NR 305 Week 7 Self-Injection Teaching Plan Example

Teaching Self-Injection of a Blood Thinner Before Discharge: A Plan for a 64-Year-Old Woman After Knee Replacement

Student Name

College of Nursing, Chamberlain University

NR 305: Health Assessment for the Practicing RN

Instructor Name

Month Day, Year

Teaching Self-Injection of a Blood Thinner Before Discharge: A Plan for a 64-Year-Old Woman After Knee Replacement

The Learner, Assessed First

Mrs. D. is a 64-year-old retired librarian, two days after a right total knee replacement, who will go home tomorrow with a prescription for enoxaparin 40 milligrams injected under the skin once daily for 14 days to prevent blood clots. She lives with her husband, who has early Parkinson disease and a tremor in both hands. Assessment of her as a learner, done during a morning conversation and a short reading task, found the following. She reads easily and likes to have instructions on paper to refer back to. She has never given an injection and says the idea of putting a needle in herself makes her feel faint; she asked whether a home nurse could do it. She wears reading glasses and did not have them on the first day. Her pain after physical therapy peaks around 1400 and makes her tired and less able to concentrate. She has good dexterity in both hands. Her husband wants to help but cannot manage fine motor tasks reliably. She believes the injections are optional if she walks enough.

Two barriers matter most: anxiety about needles and the belief that the medication is optional. Neither is a knowledge deficit that a pamphlet would fix. Bastable (2019) describes readiness to learn as depending on emotional as well as physical and experiential factors, and Mrs. D.'s anxiety needs to be addressed before the skill can be taught.

The Goal, Written as Behavior

By discharge tomorrow at 1100, Mrs. D. will give herself a correct subcutaneous injection of enoxaparin from a prefilled syringe, with the nurse observing and without prompting, and will state why she needs all 14 doses.

Objectives

Objective 1 (affective): By the end of the first session today, Mrs. D. will state one reason the injections matter to her, in her own words.

Objective 2 (cognitive): By the end of the first session, she will name the two sites where she will inject, the areas of the abdomen at least 2 inches from the navel, and the rule of alternating sides.

Objective 3 (psychomotor): By 2000 today, she will give her evening dose herself with the nurse's hands off the syringe, following the steps on the instruction sheet.

Objective 4 (psychomotor, repeated): At 1000 tomorrow, before discharge, she will give the dose again without prompting.

Objective 5 (cognitive): Before discharge, she will state three signs that mean she should call her surgeon: bleeding that will not stop, black stools or blood in urine, and a large or spreading bruise at the site.

Content and Method, Session by Session

Session one is scheduled for 1000 today, before physical therapy, when her pain is lowest, with her glasses on and her husband present. The nurse begins with the affective objective rather than the skill: explaining in plain terms that after knee replacement, clots can form in the leg veins, that a clot can travel to the lungs, and that the injection lowers that risk during the weeks she is less active, which walking alone does not fully replace; national guidance recommends continuing prophylaxis for at least 10 to 14 days after major joint replacement (Falck-Ytter et al., 2012). The nurse then asks her what matters to her about her recovery, and she answers that she wants to be walking her dog in six weeks, which becomes the reason she states for Objective 1. Next, the nurse demonstrates the injection on a practice pad with a training syringe, naming each step aloud: wash hands, choose and clean the site, remove the cap without pushing out the air bubble, pinch a fold of skin, insert the needle straight in at 90 degrees, press the plunger fully, withdraw, and let the safety shield cover the needle. Mrs. D. then practices on the pad twice.

Session two is the evening dose at 2000. Mrs. D. gives the injection to herself with the nurse beside her and the instruction sheet on the table. The nurse coaches with words only and does not touch the syringe. Session three is the morning dose tomorrow at 1000, done without prompting, followed by the teach-back questions for Objective 5. Written materials are a one-page sheet in large type with a photograph for each step and the surgeon's phone number, checked for plain language using the principles in the Agency for Healthcare Research and Quality health literacy toolkit (Brega et al., 2015).

Addressing the Barriers

For the needle anxiety, the plan uses graded exposure: handling the syringe, then practicing on a pad, then self-injection with support, rather than asking her to inject herself on first contact. She is taught to sit down for every injection, to breathe slowly and to look at the site rather than away, which many people find reduces anticipation. She is told that feeling anxious the first time is common and that most people find the second injection easier. For the belief that the medication is optional, the plan relies on connecting the injections to her own goal and on teach-back, asking her to say, as she would to a friend, why all 14 doses matter. Her husband is taught to help by keeping the calendar of doses, which fits his abilities, rather than by giving injections.

Evaluation

Evaluation is tied to each objective. Objectives 1, 2 and 5 are evaluated by teach-back, following the health literacy toolkit's approach: Mrs. D. puts each point into her own words, and anything she misses is taught again and rechecked until her explanation is right (Brega et al., 2015). Objectives 3 and 4 are evaluated by direct observation using a 10-step checklist based on the instruction sheet; each step is marked done correctly, done with prompting or not done. If she cannot complete the injection without prompting by 1000 tomorrow, the nurse will request a home health referral for the first three doses rather than delay discharge. The discharge note will record her performance on each objective, so the home health nurse, if one is involved, knows exactly where to begin.

Mrs. D. will also be asked, at the end of the last session, how confident she feels on a scale she chooses, because confidence predicts whether she will actually give the doses at home when no nurse is watching.

References

Bastable, S. B. (2019). Nurse as educator: Principles of teaching and learning for nursing practice (5th ed.). Jones & Bartlett Learning.

Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., Cifuentes, M., Albright, K., & West, D. R. (2015). AHRQ health literacy universal precautions toolkit (2nd ed., AHRQ Publication No. 15-0023-EF). Agency for Healthcare Research and Quality.

Falck-Ytter, Y., Francis, C. W., Johanson, N. A., Curley, C., Dahl, O. E., Schulman, S., Ortel, T. L., Pauker, S. G., & Colwell, C. W., Jr. (2012). Prevention of VTE in orthopedic surgery patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2, Suppl.), e278S-e325S. https://doi.org/10.1378/chest.11-2404