CLINICAL QUERIES
Teaching Patients With an Intellectual Disability MARLENA SEIBERT PRIMEAU, DNP, FNP-BC, BSHECS, AND KAREN H. FRITH, PHD, RN, NEA-BC
Q: I work in an outpatient clinic, and some of my patients have Down syndrome. Do you have any tips about how to teach these patients about medications and lifestyle changes?—K.F., ALA. his is a great question! Teaching is the key to meeting the challenge of adherence to medications and lifestyle changes. Patients with an intellectual disability (ID) can learn about their medications if you follow a few teaching principles. First, make sure that you always speak and interact with the patient, rather than just discussing the issue with a family member or caregiver. Explain the reason for learning about the medication. Plan teaching that’s appropriate to the patient’s chronological age rather than cognitive age.1 In other words, if the patient is 40, teach with adult examples, not childish ones. While staying true to the concept, simplify the language to an appropriate level. Slow down your teaching, focusing on only one or two of the most important points.2 Don’t be surprised if you need to repeat or reinforce the information at each visit. Plan on additional time for the office visit because the teaching session may take longer than usual.3 Let’s use an example to illustrate this teaching approach. You’re seeing Mr. A, 55, who has Down syndrome and hypertension; he needs information about a new antihypertensive
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and a low-sodium diet. The goal of the visit is to help Mr. A begin safe treatment with hydrochlorothiazide, a diuretic, while introducing the dietary change. Using task analysis, break the topic into small sequential components also known as chunks. In this case, Mr. A first needs to take his medication on a regular schedule. By asking a few questions, you learn that Mr. A has a job at a grocery store. He usually eats breakfast at 0630, and then his brother takes him to work by 0745. You suggest to Mr. A that he put the medicine bottle next to his cereal box so he’ll remember to take one pill every time he eats cereal in the morning. The next task is to teach Mr. A how hydrochlorothiazide works. Fill an examination glove with water until it’s tight. Ask Mr. A to feel the glove. After letting
some of the water out, ask Mr. A to feel the glove again. Tell him that in a similar way, when Mr. A takes hydrochlorothiazide, he’ll urinate to get rid of excess sodium and fluid from his body. To avoid problems, you’ll need to teach Mr. A about possible adverse reactions to hydrochlorothiazide, including fluid volume deficit, GI disorders, muscle cramps, and dysrhythmias, and the importance of taking it as prescribed. Tell him not to stop taking it unless he talks to his healthcare provider first. Now you need to teach Mr. A about reducing the sodium in his diet. Using cans of food, show him how to find the sodium content. Mr. A will be comfortable with this example because he handles cans, frozen food, and fresh fruits and vegetables every day. Teaching him how to determine sodium content has three distinct parts: finding the word sodium on the label, finding the amount (usually in milligrams) on the label, and deciding if the sodium content is too high. You can teach Mr. A about these parts using the chaining method, which combines teaching, practicing, and repeating.4 Each time the sequence is practiced, the patient does one more step in the process independently. Teach the three parts of determining sodium content to Mr. A and practice them in sequence, one step at a time. Frequent repetition of both the individual steps and
This article originally appeared in Nursing2013 2013;43(6):68–69.
vol. 32 • no. 4 • April 2014
Home Healthcare Nurse 249
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table. Teaching Techniques for Patients With ID2,5-8 Technique
Description
Task analysis
Breaking up a task into small sequential components
Chunking
Teaching information in small, easily understood units
Chaining
This is a method of teaching, practicing, and repeating. Each time the practice is repeated, the patient does one more step in the process independently.
Using communication devices
Devices can be used to enhance, augment, or replace spoken language. They can range from simple equipment such as a white board or picture cards to high-technology devices.
Role-play/simulation
Simulation must be as “real” as possible because many people with ID don’t easily transfer data from one situation to another.
Small groups
Social support is very important to learning.
Concrete examples and stories
In general, people with ID don’t understand abstract ideas.
Frequent positive reinforcement
Give verbal praise and/or small tokens for successful completion of each step or unit.
Simplify language, not the concept
Stay true to the concept but simplify language to an appropriate level.
Explain reason for learning task
Understanding the reason makes the task more real.
Chronological-age appropriateness
Address and discuss issues appropriate to the patient’s chronological rather than cognitive age.
lnvolving families and caregivers
Patients can practice tasks and concepts at home.
of the entire sequence is crucial for success. Finally, role-playing could be an easy way for you to teach Mr. A about foods that are low or high in sodium. Take a few items from the kitchen at the ambulatory clinic and ask Mr. A to sort foods high in sodium into one bag and foods low in sodium into another. When he sorts the food correctly, make sure that you give him positive reinforcement. With some creativity, you can help Mr. A learn to take his new medicine on a regular schedule and make good choices about his food. But just as important, Mr. A will have a good experience with you as his nurse. Marlena Seibert Primeau is a Clinical Assistant Professor and Karen H. Frith is a Professor at the College of Nursing at
250 Home Healthcare Nurse
the University of Alabama in Huntsville. The authors have disclosed that they have no financial relationships related to this article. DOI:10.1097/NHH.0000000000000046 REFERENCES
1. Shurr J, Taber-Doughty T. Increasing comprehension for middle school students with moderate intellectual disability on age-appropriate texts. Educ Train Autism Dev Disabil. 2012;47(3):359-372. 2. National Cancer Institute at the National Institutes of Health. Clear and simple: developing effective print materials for lowliterate readers. 2003. http:// www.cancer.gov/cancertopics/ cancerlibrary/clear-and-simple. 3. Yale College. Teaching students with disabilities guide. 2013. http://yalecollege.yale.edu/ content/teaching-studentsdisabilities-guide.
4. Pratt C. Applied behavior analysis: the role of task analysis and chaining. Indiana Resource Center for Autism, Indiana University. 2013. http:// www.iidc.indiana.edu/index .php?pageId=3458. 5. Küpper L, Hamilton K. Intellectual disabilities in your classroom: 9 tips for teachers. National Dissemination Center for Children with Disabilities (NICHCY). http://nichcy.org/intellectual disabilities-in-your-classroom. 6. National Institutes of Health. Clear communication: a NIH health literacy initiative. 2012. http:// www.nih.gov/clearcommuni cation. 7. National Institutes of Health. Plain language: tips for using plain language. 2013. http://www .nih.gov/clearcommunication/ plainlanguage.htm#tips. 8. Morrisey B. Communication. Speech Disorder. 2012. http:// www.speechdisorder.co.uk/ communication-boards.html.
www.homehealthcarenurseonline.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teaching Patients With an Intellectual Disability MARLENA SEIBERT PRIMEAU, DNP, FNP-BC, BSHECS, AND KAREN H. FRITH, PHD, RN, NEA-BC
Q: I work in an outpatient clinic, and some of my patients have Down syndrome. Do you have any tips about how to teach these patients about medications and lifestyle changes?—K.F., ALA. his is a great question! Teaching is the key to meeting the challenge of adherence to medications and lifestyle changes. Patients with an intellectual disability (ID) can learn about their medications if you follow a few teaching principles. First, make sure that you always speak and interact with the patient, rather than just discussing the issue with a family member or caregiver. Explain the reason for learning about the medication. Plan teaching that’s appropriate to the patient’s chronological age rather than cognitive age.1 In other words, if the patient is 40, teach with adult examples, not childish ones. While staying true to the concept, simplify the language to an appropriate level. Slow down your teaching, focusing on only one or two of the most important points.2 Don’t be surprised if you need to repeat or reinforce the information at each visit. Plan on additional time for the office visit because the teaching session may take longer than usual.3 Let’s use an example to illustrate this teaching approach. You’re seeing Mr. A, 55, who has Down syndrome and hypertension; he needs information about a new antihypertensive
©Apeloga/gettyimages
T
and a low-sodium diet. The goal of the visit is to help Mr. A begin safe treatment with hydrochlorothiazide, a diuretic, while introducing the dietary change. Using task analysis, break the topic into small sequential components also known as chunks. In this case, Mr. A first needs to take his medication on a regular schedule. By asking a few questions, you learn that Mr. A has a job at a grocery store. He usually eats breakfast at 0630, and then his brother takes him to work by 0745. You suggest to Mr. A that he put the medicine bottle next to his cereal box so he’ll remember to take one pill every time he eats cereal in the morning. The next task is to teach Mr. A how hydrochlorothiazide works. Fill an examination glove with water until it’s tight. Ask Mr. A to feel the glove. After letting
some of the water out, ask Mr. A to feel the glove again. Tell him that in a similar way, when Mr. A takes hydrochlorothiazide, he’ll urinate to get rid of excess sodium and fluid from his body. To avoid problems, you’ll need to teach Mr. A about possible adverse reactions to hydrochlorothiazide, including fluid volume deficit, GI disorders, muscle cramps, and dysrhythmias, and the importance of taking it as prescribed. Tell him not to stop taking it unless he talks to his healthcare provider first. Now you need to teach Mr. A about reducing the sodium in his diet. Using cans of food, show him how to find the sodium content. Mr. A will be comfortable with this example because he handles cans, frozen food, and fresh fruits and vegetables every day. Teaching him how to determine sodium content has three distinct parts: finding the word sodium on the label, finding the amount (usually in milligrams) on the label, and deciding if the sodium content is too high. You can teach Mr. A about these parts using the chaining method, which combines teaching, practicing, and repeating.4 Each time the sequence is practiced, the patient does one more step in the process independently. Teach the three parts of determining sodium content to Mr. A and practice them in sequence, one step at a time. Frequent repetition of both the individual steps and
This article originally appeared in Nursing2013 2013;43(6):68–69.
vol. 32 • no. 4 • April 2014
Home Healthcare Nurse 249
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table. Teaching Techniques for Patients With ID2,5-8 Technique
Description
Task analysis
Breaking up a task into small sequential components
Chunking
Teaching information in small, easily understood units
Chaining
This is a method of teaching, practicing, and repeating. Each time the practice is repeated, the patient does one more step in the process independently.
Using communication devices
Devices can be used to enhance, augment, or replace spoken language. They can range from simple equipment such as a white board or picture cards to high-technology devices.
Role-play/simulation
Simulation must be as “real” as possible because many people with ID don’t easily transfer data from one situation to another.
Small groups
Social support is very important to learning.
Concrete examples and stories
In general, people with ID don’t understand abstract ideas.
Frequent positive reinforcement
Give verbal praise and/or small tokens for successful completion of each step or unit.
Simplify language, not the concept
Stay true to the concept but simplify language to an appropriate level.
Explain reason for learning task
Understanding the reason makes the task more real.
Chronological-age appropriateness
Address and discuss issues appropriate to the patient’s chronological rather than cognitive age.
lnvolving families and caregivers
Patients can practice tasks and concepts at home.
of the entire sequence is crucial for success. Finally, role-playing could be an easy way for you to teach Mr. A about foods that are low or high in sodium. Take a few items from the kitchen at the ambulatory clinic and ask Mr. A to sort foods high in sodium into one bag and foods low in sodium into another. When he sorts the food correctly, make sure that you give him positive reinforcement. With some creativity, you can help Mr. A learn to take his new medicine on a regular schedule and make good choices about his food. But just as important, Mr. A will have a good experience with you as his nurse. Marlena Seibert Primeau is a Clinical Assistant Professor and Karen H. Frith is a Professor at the College of Nursing at
250 Home Healthcare Nurse
the University of Alabama in Huntsville. The authors have disclosed that they have no financial relationships related to this article. DOI:10.1097/NHH.0000000000000046 REFERENCES
1. Shurr J, Taber-Doughty T. Increasing comprehension for middle school students with moderate intellectual disability on age-appropriate texts. Educ Train Autism Dev Disabil. 2012;47(3):359-372. 2. National Cancer Institute at the National Institutes of Health. Clear and simple: developing effective print materials for lowliterate readers. 2003. http:// www.cancer.gov/cancertopics/ cancerlibrary/clear-and-simple. 3. Yale College. Teaching students with disabilities guide. 2013. http://yalecollege.yale.edu/ content/teaching-studentsdisabilities-guide.
4. Pratt C. Applied behavior analysis: the role of task analysis and chaining. Indiana Resource Center for Autism, Indiana University. 2013. http:// www.iidc.indiana.edu/index .php?pageId=3458. 5. Küpper L, Hamilton K. Intellectual disabilities in your classroom: 9 tips for teachers. National Dissemination Center for Children with Disabilities (NICHCY). http://nichcy.org/intellectual disabilities-in-your-classroom. 6. National Institutes of Health. Clear communication: a NIH health literacy initiative. 2012. http:// www.nih.gov/clearcommuni cation. 7. National Institutes of Health. Plain language: tips for using plain language. 2013. http://www .nih.gov/clearcommunication/ plainlanguage.htm#tips. 8. Morrisey B. Communication. Speech Disorder. 2012. http:// www.speechdisorder.co.uk/ communication-boards.html.
www.homehealthcarenurseonline.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
