing diagnosis to begin to formulate the goals for this particular patient.  Setting these short and long term goals will help the nurse better implement interventions in the next step.

When planning, take the assessment data and ask key questions:

• Level of education:  Will they understand big medical words? Can a family member help with understanding?
• Language barriers:  Do they speak English and how well?
• Visual or Hearing Deficits:  Do they need large type materials or additional print materials?
• Cultural barriers:  Will some instructions be ignored due to cultural restrictions?
• Economic concerns:  Can the patient afford the materials needed at home?

Take this information and lay out a plan of action including gathering additional materials as needed.  You may have a standard facility print-out for a particular set of discharge plans.  Do not assume that it will automatically be suitable for your patient. There is no “one-size-fits-all” discharge instruction sheet.

Implement

You have assessed and diagnosed a patient’s particular needs, laid out your plan of action, and gathered your materials.  Now it is time to implement.  A well known military tenet states that “no plan survives contact with the enemy.”  Flexibility is the key.

As you begin to relay the discharge instructions, here are a few things you might need to do:

• draw a diagram or picture (stick figures work, too!)
• demonstrate care to be performed at home
• repeat key points of the home care plan
• underline or highlight the discharge sheet items
• revisit phone numbers and provider or nurse contact info

Evaluate

This the point where many patients needs are not being met.  The most important part of any patient intervention is to re-evaluate the nursing intervention’s effectiveness in meeting the patient’s needs.  Before the patient leaves the hospital, the nurse must evaluate whether the patient understood the instructions.

Good communication techniques are important here. Refrain from asking closed ended questions.  These are questions that only require a “yes” or “no” answer.  It is far too easy for a patient who doesn’t have a clue about what you just said to just nod their head in agreement because they don’t want you to think they are stupid.

Ask the patient to demonstrate home care needs back for you. When demonstrating a device or technique, use this useful phrase -

“You try it.”

ADPIE Again

The shampoo bottle says, “Lather, Rinse, Repeat.” This might be a ploy to get you to use more shampoo but sometimes you need to do it all again. The nurse must be prepared to revisit the ADPIE model to cover an evaluated deficits.  Also, because of challenges with time management in the hospital setting, the follow-up telenursing call may be the best way to re-evaluate the patient’s understanding and provide opportunities for cost effective follow-up care.

What are your experiences as a nurse or student when dealing with discharge planning and instructions?  Share them using the comments link below or drop us an email to Comments@NursingShow.com.

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Don’t let tough classes keep you out of the nursing field!

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