_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________
,
CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A PATIENT TEACHING MANUAL FOR
SELECTED STAFF NURSES
A project submitted in partial satisfaction of
the requirements for the degree of Master of
Public Health
by
Dorothy C. Blair
May 1983
The Graduate Project of Dorothy C. Blair is approved:
California State University, Northridge
ii
DEDICATION
This project is dedicated to my
husband, Leslie R. Blair, whose
love and wise counsel have supported
me throughout this educational
endeavor.
iii
ACKNOWLEDGMENTS
I wish to express my appreciation to Dr. Anthony M.
Alcocer, Chairperson of my Advisory Committee for his
guidance, support, and availability throughout this project.
A special thanks to the other members of my Advisory Committee, Dr. Michael V. Kline and Dr. Jack Winkelman, for
their cogent remarks and timely review during the writing
of this manuscript.
A sincere thank you goes to members of the Curriculum
Committee, Maria Maglalang, R.N.; Genevieve La Cesa, R.N.:
Mary Walker, R.N.; Gayle Hesser, R.N.; and Adele Deming,
R.N., who supported this project from the beginning.
Also,
my thanks to Linda Heinz-Hawkins, R.N., M.S., Research Nurse
at the Sepulveda Veterans Administration Medical Center, for
her guidance during the exploratory stages of this project.
Lastly, I wish to thank Fran Weber, Program Director,
for allowing me to be a part of the Cardiac Rehabilitation
Program.
iv
TABLE OF CONTENTS
Page
Approval . •
ii
Dedication .
iii
iv
Acknowledgments
VIii
List of Tables
ix
Abstract
Chapter
1.
1
Introduction
Statement of the Problem
2
Purpose of the Project
3
Significance of the Problem .
3
Delimitations •
8
Limitations of the Project
9
Assumptions .
9
Definition of Terms •
2.
Review of the Literature
10
13
The Evolution of Hospital-Based
Patient Education Programs
13
The Role of the Professional Nurse
in Patient Education
19
Barriers to Patient Teaching Among
Hospital Staff Nurses .
23
Delivery Systems in Patient Education •
27
v
Chapter
3.
4.
5.
Page
Methodology •
33
Exploration of the Problem
33
Formulation of the Curriculum
Committee • • •
35
Identification of the Subjects and
Setting • •
• • •
. • • • •
36
The Survey Questionnaire
36
Development of the Teaching
Manual Contents
. • • . • • • • .
38
Implementation of the Manual
42
Evaluation of the Manual and
Documentation Record
44
Results .
46
•
Findings of the Survey Questionnaire
47
Findings of the Staff Nurse Evaluation
of Manual and Documentation Record
55
Findings of the Retrospective Medical
Record Review
. • • •
58
Summary, Conclusions, and Recommendations
61
Summary .
61
. •
Conclusions
64
Recommendations .
65
67:
BIBLIOGRAPHY
APPENDICES
A.
Cover Letter for Testing Questionnaire
75'
B.
Consent Form
77,
c.
Cover Letter to Participants
79
D.
The Survey Questionnaire
81
vi
APPENDICES
Page
E.
Evaluation Questionnaire
F.
Retrospective Audit Criteria
90
G.
The Teaching Manual
92
vii
.
• •
88
LIST OF TABLES
Table
1.
Page
What Should be Included in Patient
Teaching?
. • . .
48
Staff Nurses' Feelings of Competency
for Patient Teaching
. . . . .
49
Obstacles which Interfere with the
Quality and Quantity of your Patient
Teaching
50
4.
Most Frequently Named Obstacles •
50
5.
Staff Nurses' Knowledge/Feelings
About Standardized Teaching Plans .
52
6.
Basic Nursing Education .
53
7.
College Level Courses .
53
8.
Time in Present Assignment
54
9.
How Often Have you Used the Teaching
Manual? .
56
What Part of the Teaching Manual do
You Use Most Frequently?
56
Staff Nurses' Assessment of the
Documentation Record
57
2.
3.
10.
11.
12.
.
Comparison of Compliance with
Documentation Criteria Before/After
Implementation of Teaching Manual and
Documentation Record
. .
viii
.
•
59
ABSTRACT
A PATIENT TEACHING MANUAL FOR
SELECTED STAFF NURSES
by
Dorothy C. Blair
Master of Public Health
The problem which this project addressed was to
develop a teaching manual which would standardize the educational content to be taught by hospital staff nurses
participating in an in-patient cardiac rehabilitation program.
The purpose of the project was twofold:
(l) to
assess the staff nurses' perceptions of their role in
patient teaching to identify characteristics of the target
group which could be useful in planning the manual contents and inservice program; and (2) to develop, implement,
_., and evaluate a teaching manual and documentation record to'
promote staff nurse participation in a cardiac rehabilitation program.
The investigator conducted a review of the literature to assess the present status of hospital-based patient
ix
education programs.
review included:
Significant areas of the literature
(1) the evolution of hospital-based
patient education programs,
(2) the role of the profes-
sional nurse in patient education,
(3) barriers to patient
teaching among hospital staff nurses, and (4) delivery
systems in patient education.
A survey questionnaire was employed to assess the
staff nurses'
teaching,
(1) beliefs about their role
in patient
(2) feelings of competency in teaching specific
health content, and (3) knowledge of standardized teaching
plans.
The investigator designed a teaching manual and
documentation record which were implemented in conjunction
with the initiation of a cardiac rehabilitation program.
Evaluation processes included a questionnaire to
elicit the staff nurses' perceptions of the usefulness of
the teaching manual and documentation record.
Further
evaluation was accomplished through two retrospective medical record reviews to determine the percent of compliance
with the documentation criteria developed in conjunction
with this project.
Results of the staff nurses' evaluations of the teaching manual and documentation indicated that a majority of
the respondents had used the manual at l'east once.
Teach-.
ing plans and medication sheets were identified as the
,part of the manual used most frequently
Results of the
medical record review conducted six months following implementation of the documentation record reflected improvement
X
in both the quality and quantity of the nurses' entries
in the patient's chart.
Conclusions drawn from this project were:
{1)
a
teaching manual with standardized subject matter, instructional objectives, evaluative criteria, teaching resource
materials and patient handouts improved the staff nurses'
ability to delivery patient education;
(2) a standardized
documentation record substantially increased the amount
of teaching entries in the medical record by the target
group.
xi
CHAPTER ONE
Introduction
Health education has been one of the strategic
elements within the public health field since its inception.
Health teaching has also received significant
emphasis in school health programs, public health departments, and voluntary community agencies.
Emphasis on well-
ness and disease prevention has long been the focal point
of these community-based health education programs.
How-
ever, changing health care needs within the general population and the passage of certain national legislation has
prompted attention to be shifted to improvements of the
health status for specified patient groups.
Increasingly,
there has been a proliferation of hospital-based programs
planned primarily to enhance the patient's knowledge of
disease processes and provide instruction to allow the
patient to develop the necessary skills to cope with the
multiple problems association with chronic illness.
Escalating medical care costs, especially hospital
costs, has been an important factor in the emergence of the
concept of encouraging the patient to become an active participant in the therapeutic plan of care.
Hospital-based
patient education programs gained momentum as professional
.groups endorsed patient education as an jntegral component
1
2
of quality health care services.
Patient education is
generally accepted as a responsibility of the hospital
staff nurse by both nursing management and the peer group
(Zander, 1978; Redman, 1980).
This project was concerned
with the need to provide selected staff nurses with a
teaching manual and documentation record to facilitate
nursing participation in a multidisciplinary cardiac rehabilitation program.
Statement of the Problem
The problem of this project was to develop a teaching·
manual for selected staff nurses participating in a cardiac
rehabilitation program which would:
(1) delineate the role
of the nursing staff in the program;
(2) standardize the
educational content to be taught by nurses; and (3) facilitate the documentation of learning outcomes in the medical
record.
Purpose of the Project
The purpose of this project was twofold:
the staff nurses' perceptions of their role
(l) to assess
in patient
teaching to identify characteristics of the target group
which could be useful in planning the manual contents and
the in-service program; and (2) to develop, implement and
evaluate a teaching manual and documentation record to pro.mote staff nurse participation in the Cardiac Rehabilitation
Program being developed at the Veterans Administration
Medical Center, Sepulveda, California.
3
Significance of the Problem
Patient education is widely accepted as being a vital
component of quality health care by most professional
nurses today.
However, much of the teaching is informal,
unplanned and is likely to be initiated in direct response
to patient inquiry (Redman, 1978).
Additionally, the
nurse's documentation in the medical record often fails to
indicate the patient's response to the health teaching
interaction (McClurg, 1981).
Over the past decade, the impetus for formalized education has evolved from several sources, beginning with
the 1972 statement of the American Hospital Association
that the patient has a right to information concerning his/
her health status, treatment plans, and expected outcome
(AHA, 1972).
The Joint Commission on Accreditation of Hos-
pitals standards for nursing service delineates the expectation for patient education in Standard IV and more
specifically in Standard VI, which states:
"There must be
written policies and procedures concerning the role of the
nursing staff in patient and family education"
(JCAH,
1982:120).
Studies have shown that few staff nurses feel they
have adequate preparation for
teachin~
(Sutherland, 1980;
Murdaugh, 1980), yet current practice standards hold nurses
accountable for planning, implementing, and evaluating
patient education.
Since few schools of nursing include
patient teaching in their curriculum, according to Redman
4
(1976), the expectation that nurses are being prepared adequately to meet practice standards is totally unrealistic.
In addition to lack of preparation for teaching, a recent
study by Murdaugh (1980) identified lack of time to teach as
one of the major factors affecting the amount of teaching
staff nurses were able to accomplish.
According to Skillern
(1977), one of the benefits of a planned organized patient
education program is that "quality and quantity is consistent
and not subject to fatigue or lack of time."
Other studies
(Geertsen, Ford, and Castle, 1976; Troth, 1980; Scalzi,
Burke, and Greenland, 1980; Milazzo, 1980), support the
efficacy of structured patient education programs.
Madnick
(1980) makes the strongest statement yet on the need for
hospital-based patient education programs, when she says:
One of the most important components of a comprehensive hospital-based consumer health education program is the teaching plan for specific populations. A
well-designed written teaching plan is a valid document
to indicate that the hospital has an organized approach
to patient teaching and that the staff has specific
policies, guidelines and procedures to follow. This
document can be used as a reference for review by
accrediting agencies, such as the Joint Commission on
Hospital Accreditation; for third party payers, such as
Blue Cross; private insurance companies and Medicare;
and regulating agencies such as state review boards.
(Madnick, 1980:104)
Patients with coronary heart disease are one of the __
specific population groups that can benefit from a planned,.
organized patient education program.
Diseases of the heart
are the leading cause of death in the United States.
Death
rates from all categories of diseases of the heart and blood
vessels comprised approximately 60 percent of the total
5
annual death rate in the United States in 1975 (Shafer,
1975).
In terms of numbers of deaths, this equates to
nearly one million deaths due to cardiovascular diseases, of
which 722,570 are attributable to heart disease.
Ischemic
heart disease (coronary atherosclerosis) is by far the most
significant form of cardiovascular disease in terms of both
morbidity and mortality.
The prevalence of coronary heart
disease among adults ages 17-79 is about one-third the
prevalence of hypertensive heart disease.
However, whenthe
mortality figures of these two conditions are compares, one
sees that coronary heart disease is by far the most lethal.
Coronary disease is the leading cause of death among males
35-44 years of age.
Additionally, more than 34 percent of
all male deaths from coronary heart disease occur under the
age of 65.
These untimely deaths, occurring during the peak
earning years, result in economic hardships and family disruptions which impact on the greater community.
According
to Lewy in his recent book on preventive medicine:
Reductions in the leading cause of mortality in
the United States will not occur through advances in
curative treatment as rapidly as through advances in
early disease detection and preventive education (Lewy,
198l:i)
Reducing the morbidity and mortality of atherosclerosis
has been shown to be directly related to the individual's
~nowledge
about the benefits of risk factor modification,
~ccording
to Lewy (1980).
Changing the individual's
health behavior related to those factors which have
been shown to increase the risk of coronary heart
6
disease is incorporated into the preventive model endorsed
by the American Heart Association, especially for those
individuals who have not yet developed clinical symptoms
(Coronary Risk Handbook, 1973).
However, prevention of
another clinical event among persons with a known history
of heart attack is essential if we are to make any significant impact on mortality statistics.
Even in individuals
with an uneventful recovery from an acute myocardial infarction, life expectancy is significantly reduced (Harvey,
1980).
The accessibility of education as an integral part of
health care services for the hospitalized patient has
received considerable attention in the past decade
(Richards and Kalmer, 1974; Ross, 1976; Boggs, Malone, and
McCullough, 1978; Madnick, 1980).
Similarly, the nurse's
role in patient teaching has been extensively discussed
in the literature (Redman, 1976; Winslow, 1976; Redman,
1978; del Bueno, 1978).
The perspective of this integra-
tion of patient teaching into the role of the professional
nurse is supported by recent changes in Nurse Practice
Acts which have delineated health teaching as an independent function of nursing (Hall, 1975).
Nursing practice standards and the mandates of
accreditation agencies place
the hospital staff nurse in
a position of being held accountable for the delivery and
documentation of patient education.
However, nursing
7
school educational programs have yet to incorporate a systematic approach to patient education into their curriculum
(Redman, 1976).
This seeming lack of dialogue between the
educational community and the service community within the
nursing profession has left the practitioner ill prepared
to meet current performance expectations as patient educators.
A registered nurse who is also prepared as a
health educator is in a unique position to share with nursing colleagues those additional professional skills necessary in the development of standardized teaching plans.
Many factors impact on the staff nurse's performance
in the stressful environment of a large medical center.
Among these are the ever increasing knowledge explosion,
accompanied by sophisticated technological advances, and
the current recruitment and retention dilemma confronting
most medical facilities in urbanized areas.
The quality
and quantity of nurses' teaching activities have been shown
to be directly related to their acceptance of patient education as a professional responsibility and their feelings
of competency for teaching specific health content (Toth,
1980).
Redman (1976) reminds us that although many nurses
identify patient teaching as a professional responsibility,
nurses generally have little preparation as patient educators.
If nurses have not been taught the skills required
to develop, implement, and evaluate patient teaching, it is
unrealistic to believe that this activity will receive a
8
high priority compared to other pressure experienced daily
by staff nurses in a large teaching hospital.
The medical center which served as the investigator's
field training site was in the process of developing a
multidisciplinary cardiac rehabilitation program.
The nurs-
ing staff, by virtue of their twenty-four patient care
responsibilities, must be knowledgeable of their role in
this program.
Presently, the staff nurses are providing
informal, fragmented educational experiences for the cardiac
patient, but without benefit of standardized subject content, learning outcomes, teaching resource materials, or a
process for consistent documentation in the medical record.
In order to evaluate the effectiveness of the cardiac rehabilitation program, there is a definite need to develop,
implement, and evaluate a standardized teaching plan for
the nursing component, within the framework of the overall
program goals.
Delimitations
The project was undertaken to provide selected staff
nurses with a curriculum for teaching patients specific
health content as part of a cardiac rehabilitation program.
This project did not provide for:
(1) the evaluation of the
staff nurses teaching skills, or (2) the evaluation of
patient learning outcomes after introduction of the manual.
9
Limitations of the Project
The limitations of this project include:
(1) the data
derived from the initial questionnaire are specific to the
selected staff nurses at the Veterans Administration Medical Center, Sepulveda, California, and cannot be generalized to other staff nurse populations;
(2) the curriculum
content for the teaching manual was developed for a specific discipline within the overall framework of a multidisciplinary program and is not meant to represent the entire
educational package of a cardiac rehabilitation program or
to be applicable to other health care settings;
(3) the
sample size is small because the project is limited to
staff nurses on three nursing units who are voluntary participants;
[4)
the data obtained from self-administration
questionnaires force
~he
investigator to rely on the sub-
jects to follow written instructions and to provide a
response to each question;
(5) use of the medical record as
a data source forces one to contend with missing information.
Assumptions
The assumptions paramount to· the undertaking of this
project were:
1.
Patient education is valued as an essential com-
ponent of professional nursing practice by the staff nurses
at the Sepulveda Veterans Administration Medical Center.
10
2.
Establishment of learning objectives and deline-
ation of teaching responsibilities will promote a more
harmonious team relationship among the various disciplines
involved in the
3.
card~ac
rehabilitation program.
The quality of patient education endeavors will be
enhanced through development of a formalized program with
measurable learning outcomes.
4.
Teamwork among health care professionals must
exist to sustain a patient education program.
5.
Learning opportunities must be integrated into
nurse-patient interaction to enhance the educational
moment.
Definition of Terms
To promote clarity and understanding of terms used
throughout this project, the following definitions are
offered:
Patient Education:
Providing information and subject
matter, based on individual need, which will facilitate the
individual's participation in the treatment plan during
hospitalization and promote safe self-management after
discharge.
Standardized Teaching Plan:
A written document used
to impart knowledge and skills to a specific ·patient population in an organized, sequential manner, using previously
established subject matter content, instructional objectives and evaluative criteria, sometimes called a curriculum.
11
Specified Patient Population:
Individuals who by
virtue of a shared diagnosis or problem may have similar
educational needs.
Selected Staff Nurses:
Registered nurses assigned to
the Coronary Care Unit, Medical Intensive Care Unit, and
the Cardiology Ward at the Veterans Administration Medical
Center, Sepulveda, California.
Evaluation:
The process of determining the signifi-
cance, worth, or degree of achievement of specific goals
through careful study and appraisal utilizing preestablished criteria to measure outcomes.
Quality of Documentation:
Operationalized to include
specific entries in the medical record which indicate the
patient's response to the educational process and the
demonstrated level of understanding of health teaching content, including attainment of pre-established instructional
objectives.
Quantitv of Documentation:
Operationalized as the
specific number of entries in the medical record which
describe the patient teaching activities by staff nurses.
Retrospective Medical Record Review:
The process of
reviewing the medical record of specific discharged
patients to assess the level of compliance with preestablished documentation expectations, including time
frames and content.
12
Multidisciplinary Team:
A work group comprised of
representatives from several health care professions who
share a common goal and participate in different aspects of
a single program according to their area of expertise.
CHAPTER TWO
Review of the Literature
A review of the literature was conducted to assess the
present status of hospital-based patient education programs
and to identify issues which impact upon the health care
system and certain health care professionals.
areas in the literature review included:
Significant
(1) the evolution
of hospital-based patient education programs;
(2) the role
of the professional nurse in patient education;
(3) bar-
riers to patient teaching among hospital staff nurses; and
(4) delivery systems in patient education.
The Evolution of Hospital-Based
Patient Education Programs
Hospitals have traditionally been the locus of learning for numerous professional and paraprofessional health
care providers, but only in the last decade have we seen
hospitals expand their educational concerns to include
patients (Ulrich, 1972).
Impetus for the development of
hospital-based patient education programs evolved out of
concern expressed through various legislative actions and
policy statements emanating from both the private and public
sectors.
At the national level, passage of legislation to
establish a health insurance program for the elderly and a
medical assistance program for recipients of public
13
14
subsistence brought many individuals into the mainstream of
the health care system (SSA, 1965).
The resultant impact
upon the private sector led to the formation of health
planning groups at both the state and national levels,
generating a plethora of policy statements on the role of
health education in:
(1) promoting healthy life styles,
(2) developing self-maintenance skills in the chronically
ill, and (3) serving as a mechanism to contain health care
costs.
Simonds (1978) attributes the resurgence of inter-
est in health education, in part, to the spiraling cost of
medical care resulting from those health care legislative
programs of the mid-1960's.
In addition to the economic
realities, there was a growing awareness that advances in
medical technology and a national medical care program for
the elderly were less likely to produce major improvements
in the heal:th status of the nation as were changes in
individual life styles (Simonds, 1978:18).
Another milestone was reached with the advent of
Health Maintenance Organizations, defined as a "comprehensive prepaid system of health care with emphasis on the
prevention and early detection of disease"
1976:536).
(Marcarelli,
With this emphasis on prevention, there is an
implied need to educate the membership in healthful living
and the recognition of early signs of disease.
The law,
in fact, outlines specific patient education activities
which must be provided by the HMO as a condition of the
15
federal funding stemming from this legislation.
The spe-
cific language of the law reads:
An HMO shall encourage and actively provide for
its members education services and education in the
contribution each member can make to the maintenance
of his own health (P.L.93-222, Section 1301-C-9).
Mullen and her co-workers point out that the educational needs of the membership "arise out of the differences between the HMO and the fee-for-service medical
practice"
(Mullen et al., 1979:55).
Passage of the Health
Maintenance Act of 1973 (P.L. 93-222) mandated an organizational structure which brought the consumer into the
policy-making arena through participation on governing
boards and patient advisory boards.
This emergence of the
consumer movement brought a powerful new influence to health
care planning (Fox, 1979) .
Similarly, the National Health Planning and Resources
Development Act of 1974 (P.L. 93-641) amended the Public
Health Service Act to provide for the development of a
national health policy and promote state and local areawide planning of health services through health systems
agencies.
The stated purpose of these agencies was three-
fold:
(1) improving the health of area residents;
(2) increasing accessibility, acceptability,
continuity and quality of health services;
(3) restraining costs and preventing duplication
of health services.
(Wilson and Neuhauser, 1976:
186)
16
Disillusionment with the rising costs of health care
led to other developments at the federal level.
Ogden
(1978) cites various congressional actions which helped
shape public policy on health education.
Among these were
the federally funded programs whose aim was control of the
major catastrophic diseases of cancer, heart and lung, and
diabetes.
National leaders began to look beyond the tradi-
tional medical model of health care delivery toward illness
prevention and health promotion (Ogden, 1978:67).
In 1976,
the Consumer Health Information and Health Promotion Act
(P.L. 94-317) was enacted by Congress and preventive education was given another boost.
Roccella (1976) reviewed several studies outlining
the role of health education in reducing runaway hospital
costs through better utilization of resources within the
health care system.
Specifically, reductions in readmis-
sion rates (Rosenberg, 1971), fewer visits to the hospital
emergency room (Avery, 1972; Miller and Goldstein, 1972);
shorter hospital stays (Egbert, 1974) lead to the conclusion that hospital-based patient education programs .can be
cost-effective.
In the private sector, several events were occurring
which paralleled the previously reviewed legislative
actions, thus adding to the list of significant factors in
the promotion of hospital-based patient education programs.
Among the most significant of these events was the
issuance of a "Patient's Bill of Rights in 1972 by the
17
American Hospital Association.
Several landmark legal
decisions involving the patient's right to informed consent
caught the attention of physicians seeking to avoid malpractice claims and hospitals seeking to avoid liability
for failing to assure medical staff compliance with the
doctrine of informed consent (McCoughrin, 1981; Longo,
1981).
Another supporter of informed consent claims, "the
American Hospital Association, in publishing and support:ing
the Bill of Rights, has done more than any other professional organization to·define and support patient education"
(Roth, 1978:14).
Hospital-based inpatient education programs prolif-
erated as third-party payers began to issue policy statements endorsing the concept.
In August 1974, the Blue
Cross Association released a statement encouraging health
care institutions to establish and operate inpatient education programs and suggested financial support through
existing payment mechanisms (Somers, 1976).
The Board of
Governors went on to say:
The health care system is being challenged to
improve its efficiency and effectiveness. Reforms
in the system must forcefully address the need to
contain rising health care costs and to assure the
quality of health care services.
(Blue Cross
Association, 1974).
The Blue Cross White Paper postulated that patient
education programs would impact on both the cost and the
·quality of patient care.
One significant study that sup-
ports this premise was r.eported in the New England Journal
18
of Medicine two years prior to the Blue Cross statement.
At the University of Southern California Medical Center,
the revamping of the care offered diabetic patients produced dramatic results in both cost containment and quality
of care.
The authors reported a 50 percent reduction in
emergency room utilization by diabetic patients and nearly
a 66 percent decline in the incidence of diabetic coma in
their patient population (Miller and Goldstein, 1972) .
Similarly, an earlier study designed to evaluate the
impact of a patient education program for individuals with
congestive heart failure, found that not only was there a
decline in the number of readmissions, but total admissions
for the study population was also reduced (Rosenberg, 1971).
Numerous studies have identified the relationship of preoperative teaching to reduction in the amount of pain medication required post-operatively as well as its role in
reducing the number of hospital days (Healy, 1968; Lindeman
and Van Aerman, 1971; Egbert, 1974).
In 1975, the American Hospital Association enunciated
the role and responsibility of health care institutions in
providing patient education programs by issuing the following statement:
Health education is an integral part of high quality health care. Hospitals and other health care
institutions as focal points of community health care,
have an obligation to promote, organize, implement and
evaluate health education programs.
(American Hospital
Association, 1974)
19
Support for planned patient education programs came
also from the American Medical Association (1975) when two
resolutions dealing with patient education were approved at
the annual convention.
The AMA concluded that structured
educational efforts could:
care,
(1) enhance the quality of
(2) promote adherence to the prescribed treatment
program,
(3) improve physician/patient interaction, and
(4) reduce the overall cost of treatment.
The Role of the Professional Nurse
i~ Patient Education
Education. of the patient has been a part of the ongoing professional responsibility of physicians, nurses,
and other·patient-care disciplines practicing in hospitals.
Nurses, by virtue of their direct patient care responsibilities, are in a unique position within the health care
system to provide instruction to patients and families.
They are frequently perceived by patients as caring people
who are less threatening than other health professionals
(Grosser, 1981).
It has been suggested that the physician
is often the least effective patient teacher because of
his/her perceived position of authority (Simonds, 1963;
Reader, 1974; De Haes, 1982).
Zander (1978) proposes that patient education is a
universal component throughout all areas of nursing practice, regardless of the setting or patient population.
Advocacy for utilizing as teachers the health workers who
20
are already caring for the patient's other health care
needs further emphasizes the nurse's role in patient education (Ulrich, 1972:101).
Nursing leaders have discussed
the teaching responsibilities of the professional nurse
with increasing regularity in the literature (Redman, 1978;
Zander, 1978; Redman, 1980; Bille,:
1981) .
The National
League for Nursing charges the nurse with the responsibility of upholding certain patients' rights.
Specifically,
the NLN states:
Patients have the right to appropriate instruction and education from health care personnel so
that they. can achieve an optimal··level of wellness
and an understanding of their basic health needs.
(National League for Nursing, 1978)
Further evidence of the importance of teaching
patients is found in official professional nursing association statements on the role of the nurse in patient education.
A 1975 publication by the American Nurses Associa-
tion provides guidelines for the professional nurse's
partic~pation
in health education activities.
The guide-
lines state:
As a health care provider, every professional
nurse is responsible and accountable to the patient
and family for the quality of nursing care the
patient receives. This responsibility and accountability includes teaching the patient and family
relevant facts about specific health care needs and
supporting.appropriate modification behavior.
(American Nurses Association, 1975)
The nurse's role as a patient educator is both a professional mandate and a legal responsibility in some
states.
Recent changes in Nurse Practice Acts clearly
21
defines health teaching as an independent nursing function.
The specific language of the Nurse Practice Act varies
from state to state and references to patient education may
be either implicit or explicit (Hall, 1975).
Anderson
(1978) discusses changes in the Nursing Practice Act which
have dramatically re-defined the boundaries of nursing
practice in California.
An examination of the regulations
governing the curriculum content for nursing programs specifies the training necessary to achieve the basic standards
for competent performance and includes the following
language:
Explains the health treatment to the consumer and
family and teaches the consumer and family modifications of care as health care needs change.
(Anderson,
1978:5)
Evidence supporting nursing's acceptance of responsibility for patient teaching is found in a 1977 survey by
the American Hospital Association, which showed:
(1) hos-
pital staff members most involved in patient teaching were
nurses;
(2) in 68 percent of the hospitals reporting,
patient education outcomes were cited as nursing audit criteria and were used to measure the quality of care;
(3) of
all hospital professionals, nurses were more likely to
serve on the patient education policy committee; and (4)
for those hospitals reporting specific line authority for
coordinating patient education, the department of nursing
was responsible close to 60 percent of the time (Lee and
Garvey, 1977).
22
Over the years, numerous researchers have assessed
the perceptions of nursing practitioners on their roles
in patient teaching in a variety of settings (Streeter,
1953; Monteiro, 1964; Pohl, 1965; Winslow, 1976; Sutherland,
1980).
At the time of her 1953 study, Streeter found no
organized patient teaching programs in the eight hospitals
she reviewed in spite of the fact that the nurses reported
they felt their patients were not receiving enough teaching
regarding disease prevention and health promotion.
A more
recent study revealed that between 1972 and 1975 there was
better than a
~0
percent increase in the number of hos-
pitals incorporating patient education as an element of
treatment.
Much of this change was the direct result of
the legislation and policy statements previously discussed
(Green et al., 1980).
Monteiro (1964) reported that hospital staff nurses
missed many opportunities to incorporate patient teaching
into their direct care activities because of their perception of teaching as a formalized, distinct activity.
In
Pohl's study (1965), the findings demonstrated lack of
adequate preparation for the teaching role as the most significant factor in the nurse's performance as a patient
educator.
Perceptions of the role of the nurse as a
patient teacher were not supported by the staff nurses'
behavior in the 1976 study by Winslow.
Prior to develbp-
ment of a planned patient education program, Sutherland
(1980) distributed a questionnaire to two hundred
23
registered nurses to assess their perceptions of their
menti
roles in patient education.
Ironically, the respondents
comm
overwhelmingly indicated they felt the physician should be
larg
the one to tell patients about their conditions.
rie:r
BilJ
In actual
practice, however, patient teaching in preparation for discharge was perceived by the nurses to be shared equally
ciaJ
with the physician.
This seeming role confusion among pro-
Ofb
fessional nurses exists in part because of a "lack of clarity
bef
tic
about the physician's role in teaching and poor performance
by physicians"
(Redman, 1976; 15).
Ulrich (1972), on the
Mm
other hand, attributes the nurse's reluctance to teach to
the uncertainty of what the doctor wants taught.
a:
Barriers to Patient Teaching
Among Hospital Staff Nurses
Th
la
tc
v;
Nurse-Related Barriers
One of the most significant barriers to patient edu-
m
cation in the hospital setting is attributed to "profes-
t
sional territoriality"
(Bernheimer, 1980:181).
The
physician and nurse were for a long time the primary patient
care providers.
Hospital personnel today include many
other disciplines, each of which see patient instruction as
important aspects of the care they provide to patients.
Accordingly, this has led to "ill-defined boundaries among
health care professionals"
(Redman, 1978:1366).
The degree
of independence expected from the hospital staff nurse in
initiating patient education
opportunit~es
has been
35
the nursing staff bears primary and secondary responsibilities not experienced by the other team members.
This
fact served to reinforce the need to delineate and communicate the program responsibilities of the nursing staff to
other team members.
With this in mind, the decision was
made by the investigator that defining the role responsibilities of all levels of nursing personnel involved in
the program would need to be an essential component of the
teaching manual.
Formulation of the
Curriculum Committee
The first step in the actual planning process involved
a "brainstorming" meeting between the investigator and
several members of the nursing staff whose support was
essential to the completion of the project.
This group
which evolved into the Curriculum Committee, was comprised
of:
(1) the head nurses from each of the three nursing
units involved in the project,
tor, and (3)
(2) the clinical coordina-
the critical care instructor.
Collectively,
this group held a high degree of interest in the outcome
of the project and would become the sustaining force following the departure of the investigator.
At this meetinJ,
(agreement was reached that the investigator would be
responsible for development of the manual contents,
coord~
ination of the implementation scheme and final evaluation.
The Curriculum Committee would serve in_an advisory
36
capacity during the development of the manual contents and
also would serve as the approval body for the finished
product.
Identification of the Subjects
and Setting
The subjects for this project were registered nurses'
(excluding head nurses) who were assigned to one of three.
nursing units in the acute care section of a 699-bed government hospital.
These nursing units include the coronary
, care unit, medical intensive care unit, and a cardiologymedical unit.
The Survey Questionnaire
Development and Testing of
the Survey Questionnaire
The goal of this project was to develop and implement
a teaching manual for selected staff nurses participating
in a cardiac rehabilitation program.
The Curriculum Com-
·mittee expressed a desire to collect background information
. !
'to identify the staff nurses' perception of their roles 1n
patient teaching and to assist in the planning of the
in-service phase of the project.
A self-administered
que~-
!tionnaire was drafted by the investigator as the survey
I
instrument.
The purpose of the questionnaire was to
asse~s:
i
(l) the staff nurses' beliefs about their roles in patient
I
teaching,
(2)
their feelings of competency in teaching thd
:specific health content, and (3) their knowledge of
37
standardized teaching plans.
Selected demographic vari-
ables were added to assess their educational background
and length of time in their present assignment.
Following approval of the content of the questionnaire
by the Curriculum Committee, testing of the instrument was
accomplished in two phases.
First, a cover letter was
developed by the investigator (Appendix A)
to accompany the
questionnaire which was then distributed to six nurses with
Masters degrees who were not involved with the project.
This group consisted of three nursing instructors, one head
nurse, one clinical specialist, and one clinical supervisor.
Each was requested to critique the questionnaire
for clarity and content validity.
Suggested minor
revisions were made as the result of this review.
Secondly,
the questionnaire was distributed with the same cover letter to six staff nurses on a medical unit not involved in
the project.
No additional changes were recommended by
the latter group.
Next, a consent form (Appendix B) was developed by
ithe investigator and approved by the Health Science Department Human Subjects Committee chairperson, at California
State University, Northridge.
A second cover letter
(Appendix C) was developed to accompany the final version
of the questionnaire (Appendix D)
:participants.
submitted to the
38
Administration of the
Questlonnaire
The investigator prepared individual packets for each
of the potential subjects.
Each packet consisted of the
cover letter, the questionnaire, and the consent form with
a stamped envelope addressed to the investigator ' s home .
1
The instructions asked that the consent form be returned
separately from the questionnaire to provide anonymity.
A
large manilla envelope was placed on each nursing unit and
clearly marked as the receptacle to receive the
questionnaires.
compl~ted
The participants were given ten days to
complete the questionnaire.
From a potential subject popu-
lation of 30 registered nurses, a total of 17 (57 percent)
volunteered to participate in the project.
Development of the Teaching
t1anual Contents
The initial phase in the development of the teaching
manual contents involved meeting with the Curriculum Committee to establish a plan and timetable for completion.
As indicated previously, the specific content to be taught
by the nursing staff had been established through meeting~
'
with the program director.
The next step was to develop
the educational plan to be included in the teaching
manua~.
iThe investigator prepared a proposed content outline for
.the lesson plans to be included in the teaching manual.
The final draft and ordering of the lesson plans accepted
by the Curriculum Committee included the following topics
39
Basic Anatomy and Physiology of the Heart
and Blood Vessels
Coronary Heart Disease, Heart Attack and
the Healing Process
Pulse Rate Monitoring for Medication and
Activity
Medication Therapy in Coronary Heart Disease
Preparing for Discharge
Interestingly, as its first project, the Curriculum
Committee elected to develop the medication instruction
sheets to be used as patient handouts in conjunction with
the lesson plan on medications.
The nursing staff was
already involved in teaching patients about their medicationsand as the survey results indicated, this was an area
in which nurses felt the greatest degree of competency.
A list of medications to be included for the cardiac
patient was drafted by the Committee.
Each Committee mem-
ber was responsible for reviewing the literature and developing the content of the individual medication instruction
sheets assigned to them.
The format and final design of
the patient handout was developed by the investigator and
approved by the Curriculum Committee.
Over a series of several weeks the individual teaching
plans were developed by the investigator and presented to
ithe Committee.
The conceptual framework of curriculum
~esign as prescribed by Fodor and Dalis (1974) was chosen
py
the investigator as the format for the standardized
~eaching
plans.
The curricular approach provides a
40
systematic design for the presentation of a series of
learning activities.
It is built upon conceptual state-
ments which serve as the basis for the development of the
major areas of emphasis of the subject matter content.
Included are instructional objectives which identify the
terminal behavior sought in the learner and evaluative
criteria specifying the parameters which indicate accomplishment of the instructional objectives.
The teaching
plans serve as a guide to assure that all relevant content
is identified and standardized.
The survey questionnaire
indicated a need to provide a variety of learning opportunities to accommodate both the experienced and inexperienced nurse instructor in the use of the curriculum.
Resources for the nurse instructor and the patient were
included with each teaching plan.
An essential component of any patient teaching activity
is the evaluation of the patient's performance or response
to the educational program.
Proof that the patient has
achieved the desired learning outcomes can be accomplished
through use of pre- and post-test questionnaires or
oral questioning.
throu~h
The Curriculum Committee rejected the
:use of pencil- and paper-testing as adding an additional
.workload for the staff nurse.
Also, the literature sug-
gests that the adult learner is often intimidated by written questioning.
Based upon the Curriculum Committee's
~oncern and the survey result~ the inve~tigator developed~n interview guide as a
teaching resource.
The guide
41
provides a standardized approach to oral questioning and
provides a range of acceptable answers based upon the subject·matter covered in the curriculum.
Questions were
developed to elicit a response for evalauting each learning
objective.
It was hoped that the staff nurses would use
the interview guide as a pre-assessment tool to identify
specific learning needs of individual patients as well as
for evaluation of learning outcomes.
Evaluation of the use
of the interview guide was beyond the scope of this project.
To facilitate the recording of teaching activities in
the medical record, several forms were developed in conjunction with this project.
l.
These· included:
Orientation Checklist--to record orientation to
the Coronary Care Unit and preparation for transfer
2.
Continuing Medical and Treatment Record Over-Print
--to record progressive activities
3.
Teaching Summary Record--to record the learning
outcomes.
'Each documentation record was developed by the investigatdr,
:approved by the Curriculum Committee and the Medical Record
Review Committee at the Veterans Administration Medical
!center.
The last phase in the development of the teaching
!manual was organizing the content format.
:
To provide the
staff nurses with a more comprehensive resource, additionJl
sections were added to the manual.
Each section was
developed by the investigator and presented to the
42
Curriculum Committee for final review and approval.
These
additional sections may be found in the Teaching Manual
(Appendix G).
The final version of the teaching manual was
assembled by the investigator and distributed to the Curriculurn Committee and program director for a final review
for accuracy and clarity.
When concurrence was obtained,
the manual was readied for implementation.
Implementation of the Manual
The teaching manual was introduced to the staff nurse
through a formal one and one-half hour in-service class.
The Curriculum Committee met with the program director
to schedule a series of classes designed to accommodate
the schedules of the staff nurses from each of the three
nursing units involved in the project.
This meant schedul-
ing classes at three different times in the day to reach
nurses on each shift.
A total of nine classes were sche-
duled on three consecutive days.
The classes were held
three times each day at 6:30 a.m., 10:30 a.m., and 3:30 p.,m.
The table of contents of the manual served as the outline
and the manual contents as the subject matter for the inservice classes.
The program director was particularly
supportive during this phase of the project assuming respo:n:sibility for presentation of the overview of the Cardiac
;Rehabilitation Program for all classes.
i
Members of the
I
,Curriculum Committee agreed to assist the investigator wi tp
43
the in-service classes by assuming responsibility for
designated classes.
In preparation for the in-service, audio-visual aids
1n the form of color transparencies were developed to
highlight the presentation of the subject content, the
instructional objectives, and the documentation forms.
The
investigator arranged to have copies of the manual reproduced so each nurse could be provided with an individual
copy.
The investigator hoped that having a personal copy
of the manual would give the nurse easier access to the
contents.
During the in-service, the nurses were encour-
aged to make notations in the manual of problems encountered in its use to be able to provide feedback to the
investigator during the evaluation of the project.
In addition to the classes for the nursing staff,
arrangements were made to meet with the ward clerks from
each nursing unit to review the documentation forms that
would now be a part of the permanent medical record of each
patient in the program.
To readily identify patients in
the Cardiac Rehabilitation Program, red labels reading
"Coronary Teaching" were affixed to the outside of each
medical record as the patient entered the program.
The program was targeted to receive its first patient
one week following the in-service.
During the first few
days after the implementation, the investigator and other
members of the Curriculum Committee monitored the performance of the nursing staff and served in a supportive
44
role to the staff nurses involved in the program.
EValuation of the Manual
and Documentation Record
Evaluation of the project was accomplished through two
separate processes.
A questionnaire (Appendix E) was
developed to elicit the staff nurses' perceptions of the
usefulness of the teaching manual and the documentation
record.
An additional evaluative process included two
retrospective medical record reviews by the investigator.
Each review utilized criteria developed from a restatement
of the instructional objectives (Appendix F).
The written evaluation by the staff nurses was
developed to provide:
quency of use,
frequently,
(1) feedback concerning the fre-
(2) the section of the manual used most
(3) an assessment on the usefulness of the
documentation form, and (4) suggestions for additional content to be added to the manual at the time of revision.
Prior to distribution of the questionnaire, it was evaluated by the Curriculum Committee for clarity.
Six months following implementation of the teaching
manual, each participant received a questionnaire with
instructions to place the completed form in the marked
envelope at each nursing station.
Again, anonymity for
the individual nurse's response was protected.
The retrospective medical record reviews were selected
by the investigator as the mechanism to evaluate whether
the documentation form developed in conjunction with this
45
project improved staff nurse performance in this area.
Although several documentation forms were developed as part
of this project, the record review was limited to the
Teaching Summary Record.
Documentation of the patient's
response,to the educational process and the demonstrated
level of understanding of health teaching content are
expectations of the Nursing -service
~uality
Assurance Pro-
gram at the Veterans Administration Medical Center.
At the time the manual was being in-serviced, the
investigator conducted a record review to assess the quality and quantity of teaching activities being documented
by the staff nurses prior to introduction of the manual.
A second retrospective medical record review was completed
by the investigator six months following implementation of
the manual.
CHAPTER FOUR
Results
The purpose of this project was twofold:
(l) to assess
the staff nurses' perceptions of their role in patient
teaching to identify characteristics of the target group.
which could be useful in planning the manual contents and
the in-service program, and (2) to develop, implement, and
evaluate a teaching manual and documentation record to promote staff nurse participation in the Cardiac Rehabilitation Program being developed at the Veterans Administration
Medical Center, Sepulveda, California.
A survey questionnaire was employed to assess the
staff nurses:
teaching,
(1) beliefs about their role
in patient
(2) feelings of competency in teaching specific
health content, and (3) knowledge of standardized teaching
plans.
Selected demographic variables were added to assess
the staff nurses' educational backgrounds and lengths of
time in their present assignment.
Evaluation of the teaching manual and documentation
record by the staff nurses was accomplished with a written
questionnaire.
A retrospective medical record review was
chosen as the process to evaluate use of the documentation
record.
46
47
Findings of the Survey
Questionnaire
The results of the survey indicated that all seventeen
respondents were of the opinion that patient education
should be an integral part of nursing practice.
Patient
education was also viewed as having a positive effect on
the outcome of care by all seventeen nurses.
Element (65
percent) of the respondents did not feel it was necessary
for the physician to write an order for what was to be
taught to patients and only five nurses
(30 percent) felt
that teaching patients was the physician's responsibility.
All but one (94 percent) of the staff nurses saw patient
teaching as a personally rewarding experience.
Fifteen
(88 percent) of the nurses saw themselves as teachers as
well as caregivers, but twelve (70 percent) did not feel
nursing was presently providing patients with enough information.
When the respondents were asked to select topics
that should be included in their teaching, the most frequently named were medications, purpose of the treatment
plan, and activity limitations (Table 1).
However, nearly one-half of the nurses did not feel
comfortable teaching patients about the purpose of the
treatment plan or their activity levels.
Only four nurses
(24 percent) felt they had all the skills needed for
patient teaching, but, as shown in Table 2, fourteen
respondents (82 percent) did not support the statement
48
Table 1
What Should be Included in
Patient Teaching?
Response
Frequency
Percentage _
1.
Medications
16
94%
2.
Purpose of Treatment Plan
17
100%
3.
Effects of Disease Process
14
82%
4.
Activity level/limitations
16
94%
5.
S/S Requiring Medical Attention
14
82%
6.
Understanding Diagnostic
13
76%
Tests
that individuals should be hired just for the purpose of
patient teaching.
Thirteen staff nurses
(76 percent) responded affirma-
tively when asked if there were any obstacles affecting
the amount of teaching they were able to accomplish
(Table 3) •
Table 4 reflects that lack of time was identified most
frequently as a detractor from the quality and quantity of
patient teaching performed by the nurses.
Patient care
workload was named by four respondents (24 percent) as
another obstacle.
"lack of time."
The latter may
.be another way of saying
One must keep in mind that the literature
review indicated that "I don't know how" was what the nurse
49
Table 2
Staff Nurses' Feelings of Competency
for Patient Teaching
Yes
No
Don't
Know
{%)
(%)
(%)
In order to teach effectively,
one needs special classes.
66%
17%
17%
I have all the skills I need
to conduct patient teaching
activities.
24%
71%
6%
I feel comfortable teaching
patients about risk factors.
59%
17%
24%
I feel comfortable teaching
cardiac patients about their
medications.
82%
12%
6%
I feel comfortable teaching
cardiac patients about their
disease process.
41%
35%
24%
I feel comfortable teaching
cardiac patients the purpose
of the treatment plan.
54%
17%
29%
I feel comfortable teaching
cardiac patients about their
activity level.
53%
41%
6%
Patient teaching should be
done by individuals hired for
this purpose.
6%
82%
12%
I feel it is part of my nursing responsibility to facilitate patient acceptance of
changes in life style to
promote good health-
82%
0
18%
Response
50
Table 3
Are there Obstacles which Interfere with the
Quality and Quantity of
Your Patient Teaching?
Response
Frequency
Yes
Percentage
13
76%
No
3
18%
No answer
1
6%
Total
17
100%
Table 4
Most Frequently Named Obstacles
Obstacle
Frequency
Lack of time
9
Lack of visual aids/literature
5
Patient care workload
4
Lack of patient cooperation
3
Lack of pre-determined content
2
Lack of physician cooperation
2
Personal inadequacy
1
Decreased emphasis by nursing hierarchy
1
51
really meant when the lack of time excuse was used (Bille,
1980).
As indicated in Table 5, most of the respondents (82
percent) felt their teaching was often informal, was not
planned ahead of time, and was frequently initiated by
questions from the patient.
The results seemed to reflect
a positive attitude toward standardized teaching plans.
A total of eleven nurses (65 percent) in this group
have academic degrees.
The Associate degree of the two..;:..year
nursing program makes up the largest group, with Diploma
Programs next .(Table 6) •
Two of the six Diploma nurses
and one of the seven Associate degree nurses have also
acquired a Baccalaureate degree in nursing.
Additionally,
one Diploma graduate holds a Masters in nursing.
half
Less than
(47 percent) of the nurses reported having had a col-
lege level course on writing behavioral objectives (Table
7).
Only five
(29 percent) of the nurses reported having
courses in developing lesson plans and evaluation of learning.
The number reporting student teaching experience
seems incongruent with their educational preparation in
related course work.
Lacking academic preparation in the
educational process, the respondents may have assigned a
different meaning to "student teaching" than was intended
by the investigator.
52
Table 5
Staff Nurse Knowledge/Feelings About
Standardized Teaching Plans
(%)
(%)
Don't
Know
(%)
Use of standardized teaching
plans allow me to teach same
content as other nurses
88%
0
12%
Most patient teaching on my
unit is initiated by questions from the patient
53%
41%
6%
Standardized teaching plans
make it easier to document
teaching activities in
the medical record.
76%
12%
12%
A written outline of the
content and outcome criteria
are part of a standardized
teaching plan.
82%
6%
12%
Most teaching I do lS
informal and not planned
ahead of time.
82%
12%
6%
I feel comfortable in leading a group discussion
while teaching patients.
18%
35%
47%
I am more comfortable in
a one-to-one teaching
situation.
88%
12%
0
True
False
53
Table 6
Basic Nursing Education
Response
Frequency
Percentage
Diploma
6
35%
A.A. Degree
7
41%
B.S.N. Degree
4
24%
17
100%
Totals
Table 7
College Level Courses
Response
Frequency
Percentage
Writing Behavioral
Objectives
8
47%
Developing Lesson
Plans
5
29%
Evaluation of Learning
5
29%
Student Teaching
Experience
9
53%
54
In summarizing the characteristics of the target
group, the following profile was drawn:
Although the
nurses agreed that patient teaching is an integral part of
nursing practice, they expressed insecurity in their abilities to teach.
Most of their teaching was informal, not
planned ahead of time, and was often associated with the
complaint of lack of time to teach.
The majority (60%) of
the nurses have been in their present assignment one year
or less (Table 8).
This is most likely another factor in
their lack of feelings of competency for teaching specific
health content to cardiac patients, especially since less
than one-third of the group have had academic courses
relating to the teaching process.
Table 8
Time in Present Assignment
Response
Frequency
Less than 6 months
3
18%
More than 6 months/
Less than l year
4
24%
One year
3
18%
Over l year/less than 3 years
5
29%
3-6 years
l
6%
More than 6 years
0
0
16*
95*
Totals
*This section was blank on one questionnaire.
Percentage
55
Findings of Staff Nurses' Evaluation
of Manual and Documentation Record
Questionnaires were distributed by the investigator to
the participants six months following the introduction of
the teaching manual.
During the six-month period, there
was a loss of three of the original participants.
One
nurse terminated employment, a second nurse transferred to
another area of the hospital, and a third nurse was away on
maternity leave.
A total of 11 questionnaires were
returned, indicating that in addition to the previously
mentioned losses, three of the original participants did
not return a questionnaire.
The results of the question-
naire from the remainder of the staff nurses reflected that
nine (81 percent) participants had used the manual at least
once.
As shown in Table 9, one staff nurse (9 percent)
reported using the manual two to three times a week.
Two
staff nurses (18 percent) used the manual at least once a
week.
Five nurses (46 percent) reported using the manual
at least once a month.
One nurse (9 percent) wrote that
her usage was "less than once a month."
dents
Two of the respon-
(18 percent) had never used the manual.
The teaching plans were named by four nurses (36 per-
cent) as the part of the manual they used most frequently
(Table 10).
Two nurses (18 percent) indicated the part of
the manual they used most frequently was the medication
sheets.
question.
Five nurses (46 percent) did not complete this
56
Table 9
How Often Have You Used
the Teaching Manual?
Frequency
Percentage
Daily
0
0
2-3 Times Weekly
1
9%
At Least Once a Week
2
18%
At Least Once a Month
5
46%
Never
2
18%
1
9%
11
100%
Response
"Less than Once a Month"*
Totals
*Added comment
Table 10
What Part of the Teaching Manual Do You
Use Most Frequently?
Response
Frequency
Percentage
Teaching Plans
4
36%
Medication Sheets
2
18%
No Answer Given
5
46%
11
100%
Totals
57
Comments by the staff nurses concerning the documentation record were generally favorable.
The nurses were
asked to respond to a series of statements about the documentation record and to select all statements which
reflected their assessment of the documentation record.
Table 11 reflects the frequency of the individual responses
of the staff nurses.
Table 11
Which of the Following Statements Reflects Your
Assessment of the Documentation Record?
Response
Frequency
Improved 1'--ly Patient Teaching
Documentation
3
27%
Helped Me Focus on the Content
to be Taught
5
46%
Helped Me Focus on the Content
but Took Too Much Time
0
0
Required Less Time to Complete
than Narrative Notes
5
46%
Was Useful in Identifying
Content Covered by Others
4
36%
Note:
Percentage
Totals do not equal 100 percent since there was more
than one response possible.
58
Three nurses (27 percent) indicated the documentation
improved their recordings of patient teaching in the medical record.
Five nurses (46 percent) stated the documenta-
tion record helped them focus on the content to be covered
by their teaching.
Five of the 11 nurses (46 percent) also
agreed that the documentation record required less time to
complete than narrative notes.
Finally, four nurses (36
percent) felt that the documentation record was useful in
identifying content covered by other nurses.
None of the nurses suggested
content.
addit~onal
How-
ever, one nurse commented that "some patients seem uninterested or confused by facts on the circulatory system and
the heart's electrical conduction system."
This comment
will be referred to the CurriculUm Committee for consideration at the time of the annual review.
Findings of the Retrospective
Medical Record Reviews
Two retrospective medical record reviews were conducted by the investigator.
The first review was completed
on 23 records of patients with a diagnosis of confirmed
myocardial infarction for the six-month period prior to
introduction of the teaching manual.
A second retrospec-
tive record review was conducted on 22 medical records for
the six-month period following implementation of the teaching manual and documentation record.
Table 12 reflects a
comparison of the percent of compliance with the documentation criteria before and after implementation of the
59
Table 12
A Comparison of the Percent of Compliance with
Documentation Criteria Before and After
Implementation of the Teaching Manual
and Documentation Record
Documentation in the Medical
Record Indicates the Patient
is Able to:
1.
2.
3.
4.
5.
6.
7.
8.
State in own words the
meaning of a heart attack.
Percent
of
Compliance
Percent
of
Compliance
13%
55%
Use own pulse rate to
monitor activity.
4%
55%
Explain the healing
process in,own words.
4%
45%
Use activity chart to
identify own prescribed
level.
0%
41%
State name, purpose, and
dosage of each prescribed
discharge medication.
39%
50%
State correct use of
nitroglycerin.
22%
64%
Recall the signs and
symptoms requiring prompt
and medical attention.
4%
73%
State a plan of action to
be followed if chest pain
lasts longer than 15 minutes.
4%
73%
teaching manual and documentation record.
The results
reflect an increase in the percentage of compliance for
all eight of the documentation criteria.
Before imple-
mentation of the manual and documentation record, the
learning outcome most frequently recorded by the
60
respondents was the patient's knowledge about their medications.
Ironically, only an 11 percent increase was
noted in this criteria at the time of the second medical
record review, even though 14 (82 percent) of the respondents had indicated earlier that they felt comfortable
teaching patients about their medications.
Increases in
pre
compliance for the remaining documentation criteria ranged
ca1
from 41 percent to 69 percent.
anc
inc
mec
re~
of
dil
as
con
em!
pre:
tic
doc
pr<
pa1
do<
to
foJ
64
audit represented the entire population admitted to the
Cardiac Rehabilitation Program during the six-month period
being evaluated.
Conclusions
The conclusions drawn from this project were:
1.
A teaching manual with standardized subject mat-
ter, instructional objects, evaluative criteria, teaching
resource materials, and patient handouts can improve the
staff nurses' abilities to deliver patient education.
Although originally developed for an in-patient population,
the teaching manual could be equally useful in providing
an organized approach to the delivery of health education
in an outpatient setting.
2.
The standardized documentation record substanti-
ally increased the amount of patient teaching entries in
the medical record by the target group.
Additionally, it
helped the nurses focus on the content to be taught and was
perceived to require less time than narrative notes.
3.
Although the initial survey questionnaire demon-
strated the target groups' acceptance of patient education
as an integral part of nursing practice, such acceptance
had not changed the nurses' behaviors in the actual performance of patient teaching.
Hence, one must conclude
that positive attitudes toward patient teaching do not
always lead to changes in behavior.
Unforeseen events may
have contributed to this inconsistent behavior.
These
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vL
S3:;::naN3:ddV
SL
\I XIGN3:dd\l
76
March 10, 1982
Dear Colleague:
The attached questionnaire will be utilized in a graduate
project to develop and evaluate a standardized teaching
plan for patients with coronary heart disease.
The questionnaire will be administered prior to introduction of the teaching plan to gather information on
staff nurse perceptions of their role in patient teaching
and for planning of in-service.
I would appreciate your input as to the clarity of the
questions and content validity. Please feel free to
write your comments on the sample questionnaire if you
believe some modification is indicated.
If you feel the item is satisfactory as written, draw
a circle around the item number on the left margin.
Return to D. Blair before March 16, 1982.
for your participation in this project.
):(6-YL-;I/'-7txz~L~ R.JJ.
Dorothy Blair, R.N.
Thank you
LL
waOd J.N::iiSNO;)
8:
XIGN::ildd\l
78
C 0 N S E N T
F 0
R M
I have read the cover letter and understand that my
participation in this project is entirely voluntary.
Further, I understand that I will be requested to
complete a questionnaire at the beginning of the
project and an evaluation form at the conclusion of
the project.
Signature
Date
( ) YES, I would be interested in receiving a summary
of the final results of this project.
6L
;) XIGN::!IddV
80
I
bear Colleague:
I
~he
attached questionnaire is part of a graduate project to
I
pevelop and evaluate a standardized teaching plan for
I
patients with coronary heart disease.
In order to facili-
,
tate measurement of the outcomes, it is necessary to obtain
!
$Orne information from you prior to the introduction of the
I
-):eaching plans.
I
kf you agree to participate in this project, you will be
I
~sked
I
to complete a short evaluation form at the completion
of the project.
To protect the confidentiality of your response, please DO
llifOT SIGN
- your name on the questionnaire and remember to
-~-
~etach
this sheet before returning the questionnaire.
~lease
read and sign the consent form and return it in the
~ttached return envelope.
Return the completed question-
naire to the special envelope placed on your nursing unit.
+f you are interested in receiving a summary of the final
tesults of this project, please check the box at the bottom
~f the consent form.
Thank you for your cooperation in this project.
i.£~1!:;·
. c~<....:U fVr.)
I
'
~orothy
I
lair, R.N., B.S.N.
f1PH Candidate
qalifornia State University
~orthridge, california
18
a
XIGN3:dd'il
82
Date=---------
GENERAL INSTRUCTIONS:
The following questions may be answered by placing an {X)
under your response, cir~ling your response or short answers.
Please read each question carefully, as some ask for more
than one response.
SECTION I.
This section asks some general
questions about how you feel about patient teaching.
1.
Teaching patients is the physician's responsibility.
Strongly
disagree
Somewhat
disagree
2
'1
2.
Somewhat
disagree
(
(
Strongly
agree
5
4
3
Agree
Somewhat
agree
(
2
1
Strongly
agree
(
(
4
3
5
Physicians should write an order for what is to be
taught to patients.
Strongly
disagree
(
)
.
Somewhat
disagree
(
1
4.
Somewhat
agree
Patient teaching is an integral part of nursing practice.
Strongly
disagree
_.3.
Agree
Agree
(
2
Somewhat
agree
(
3
Strongly
_agree
(
4
5
Patient teaching can improve the outcome of care.
Strongly
disagree
(
Somewhat
disagree
(
1
Agree
(
2
Somewhat
agree
(
3
Strongly
agree
(
4
CONTINUE NEXT PAGE
5
82
5.
Patient teaching is a personally rewarding aspect
of patient care.
Strongly
disagree
Somewhat
disagree
2
1
6.
Somewhat
agree
(
Somewhat
disagree
2
Agree
Somewhat
agree
(
3
Strongly
agree
(
5 '
4
I feel nursing currently provides enough information to
patients to enable them to follow the therapeutic
plan of care after discharge.
Strongly
disagree
Somewhat
disagree
Agree
Somewhat
agree
),
Strongly
agree
(
I feel it is the patient's responsibility to ask
questions to learn about their conditions and
treatment plan.
Strongly
disagree
~-·
5
4
- 3
(
(
'
1
8.
Strongly
agree
I feel my role as a nurse is to give patient care,
and not to teach.
Strongly
disagree
1.
Agree
Somewhat
disagree
Agree
Som.ewhat
agree
Strongly
agree
The primary purpose of patient education is to
facilitate behavioral change. (e.g, attitudes, beliefs,
and actions).
Strongly'
disagree
(
).
Somewhat
disagree
).
Agree
Somewhat
agree
).
CONTINUE NEXT PAGE
Strongly
agree
83
10.
Does nursing have a role in patient teaching?
)NO
)YES .•.•••• If yes, what aspects of patient
teaching are included?
More than one answer may be checked.
Medications, including purpose, dosage and
side effects.
Purpose of the treatment plan.
Effects of the disease process.
Activity level or limitations.
(.
Signs and symptoms requiring medical
attention.
Understanding diagnostic tests.
Other, please specify______________
None of the above.
11.
Do you feel there are any obstacles which interfer
with the amount and/or the quality of the teaching
you are able to accomplish?
)NO
)YES ....... If yes, please specify.
a. _______________________________________
b. ____________________________________________
c. _______________________________________________
d. ____________________________________________
e. _______________________________
f. ___________________________________________
Use the space below if you need addtiona1 room for
comments.
CONTINUE NEXT PAGE
84
Section II.
This sections asks some general questions
relating to the process of teaching.
PLEASE CIRCLE (Y) FOR A "YES ANSWER .•. AND (N) FOR A
"NO" ANSWER.
IF YOU DON'T KNOW OR ARE UNDECIDED,
CIRCLE (OK).
12.
13.
YES
NO
DON'T
KNOW
In order to teach effectively, one needs
special classes to prepare oneself.
y
N
Dk
I feel I have all the skills necessary to
conduct patient teaching activities.
y
N
DK
14.
I feel comfortable teaching patients
about the risk factors associated with
coronary heart disease.
Y
N
DK
15.
I feel comfortable teaching patients with
coronary heart disease about their medications.
Y
N
DK
16.
I feel comfortable teaching patients about
their cardiac disease process.
Y
N
DK
_.17.
I feel comfortable teaching patients with
coronary heart disease about the purpose
of the treatment plan.
Y
N
DK
18
I feel comfortable teaching patients with
coronary disease about their progressive
activity level following a heart attack.
Y
N
OK
y
N
DK
19.
Patient teaching should be done by
individuals who are specifically hired
for this purpose.
CONTINUE NEXT PAGE
85
YES
20.
y
I feel it is part of my nursing responsibility
to facilitate patient acceptance of changes
necessary in their life style to promote
good health.
NO
DON'T
KNOW
N
DK
Section III. This section asks some general questions
about your beliefs and feelings of standardized teaching
plans.
PLEASE CIRCLE (T)~ IF YOU THINK THE STATENENT IS TRUE;
AND
(F), IF YOU THINK THE STATENENT IS FALSE.
IF YOU
ARE UNDECIDED OR DON'T KNOW, CIRCLE
(OK).
TRUE
FALSE
DON'T
KNOW
21.
Use of standardized teaching plans would
allow me to teach the same content as other
nurses to a specified patient group.
T
F
OK
22.
Host patient teaching on my unit is initiated
by questions from the patient.
T
F
DK
23.
Standardized teaching plans make it easier
to document teaching activities in the
medical record.
T
F
DK
24.
A written outline of the content and outcome
criteria are part of a standardized teaching
plan.
T
F
DK
25.
Generally, most teaching I do is informal
and not planned ahead of time.
T
F
DK
26.
I feel comfortable in leading a group
discussion while teaching patients.
T
F
DK
27.
I am more comfortable in a one-to-one
teaching situation.
T
F
OK
CONTINUE NEXT PAGE
86
Section IV.
Finally, some basic data about yourself.
Please place and (X) mark in·front of your answer.
28.
What is your basic nursing education?
(check one).
DIPLOMA
A.A. DEGREE
B.S.N. DEGREE
29.
What is the highest degree you have obtained, beyond
your basic education?
B.S.N.
M.N. OR M.S.N.
PhD.
OTHER .... Please specify____________
30.
Have you ever had a college level course that included
any of the following?
(Check all that apply) .
. ("
Writing behavioral objectives
Developing lesson plans
Evaluation of learning
Student teaching experience.
CONTINUE NEXT PAGE
87
31.
How long have you been in your present assignment?
Less than 6 months.
More than 6 months,
but less than 1 year.
One year.
Over 1 year,
but less than 3 years.
Three to 6 years.
More than 6 years.
THIS COMPLETES THE QUESTIONNAIRE
THANK YOU FOR YOUR PARTICIPATION
88
aHIVNNOI~SanO NOI~Vil~VAa
a XIGNaddV
89
CA!l.DIAC REHAB TEACHING MANUAL
EVALUATION FORH
The manual was developed to assist staff nurses in teaching patients
in the Cardiac aehab ~rogram.
In order to evaluate the usefulness of
the manual, you are being asked to answer the following questions.
1.
How often have you used the manual?
___ Daily
___ 2-3 times veekly
At least once a week
At least once a month
_ _ _Never
2.
What part of the manual do you use most frequently?
).
Which of the following statements reflects your assessment of the
documentation forms?
(check all that apply)
___ Improved my patient teaching documentation.
Helped me focus on the content to be taught.
_____Helped me focus on content, but took too much time to
document ..
_ _ _ Required less time to complete than narrative notes.
Was useful in identifying content covered by others.
4.
Is there any additional content you would like to see added to
this manual?
(Please list)
When you have completed this evaluation form, please place it in
the marked envelope at the Nurses Station on your unit.
Thank You for participating in this project.
APPENDIX F
RETROSPECTIVE MEDICAL RECORD
REVIEW CRITERIA
90
93
NURSING STAFF TEACHING MANUAL
FOR THE
CARDIAC REHABILITATION PROGRAM
VETERANS ADMINISTRATION
MEDICAL CENTER
SEPULVEDA, CALIFORNIA
JUNE,
1982
94
TABLE OF CONTENTS
I.
II.
III.
IV.
CURRICULUM COMMITTEE. • • • • . . . . . • • . . . . . . . . • • • • • . • •
i
PREFACE. . • . . . • . • . • • . • • • . • . . • . • • • . . . . • . . . • • . . . • • •
ii
OVERVIEW OF THE CARDIAC REHAB PROGRAM
A.
PROGRAM GOALS. • • • • . • . . • • . . • • • . . • . . . . • • • . • • • . • • 1
B.
THEME. . . • . . • • • • . • . • • . . . • . . . • . . . • • . . . • . • . . . . . • • 1
C.
TEAM RELATIONSHIPS. • • • • • . . . • • • . . . . . • • • . . . . . . • •
ROLE
A~~
2
RESPONSIBILITY OF THE NURSING STAFF
A.
REGISTERED NURSES .•.•.•....•...... ._. . • . . . . • . • • 3
B.
LICENSED VOCATIONAL NURSES .•...••...••.•.••.•• 6
C.
NURSING ASSISTANTS. . . . . . . . . • . . . • . • . . • . • . . • • • • . 6
PATIENT EDUCATION
A.
PHILOSOPHY OF HEALTH EDUCATION . . . . . . . . . . . . . . . . 7
B.
THE ADULT LEARNER ..•..............•..••......• 7
C.
FACTORS WHICH PROMOTE SUCCESSFUL TEACHINGLEARNING INTERACTIONS. . . . . . . . . . . . • . . . . . . . • . . . . 8
THE EDUCATIONAL PLAN
A.
CONTENT OUTLINE ...•.........•....•...•.•... ··. 9
B.
CONCEPTS AND OBJECTIVES . . . . . . . . . . . . . . . • . . . . . . . 10
C.
THE CURRICULUM . . . . . • . . . . . . . . . • . . . . . . . • • . . . . . . . l2
100
II.
ROLE AND REPONSIBILITY OF THE NURSING STAFF
The nursing staff, by virtue of their twenty-four
hour patient care responsibilities, must be
knowledgeable of their role in the Cardiac Rehab
Program.
To assure continuity within a multi-
disciplinary program, the individual disciplines
must delineate those areas for which they accept
primary responsibility from those areas of the
program in which there is an interdependency among
one or more disciplines.
The following roles and responsibilities have been
identified for Nursing Service:
A.
REGISTERED NURSES
HEAD NURSES in CCU, MICU and WARD 33C will:
1.
Attend scheduled team conferences to provide
input on the patient's response to nursing
care and the educational process.
2.
Participate in the educational component by
assuring that each patient is assigned a
primary nurse to coordinate the individual
patient's educational program.
The Head
Nurse may assign herself to a primary role.
3.
Maintain an awareness of the patient's
designated activity level and be responsible
for delegating supervision of individual
patients to other staff members.
3
101
~TAFF
NURSES in CCU and MICU
The primary responsibility of the nursing staff
to the M.I. patient on admission is controlling
pain and stabilizing physiological parameters.
When the patient has been stabilized, the nurse
will:
1.
. 2.
Orient the patient and family to the intensive
care unit utilizing the standardized checklist .
Provide individualized health teaching based
upon an. assessment of the patient's readiness
to learn and present anxiety level.
3.
Teach on an informal basis, giving simple
explanations of the purpose and action of
each medication when administered, utilizing
the information and langua~e from the
standardized medication information sheets.
4.
Look for opportunities for teaching during
routine nursing activities.
Give simple
explanations of how the heart works and the
healing process.
Provide the patient with
information necessary to accept activity
restrictions.
5.
Arrange for patient and family to view
appropriate audio-visual programs.
6.
Document all teaching activities and the
patient's response, utilizing the guideline
outlined in this manual.
7.
Attend scheduled team conference when
possible.
4
102
STAFF NURSES--WARD 33C
The staff nurse on Ward 33C will:
1.
Serve as a primary nurse to coordinate the
educational program for individual patients.
2.
Utilize the standardized teaching plans in this
manual to guide patient education activities.
3.
Observe and record the patient's response to
prescribed activity level.
4.
Interpret goals of the Cardiac Rehabilitation
Program to patients, families and the nonprofessional nursing staff.
5.
Document all teaching activities and the patient's
response utilizing the guidelines outlined in
this manual.
6.
Attend scheduled team conferences when possible.
PUBLIC
H~~LTH
NURSE
The public health nurses will:
1.
Provide continuity between in-hospital and
post-hospital care for patients in the Cardiac
Rehabilitation Program through participation
in discharge planning and through follow-up
educational programs in the clinic.
2.
Consult with other team members, when indicated.
3.
Attend scheduled team conferences.
4.
Provide feedback on the patient's learning
retention to the nursing staff in CCU, MICU
and Ward 33C.
5
103
LICENSED VOCATIONAL NURSES--CCU, MICU. WARD 33C
The primary responsibility of the licensed vocational
nurse is to be knowledgeable of the program goals,
activity schedule and exercise routine to be able to
interpret these to patients, families and nursing
assistants.
In addition, the licensed vocational
nurse will:
1.
Teach on an informal basis, giving simple explanations of the purpose and action of each
medication when administered, utilizing the
information and language from t~ standardized
medication information sheets.
2.
Document all teaching activities and the patient's
response, utilizing the guidelines outlined in
this manual.
3.
Be aware of which patients are in the Cardiac
Rehab Program.
4.
Arrange for patient and families to view
appropriate audio-visual programs.
NURSING ASSISTANTS--CCU, MICU, WARD 33C
Nursing Assistants assigned to these areas will:
1.
Be aware of which patients are in the Cardiac
Rehab Program.
2.
Understand the rationale for the progressive
nature of the activity schedule and be able to
interpret this to the patient.
3.
Re-inforce activity level for assigned patients.
4.
Be able to interpret to newly assigned nursing
assistants the use of the Cardiac Rehab
Calendar, "The Heart".
6
104
III.
PATIENT EDUCATION
A.
PHILOSOPHY OF HEALTH EDUCATION
Health education is a vital component of quality
health care services, which can provide patients
with relevant information to assist them in developing adaptive and coping behaviors that
promote wellness.
As a treatment modality,
patient education must be planned to allow
for modifications to meet individual learning
needs and is based not only on what the clinical
staff believes the patient needs to know, but
also on the patient's perceived needs.
To be effective,
patient education should be
continuous from admission through discharge
and include the family and/or significant other.
B.
THE ADULT LEARNER
In planning successful educational experiences
for the adult learner, several important factors
need to be considered.
1.
These include:
The learning environment must be free of
distractions and the patient must be free
of stress, discomfort or pain.
7
105
C.
2.
Adult learners must be involved in determining
their own educational objectives.
3.
Adults learn only if they see the value of
the information.
They cannot be intimidated
into learning something new just for the
sake of learning.
4.
Adults are motivated to learn if the information
will help them overcome a perceived problem.
FACTORS WHICH PROMOTE SUCCESSFUL TEACHING-LEARNING
INTERACTIONS
1.
JIMING--assessing the patient's readiness to
learn, evaluating what the patient already
knows, and identifying what the patient wants
to know before you start to teach will promote
individualized instruction.
2.
IDENTIFYING BARRIERS TO LEARNING--barriers
which interfere with the patient's ability
to benefit from the educational process include:
a. Psychological Barriers--boredom, anxiety,
emotional stress,denial of illness, anger,
family or financial problems.
b. Physical Barriers--pain or discomfort, sensory
deficits, muscular or neurolgical deficits.
c. Cultural Barriers--the individual's health
belief system is dependent on personal values
and the amount of influence on health outcomes
that are perceived to be within the control
of the individual. Health behavior is also
governed by the amount of personal responsibility for one's health that is expected
within the culture.
8
106
IV. THE EDUCATIONAL PLAN
A.
CONTENT OUTLINE
I.
Basic Anatomy and Physiology of the Heart and
Blood Vessels
A.
B.
c.
II.
Coronary Heart Disease. Heart Attack and the
Healing Process.
A.
B.
C.
D.
III.
Definition of the Term Pulse Rate
Pulse Rate Changes
Pulse Taking Procedure
Benefits of Pulse Rate Monitoring
Medication Therapy in Coronary Heart Disease
A.
B.
C.
D.
E.
F.
G.
v.
Atherosclerosis
Disease Progression
Meaning of Heart Attack
The Healing Process
Pulse Rate Monitoring for Medications and Activity
A.
B.
C.
D.
IV.
Normal Heart Structure
How The Heart Works
Understanding the Electrocardiogram
Medication--facts and fiction
Specifics You Should Know
Suggestions to Help You Take Your Mediation as
Prescribed
Purpose, Action, Dosage and Precautions of
Common Cardiac Medications
Preventive Uses of Selected Medications
Effect on Heart Rate
Safe Storage of Medications
Preparing For Discharge
A. Signs and Symptoms Requiring Prompt Medical
Attention
B.
Discharge Medications
c. Follow-Up After Care
9
107
B.
CONCEPTS AND OBJECTIVES
I.
BASIC ANATOMY AND PHYSIOLOGY OF THE HEART AND BLOOD
VESSELS
II.
Concept: Ul
Knowledge of the normal structure and function
of the heart and blood vessels can enhance
the individual's understanding of coronary
heart disease.
Objectives:
Following instruction, the patient will be
able to:
1.
Identify the major structures of the
heart and blood vessels.
2.
Trace the blood flow through the heart,
lungs and coronary arteries.
3.
Explain the functional'event recorded
by the electrocardiogram.
CORONARY HEART DISEASE, HEART ATTACK AND THE HEALING PROCESS
Concept:
n1
Objectives:
Coronary heart disease is a progressive process
which is often well advanced before the
appearance of symptoms.
Following instruction, the patient will be
able to:
1.
Concept:
n2
Objectives:
Explain the effect of plaque formation
on coronary blood flow and oxygen
delivery.
Knowledge of the coronary disease process
can increase the individual's understanding
of his present illness.
Following instruction,
able to:
the patient will be
1.
Recall the meaning of heart attack.
2.
Explain the healing process.
10
108
III.
PULSE RATE MONITORING FOR MEDICATIONS AND ACTIVITY
TOLERANCE
~1
The individual with coronary heart disease
can become an active participant in his
own treatment program.
Objectives:
Following instruction, the patient will be
able to:
Concept:
IV.
Count his own pulse.
2.
Define pulse rate and identify two (2)
pulse taking areas on the body.
3.
Recall variations in pulse rate which
need to be reported to the doctor.
MEDICATION THERAPY IN CORONARY HEART DISEASE
Concept:
~1
Objectives:
V.
1.
Awareness and understanding of the purpose,
action and side effects of cardiac medications can enhance the individual's compliance with the treatment regimen.
Following instruction,
able to:
the patient will be
1.
State the name, actiop dosage and side
effects of his prescribed medication.
2.
Apply the principles of prophylactic
use of certain medications.
PREPARING FOR DISCHARGE
Concept: ijl
Individuals with coronary heart disease need
to be prepared to cope with cardiac
emergencies after discharge.
Objectives:
Following instruction,
able to:
the patient will be
1.
Recall the signs and symptoms requiring
prompt medical attention.
2.
State a plan of action to be followed
if his chest pain lasts longer than
fifteen (15) minutes.
11
109
C.
THE CURRICULUM
A curriculum is an organized
plan for the presentation
of a series of learning activities.
It is build
around a conceptual scheme which serves as the focal
point for the development of the educational program.
The learning objectives are sequenced and identify
the terminal behaviors sought in the learner.
The
curriculum content is designed to provide the patient
with the knowledge and skills necessary for him to
become an active participant in the therapeutic plan
of care.
Evaluative criteria are stated in terms of the
degree of accomplishment to be demonstrated by the
learner to indicate mastery of the learning objective.
The curriculum is provided to serve as a guide to
assure that all relevant content to be covered is
identified and standardized.
Use of the learning
outcomes and the interview guide before instruction
begins, will assist the nurse instructor in identifying
the specific learning needs of each patient and provide
an individualized educational program.
A variety of learning opportunities are provided to
accomodate both the experienced and inexperienced
patient educator in the use of the curriculum.
12
UNIT I.
BASIC ANATOMY AND PHYSIOLOGY OF THE HEART AND BLOOD VESSELS.
CONCEPT: ffl
Knowledge of the normal structure and function of the heart and blood vessels
can enhance the individual's understanding of coronary heart disease.
OBJECTIVE: Ul
Following instruction, the patient will be able to identify the major
structures of the heart and blood vessels.
EVALUATIVE CRITERIA:
·OBJECTIVE: U2
Following instruction, the patient will be able to trace the blood flow
through the heart, lungs and coronary arteries.
EVALUATIVE CRITERIA:
OBJECTIVE: U3
The patient will describe in his own words, the flow of blood
through the heart, lungs and coronary arteries.
Following instruction, the patient will be able to explain the functional
event recorded by the electrocardiogram. ·
EVALUATIVE CRITERIA:
SUBJECT CONTENT
NORMAL HEART STRUCTURE
When given a diagram of the heart and blood vessels, the patient
will accurately label at least five (5) major structures of the
heart and blood vessels.
The patient will explain, in his own words, the heart action
recorded by the ~lectrocardiogram.
RESOURCES
LEARNING OPPORTUNITIES
1.
Heart Size and Location
a. Size of man's fist.
b. Weighs approximately
one pound.
c. Located in center of
chest.
d. Slightly egg shaped.
2.
At the beginning of each instructional period,
the instructor will:
a.
Introduce yourself (do not assume that the
patient knows your name).
b.
State the type(s) of learning opportunities
to be provided, i.e. (lecture, film or
discussion).
c.
Review learning objectives for this unit of
instruction.
Instructor tells patient that to better understand what has happened to his heart, this
lesson has been planned to increase his knowledge
of the normal structure and function of the heart
1.
Nurse Instructor
2.
Time Allotment-30-45 minutes.
SUBJECT CONTENT
Internal Structure
a. Divided into four
chambers.
2 upper-~tne atria
2 lower--the ventricles
LEARNING OPPORTUNITIES
3.The instructor will initiate the lesson
by locating and identifying the major
structures of the heart and blood vessels
using the anatomical heart model or wall
chart.
RESOURCES
~- Audio-visual program-~
"The Heart and How It
Works"--Trainex Corp.
4. Handout--line drawing of
heart chambers and blood
b. Heart valves lie between 4.Following this review, the patient will view
flow through the heart.
and connect the chambers
t~e audio-visual program.
and major vessels. Valves
serve as "trap doors" to
5.After viewing the film, the instructor will 5. Anatomical Heart Model
allow blood to flow in
allow the patient to examine the heart
only one direction.
model to locate the four chambers, the
va~ves and the septum.
'
1) Mitral Valve--lies
6. Wall Chart of Heart and
between the left atriun
.
Major Vessels~-American
and left ventricle.
6.The lnstructor will ask the patient if he
Heart Association.
has any quest1ons from the audio-visual
2) Tricuspid Valve--lies
program or from the material covered this
between the right
far.
atrium and the right
7. Handout~-line drawing,
ventricle.
same as in U4 but un7.The instructor will give the patient an
marked--to use in
3) Aortic Valve--lies
unmarked line drawing and ask him to
testing patient's knowbetween the aorta and
identify at least five (5) major structures
ledge.
·
the left ventricle.
covered in the film or discussion.
4) Pulmonary Valve--lies
between the pulmonary
8. Booklet--"The Real Pitch
artery and the right
About Heart Disease"-ventricle.
Crozer-Chester Medical
Center (Chester, Pa.).
c. Septum
1) Divides right and left
side of heart
14
I-'
I-'
I-'
SUBJECT CONTENT
LEARNING OPPORTUNITIES
External Structure
a. Pericardium--outer layerfibrous sac enclosing
heart.
b. Myocardium--muscular
middle layer.
c. Endocardium--inner layerlining chambers of heart.
HOW THE HEART.WORKS
8.
Heart as a Double Pump
a. Heart is a pump that
keeps blood circulating
throughout the body.
b. Special muscle tissue-like other muscles it
contracts and relaxes-unlike other muscles it
never rests.
c. Beats approximately
100,000 times per day.
d. Left ventricle pumps
oxygen-rich blood to the
body organs and tissues
bringing nutrients to the
cells and removing waste
products.
e. Right ventricle pumps
blood to the lungs for
gas-exchange and reoxygenation.
9.
The instructor will use the line drawing
or wall chart to trace the flow of blood
through the heart into the systemic
vessels and back through the heart to
the lungs. Pointing out the coronary
arteries, the instructor will emphasize
that the heart muscle needs nutrients
like other parts of the body and the
coronary arteries are the heart's
·personal blood supply.
Using the wall chart, the instructor will
point out the SA node and explain the
electrical and mechanical events in the
cardiad cycle.·
15
RESOURCES
2.
Electrical Activity
10.
The instructor will use poster of EKG
tracing during the discussion of the
electrical events represented on the
tracing.
Instructor will point to each
wave deflection during the explanation
to the patient.
11.
In closing this session, the instructor
will again ask the patient if he has
any questions or needs further explanatior
of any of the material covered.
a. Heart beat originates
in the sino-atrial (SA)
node in the upper right
side of the heart.
b. At regular intervals
the SA node sends out
tiny ectrical messages.
c. Messages travel over a
special route of fibers
to the ventricles-telling them to contract
and pump out blood--the right venticle to
the lungs and the left
ventricle to the body.
UNDERSTANDING THE ELECTROCARDIOGRAM
1.
RESOURCES
LEARNING OPPORTUNITIES
SUBJECT CONTENT
What We See
a. P wave--the firing of
the electrical impulse
in the SA node.
b. P-R interval--electrical
impulse travels across
atrium.
c. QRS Complex--produced
during the transmission
of the electrical wave
through the conduction
16
9. Instructor made poster-Normal EKG Tracing drawn
to scale.
SUBJECT CONTENT
LEARNING OPPORTUNITIES
tissue which stimulates
the ventricles to contract.
d. T wave--the refractory
period--as the heart
recharges itself to
prepare to respond to a
new P wave.
What the EKG Tells Us.
a. Many important inferences about the heart
can be derived from the
EKG
12.
The instructor will verbally question the
patient and ask him to recall the flow
of blood through the heart and to
describe in his own words the heart
action recorded by the electrocardiogram,
b. Conduction system within
normal range.
c. Previous myocardial
infarction.
d. Drug toxicity.
17
RESOURCES
UNIT II.
CORONARY HEART DISEASE, HEART ATTACK AND THE HEALING PROCESS
CONCEPT: ijl
Coronary heart disease is a progressive process which is often well advanced
before the appearance of symptoms.
OBJECTIVE: Ul
Following instruction, the patient will be able to explain the effect of
plaque formation on coronary blood flow and oxygen delivery.
EVALUATIVE CRITERIA:
CONCEPT: U2
The patient will accurately explain, in his own words, the
effect of plaque formation on coronary blood flow and oxygen
delivery.
Knowledge of the coronary disease process can increase the individual's
understanding of his present illness.
OBJECTIVE: Ul
Following instruction, the patient
"heart attack".
EVLAUATIVE CRITERIA:
OBJECTIVE: U2
SUBJECT CONTENT
Definition--the process
involving the build-up of
fatty substances such as
cholesterol on the inside
lining of the walls of the
arteries.
Develops over many years.
be able to recall the meaning of
The patient will accurately recall the physical changes that
occur in the coronary arteries and how these changes relate to
heart muscle damage.
Following instruction, the patient will be able to explain the healing
process.
EVALUATIVE CRITERIA:
ATHEROSCLEROSIS
wil~
The patient will explain~
the healing process.
in his own words, the evolution of
LEARNING OPPORTUNITIES
1.
At the beginning of each
the instructor will:
inst~uctional
RESOURCES
period,
a.
Introduce yourself.
(Do not assume that the
patient knows your name).
b.
State the type(s) of learning opportunities
to be provided, (lecture, film, discussion).
c.
Review learning objectives for this unit of
instruction.
1. Nurse Instructor
2. Time Allotment= 30
minutes.
3. Booklet--"Heart
Attack--What Now"
Georgia Heart Assoc.
DISEASE PROGRESSION
A¥~mptomatic
4. Instructor-made
poster showing progressive nature of
the disease process.
Stage
a. Plaque formation begins
early in life.
18
I-'
I-'
Ul
SUBJECT CONTENT
b. Composed of lipid
and fatty substances
c. Causes narrowing of
inside diameter of
arteries
2. Effect on Blood Flow and
Oxygen Delivery
Plaques or fatty deposit
in the coronary arteries
cause:
a. Decreased blood flow
to heart muscle.
b. Results in reduction
of amount of oxygen
delivered to heart
muscle.
c. Decreased oxygen to
heart muscle leads to
chest pain (angina).
LEARNING OPPORTUNITIES
The instructor will define atherosclerosis 5. Handout--Diagram of the
and in discussin~ plaque formation, will
Heart and coronary arteries
compare it to the build-up of rust inside
water pipes.
Using the instructor-made
poster, or drawings from booklet, the
instructor will display the contrours of
normal artery and illustrate the proAudio-visual Program--"Your
gressive nature of the disease process
Heart Attack and Your Future"
through a series of plates which demonstrat
American Heart Association.
narrowing of the arteries.
The instructor will discuss the effects of
the decreased blood flow to the heart
muscle and its relationship to the onset
of angina, using the diagrams which depict
the heart and narrowing of the coronary
arteries.
The instructor will arrange for the patient
to view the audio-visual program "Your
Heart Attack and Your Future" before
discussing the healing process.
3. Symptomatic Stage
a. Angina--chest pain
due to temporary lack
of oxygen to the
heart muscle.
1) May be brought on·
by increased exercise, temperatur(
extremes or stress
--which causes the
heart to demand
more oxygen than
r~~ 8HEr8~!~v~f~er·
RESOURCES
19
LEARNING OPPORTUNITIES
3JECT CONTENT
RESOURCES
b. Heart Attack--if one
of the coronary
arteries becomes
completely blockedthat part of the
heart muscle it
supplies--dies from
lack of oxygen.
c. This muscle tissue
damage is called a
heart attack--orM.I.
Myocardial Infarctio
Coronary Occlusion,
Coronary thrombosis.
The Healing Process
5.
a. The body starts the
repair process
immediately after the
heart attack.
b. White blood cells
come into the injured
muscle to carry away
dead tissue.
c. Healing of the heart
muscle occurs much
like healing in other 6 ·
injured areas.
Scar
tissue gradually replaces the damaged
tissue. This usually
takes six to eight
weeks for the scar
tissue to form.
The instructor will discuss the healing
process in detail on several occasions
during the patient's stay in CCU to
promote Understanding of why it is
necessary to restrict his activity and
monitor his return to normal activities
through pulse rate response. EMPHASIZE:
Once healing is complete, most people can
resume their normal activities and may
never have another heart attack if willing
to make-modifications in life-style.
The instructor will use the diagram handout depicting the development of collateral
circulation during the discussion on the
healing process.
20
7. Handout--Diagram of
Collateral Circulation
Development
LEARNING OPPORTUNITIES
SUDJECT CONTENT
d, It is important
that the heart
muscle to less work
during the repair
period.
This is
why activity levels
are restricted and
monitored.
e. During the healing
process--blood
supply to the area
around the damaged
area increases
through the development of collateral
circulation.
7.
Ward nurses will verify patient's understanding of what has been taught in ccu.
Using the interview guideline, the
instructor will assess the patient's
understanding of --How the Heart Works,
Meaning of Heart Attack and The Healing
Process.
f. Nearby arteries wider
and lengthen to
bring more blood
and oxygen to the
affected area. This
new blood supply
can not revive the
dead tissue--but
will protect the
area surrounding the
dead muscle from
permanent damage.
21
RESOURCES
UNIT III.
PULSE RATE MONITORING FOR MEDICATIONS AND ACTIVITY TOLERANCE
CONCEPT:
The individual with coronary heart disease can become an active participant in
his own treatment program.
OBJECTIVE: Ul
Following instruction, the patient will be able to count his own pulse.
EVALUATIVE CRITERIA:
The patient will count his own pulse, using a clock/watch
with a second hand, with no more than a (+) or (-) four (4)
variance, when valid.ated by the instructor.
Following instruction, the patient will be able to define pulse rate and
identify two (2) pulse taking areas on the body.
OBJECTIVE: #2
EVALUATIVE CRITERIA:
OBJECTIVE: U3
Following instruction, the patient will be able to recall variations in
pulse rate which need to be reported to the doctor,
EVALUATIVE CRITERIA:
SUBJECT CONTENT
'· DEFINITION OF TERM--PULSE
RATE
1. A pulse is caused by
the beating of the
heart.
2. Pulse rate is the number
of times the heart beats
in one minute.
The patient will define pulse rate as the number of heart
beats per minute and correctly point to two (2) places on
the body where the pulse may be felt.
The patient will recall at least three (3) variations in
pulse rate which need to be reported to the doctor.
LEARNING OPPORTUNITIES
1.
RESOURCES
At the beginning of each instructional period,
the instructor will:
1. Nurse Instructor.
a. Introduce yourself. (Do not assume that the
patient knows your name).
2. Clock/watch with
second hand.
b. State the type(s) of learning opportunities
to be provided, (lecture, film, discussion).
c. Review learning objectives for this unit of
instruction.
d. Tell patient that next few minutes have been
set aside to teach him how to count his
pulse rate.
22
3. Handout-"Instruction
Sheet for Counting
Your'Own Pulse"
4. Time Allotment--3D
minutes.
~:iUBJECT
LEARNING OPPORTUNITIES
CONTENT
3. A pulse can be located 2.
at several points on
your body:
a.
b.
c.
d.
4.
Wrist
Neck
Temple
Groin
Normal pulse rate for
adults may range from
60-100 beats per
minute.
a. Taking your own
pulse regularly
will help you to
identify your norma
range.
3.
The instructor will point to each of the
areas where the pulse can be felt while
defining the term "pulse rate".
The patien
will be asked to follow along with the
demonstration by locating their radial,
carotid or temporal pulse and indicating
to the instructor when he is able to feel
the beats.
The instructor will verbally question the
by asking him to identify the
normal pulse range for adults and to
define pulse rate. The instructor will
review the subject matter covered so far
if the patient is not able to answer
correctly.
~atient
b. Deviations from
your normal range
may indicate you
are getting too
much or too little
of the medication
prescribed to
regulate your heart
rate and rhythm.
5. Normally the pulse
rate is regular.
a. Anyone may have an
occasional irregular beat.
b. Some people-normall
have an irregular
pulse.
23
RESOURCES
SUBJECT CONTENT
Pulse Rate Changes
LEARNING OPPORTUNITIES
4.
L. Factors that increase the
Pulse Rate:
a.
b.
c.
d.
e.
Exercise
Emotional Upset or Anger
Elevation of temperature
5
Caffeine and Nicotine
·
Medications such as
Atropine and Isuprel.
f. Hot weather
When reviewing factors that increase the
pulse rate, the instructor will emphasize
the need to reduce intake of coffee, tea
or cola drinks as these all contain
caffeine.
During this discussion the instructor
will explain to the patient that a
rapid pulse rate means the heart is
having to work harder and can put a
strain on a heart that is recovering
from a heart attack.
2. Factors that slow the
Pulse Rate:
a. Rest
b. Sleep
c. Medications such as
Digitalis and Inderal.
l'ulse Taking Procedure
6. The instructor will demonstrate on own
wrist (neck or temple) the technique for
taken at the wrist (this
counting one's own pulse. The patient
will then be ask to count his own pulse
is called the radial pulse)
and report rate to instructor.
because this area is easily
accessible.
7. The instructor will verify patient's
l, The pulse is usually
l. Other locations where the
accuracy by taking patient's pulse,·
pulse can easily be
counted are the temple and
the neck.
I,
Alway-s count pulse for one
full minute while looking
at c~lock/watch with a
second hand.
24
RESOURCES
SUBJECT CONTENT
LEARNING OPPORTUNITIES
Benefits of Regular Pulse
Monitoring
1. Detecting early signs of
medication side effects,·
some cardiac medications
can cause:
a. Increased Rate
b. Very slow rate
2. Evaluating the Quality of
the Heart Beat:
a. Irregular rhythms
b. Fluttering or pounding
rhythms
c. Weak beats
3. As a measure of exercise
tolerance following heart
attack.
8. The instructor will summarize this
sessions by emphasizing that, some of the
side effects of cardiac medications can
be detected through regular monitoring
of the pulse rate and the patient will be
asked to recall at least three variations
in pulse rate that need to be reported to
the physician.
9. The instructor will give the patient a
copy of the handout "Instruction Sheet
for Counting Your Pulse" and explain the
use of the pulse rate record keeping
procedure when he returns home.
10. The instructor will ask the patient if
he has any questions about•the material
just covered, answer them and tell the
patient this material will be reviewed
with him just prior to discharge.
11. The instructor will document the
teaching in the medical record where
designated.
25
RESOURCES
UNIT
IV.
MEDI~ATION
CONCEPT:
THERAPY IN CORONARY HEART DISEASE
Awareness and understanding of the purpose, action and side effects of cardiac
medications can enhance the individual's compliance with the treatment regimen.
OBJECTIVE: #1
Following instruction, the patient will be able to state the name, action
and side effects of his prescribed medications.
EVALUATIVE CRITERIA:
OBJECTIVE: #2
Following instruction, the patient will be able to apply the principles
of pr6phylactic use of certain medications.
EVALUATIVE CRITERIA:
SUBJECT CONTENT
A.
Medications--facts and
fiction.
Every medication has
1.
both advantage and
disadvantages.
What you should know
about any medication.
2.
The patient will accurately state the name, action and at least
one possible side effect of his prescribed medications.
The patient will relate the rationale for the use of medications
prophylactically by citing one example where this approach is
indicated.
RESOURCES
LEARNING OPPORTUNITIES
1. At the beginning of each instructional period,
the instructor will:
a. Introduce yourself (do not assume that the
patient knows your name)
b. State the type(s) of learning opportunit~ to
be provided., (lecture, film, discussion).
Take only at the
time and in the
2. The instructor will arrange to show
amount prescribed.
tape program "Your Prescription for
If you miss a dose,
Before viewing the film the patient
never try to double
given an overview of the key pointn
up.
26
the slide/
Health".
will be
in the film.
1. Nurse Instructor
2. Slide/Tape Program,
"Your Prescription
for Health"-3. Handout--Medication
Instruction Sheet for
each prescribed
medication.
4. Handout--"About Your
Medications".
5. Time Allotme~t--Two
30 minute sessions
1-'
N
w
SUBJECT CONTENT
LEARNING OPPORTUNITIES
3)NEVER stop taking
your medication with
out your doctor's
consent.
3. After viewing the film, ·the instructor
will summarize the key points and give
the patient a copy of the handout "About
Your Medications" and then discusswhat
specific information should b~ known
about any medication the patient takes.
4)NEVER run out of'your
medication.
S)NEVER take your
medication in the
dark.
.
4•
6)ALWAYS carry a list 0,,
your medications and
the dose you are
taking--in your wallet
L
Specifics You Should Know
About Your Medications.
1. Its correct name--trade or
brand name and generic.
2. Its purpose
a. Why you are taking it.
b. What changes you can
expect.
3. Its Dosage
a. How much you should take
The instructor will stop frequently and
ask the patient if there are any
questions he would like to ask or any
points he would like clarified. The
instructor should stay alert for signs
of fatique on the part of the patient
and terminate the instruction if patient
has chest pain or other discomfort.
5. If instruction is given on more than one
occasion to cover all the material, the
instructor will review what had been
covered in any previous lessons.
b. How often
4. Its Possible Side Effects
a. Any medication can have
unpleasant side effects
b. Knowing those commonly
associated with your
medication so you can
renort them to your
doctor if they occur.
27
RESOURCES
SUBJECT CONTENT
LEARNING OPPORTUNITIES
Suggestions to Help You Take
Your Medication as Prescribed. 6. The instructor will explore with the
patient his feelings and fears about
1, Attitude--no one likes to
taking medications to reinforce positive
take medications. A
attitudes and clear up any myths or
positive attitude toward
mis-information held by the patient.
medication will help you
to take it correctly.
1. The instructor will ask the patient how
2, Reminder System--develop
he remembers to take his medications as
some method to help you
directed and discuss various methods
reember to take your
which may help him establish a method
medication correctly.
that will work for him.
a. Cross off dates on a
Calendar.
b. Put out a days supply in
separate glasses each
morning on arising.
c. Commercial reminders-sometime available at
a pharmacy.
Action and Side Effects of
Specific Cardiac Medications
1.
2.
3.
4.
5.
6.
7.
Antianginal
Antiarrhythmic
Anticoagulants
Antihypertensives
Digitalis Preparations
Di.uretics
Putassium
B. Tranquilizers
B. The instructor will give patient a copy
of the medication instruction sheet handout for each cardiac medication prescribed.
Together, the instructor and the patient
will review the name, action and side
effects of each medication.· The instructo
will emphasize that some medications can
cause depression and since this may alread
be a problem for the heart attack patient,
his awareness of this possible side effect
and the prompt reporting to the doctor,
may minimize the problem.
2B
RESOURCES
SUBJECT CONTENT
before taking over-thecounter medicines such as
aspitin, cold remedies ~nd
alka seltzer.
Don't mix several medicines
together in one bottle. Keep
all medicine inthe own
labled bottle.
Don't give your medication to
someone else and NEVER take
another persons's medicine.
LEARNING OPPORTUNITIES
12. The instructor will terminate this
instructional unit with a review on
the safe storage of medication , and
encourage questions from the patient.
Discuss with patient that he will
begin to feel better but this doesn·'t
mean he should stop taking his medicatio
Only his doctor should advise him to
make any changes. Abruptly stopping
some medication can be harmful.
13. The instructor will document the
medication instruction in the designated
areas in the medical record. If unable
to complete the entire instructional
unit in one time frame, the instructor
will indicate in the medical record
those sub-heading which were covered.
29
RESOURCES
SUBJECT CONTENT
Preventive . Uses of Selected
Medications.
1. When--prior to activity
2. Why--to increase blood
flow and lessen the
·
incidence of chest pain.
LEARNING OPPORTUNITIES
Following review of spec{fi~ cardiac
medications, the instructor will define
and discuss the principle of prophylactic
use of certain medications, EMPHASIZING
that the patient should only use this
approach if it is recommended by his
doctor.
3. What--Long acting Nitrates
prior to :
lO.The patient will be asked to study the
medications sheets until he is aple to
a. sexual activity
state the name, action and one possible
b. emotional events--glad
side effect of the prescribed medications
or sad.
and give one example of when prophylactic
c. extremes in temperature
usuage is indicated.
4. Other--Anticoagulants to
thin the blood and prevent
clot formation.
Effect on Heart Rate
1. Review the relationship
of Medication and Heart
ll.Review with patient that some medication
may alter the heart rate and his monitoring
of his heart rate may prevent side effects
from becoming serious.
Safe Storage of Medication
1. Medications tend to lose
their potency after certair
length of time. Don't take
old medications.
2. Keep all medicines out of
the reach of children.
3. Some medications work
aqainst each other--so
check with your doctor
30
RESOURCES
UNIT V.
PREPARING FOR DISCHARGE
CONCEPT:
Individuals with coronary heart disease need to be pr•pared to cope with
cardia~ emergencies after discharge.
OBJECTIVE: ijl
Following instruction, the patient will be able to recall the signs and
symptoms requiring prompt medical attention.
EVALUATIVE CRITERIA:
OBJECTIVE: ij2
Following instruction, the patient will be able to state a plan of action
to be followed if his chest'pain lasts longer than fifteen. (15) minutes.
EVALUATIVE CRITERIA:
SUBJECT CONTENT
SIGNS AND SYMPTOMS
REQUIRING PROMPT MEDICAL
ATTENTION
The patient will accurately state a plan of action to be
taken by an ind~vidual with known heart disease for episodes
of chest pain lasting longer than fifteen (15) minutes.
LEARNING OPPORTUNITIES
1.
Early Warning Signs--You
muy be having a heart
attack if:
a. You have chest pain,
shortness of breath,
dizziness, weakness or 2.
unexplained sweating.
b. If any of the above
symptoms occur--STOP
WHAT YOU ARE DOING AND
REST.
The patient will be able to recall at least four (4) signs
and symptoms requiring prompt medical attention.
RESOURCES
At the beginning of each instructional period,
the instructor will:
1. Nurse Instructor
a ... Introduce yourself. (Do not assume that the
patient knows your name).
2. Time Allotment=30-45
Minutes
b.
State the type(s) of learning opportunities
to be provided, (lecture, film, discussion).
c.
Review learning objectives for this unit
of instruction.
At least one day prior to discharge, the
instructor will arrange for the patient to view
the audio-visual program "Signals for Action".
3. Audio-Visual Program
"Signals for Action"
American Heart
Association.
LEARNING OPPORTUNITIES
SUBJECT CONTENT
c
2.
If your doctor has
3.
ordered nitroglycerin
take one and lie down
and wait five (5)
. minutes.
If chest pain continuestake two (2) more
Nitroglycerin--five (5)
minutes apart.
4.
3.
B.
If chest pain lasts or
persists after fifteen
(15) minutes and three
(3) Nitroglycerin--call
your doctor or have some
one take you to the
S.
hospital emergency room.
DISCHARGE MEDICATIONS
1.
2.
3.
4.
Purpose
Action
Dosage
Precautions
C. FOLLOW-UP AFTER CARE
6.
1. Full recovery after a
heart attack will vary
with the individual.
2. Check with your doctor
regarding his plans
7.
for your follow-up
care.
RESOURCES
4. Handout--"Points to Remember
Following the audio-visual· program, the
After You Leave the Hospital"
instructor will review the warming signs
and verbally question the patient as to
the action to be taken if chest pa1n lasts 5. Handout--About Your
longer than fifteen(l5) minutes and is
Medications
not relieved by Nitroglycerin.
EMPHASIZE:
The first hour's importance in saving
lives.
6. Handout--"Medicines I Take"
The instructor will assure that the
patient has the appropriate discharge
medication instruction sheets, and will
'review the purpose, action, dosage and
precautions of each discharge medication.
7. Handout--Medication Instruc-
To evaluate the·patient's understanding of
the purpose, action, dosage and precautions
for each'discharge medication, the instructor will give the patient a form to
complete "Medicines I Take". Following
completion, the nurse will review the
patient's responses for accuracy and
assist the patient in correcting any
incorrect answers.
The instructor will stress that the patient
should continue the same activity and exercise at home during the first few days
at the same level he had achieved the last
few days in the hospital.
The instructor will evaluate the patient's
'learning outcomes through interview and
verbal questioning utilizing the Interview
Guideline in this manual.
32
tion Sheet for each Discharge
Medication
Interview Guidelines
130
V.
DOCUMENTATION OF PATIENT TEACHING
A.
ORIENTATION CHECKLIST
Orientation activities will be documented as follows:
B.
1.
CCU/MICU--initiates checklist and nurse indicates
items covered and understood by the patient by
initialing in Column A or B as defined on the
checklist.
2.
Prior to transfer out of CCU/MICU--complete the
front sheet of the checklist by reviewing with
the patient the changes he/she can expect on
Ward 33C.
3.
WARD 33C--complete reverse side of the checklist.
Enter the date of transfer and review with the
patient the orientation to the ward environment.
Follow instructions on checklist sheet for
initialing as items are covered and patient
indicates understanding.
CONTINUING MEDICATION AND TREATMENT RECORD OVERPRINT
1.
Progressive activities are monitored by the
nursing staff and documented on this overprint
according to established procedure.
2.
Exercise activities are monitored by the physical
therapist during their scheduled hours and by
the nursing staff in their absence.
Both
physical therapy and nursing will document in
the appropriate space on this form.
3.
If for any reason, one or more stages are not
ordered by the physician, indicate this by
drawing a diagonal line through the space not
used for initials, and write "not ordered"
above the line.
Example:
be~bidc
for one l'linlllC h"i th
of ph~·~ic:J! tlll'rJpist.
'· P:1ticnt docs :Jctivc :Jnklc l"lc·.\iuu .l\
d;Jily ]0 ti111c~.
St:nltl :-tt
supcn·i~ion
33
131
C.
TEACHING SUMMARY RECORD
1.
Document on this form your teaching activity
and the patient's response to teaching.
2.
If, on initial assessment of learning needs,
the patient demonstrates knowledge and mastery
of any of the learning objectives, indicate
that the objective has been met by checking the
"MET" column and entering the date. Add a
notation under comments that patient met
objective on initial assessment and sign your
name and title.
3.
Prior to discharge, the nurse responsible for
coordinating the patient's educational program
will review the teaching summary record to
assure that all objectives have been met.
4.
If the patient fails to meet any of the objectives,
additional learning needs~hould be indicated at
the bottom of the Teaching Summary Record so these items may be followed-up as the patient
enters Phase II of the program.
34
132
VI.
THE EVALUATION PROCESS
An essential component of any patient teaching activity
is the evaluation of the patient's performance or
response to the educational program.
Proof that the
patient has achieved the desired learning outcomes
is often accomplished through use of pencil and paper
testing which then serves as the documentation mechanism.
However, this approach to evaluation more often
meets the needs of the health professional to comply
with documentation mandates than i t meets the patient's
need to receive feedback on his/her learning.
Evaluation techniques should take minimal patient
With proper preparation,
time and be unobtrusive.
the patient's knowledge can be successfully evaluated
through oral questioning.
The Interview Guideline, developed in conjunction with
this manual, will serve as the evaluation tool for the
educational component.
It has been developed to elicit a
response for evaluating each learning objective.
It
provides a standardized approach to oral questioning
and provides the range of acceptable answers based on
the subject content covered in the curriculum.
This
guide can also serve as an assessment tool prior to
instruction to identify the patient's learning needs.
35
133
VI.
REVIE\i AND UPDATING
The teaching manual will be reviewed annually by the
curriculum committee, in consultation with the Program
Director to assure it is current with the "state of
the art" in cardiac teaching.
It is anticipated that
the subject matter of the educational plan will remain
relatively constant.
The medication instruction sheets will be reviewed
every six months and new sheets added if new cardiac
drugs have been introduced.
New teaching aids will be evaluated and added to the
program as they become available if the curriculum
committee considers them of value to the program.
36
134
BIBLIOGRAPHY
1.
Bader, Catherine A. "Teaching the Coronary Patient and
His Family", Nursing Clinics of North America. Vo. 7,
No. 3. September, 1972.
2.
Briney, Kenneth L. Cardiovascular Disease: A Matter of
Prevention. Belmont:Wadsworth Publishing Company. 1970.
3.
Cassem, N.H. and Hackett, Thomas P., "Psychological
Rehabilitation of Myocardial Infarction Patients in the
Acute Phase". Heart and Lung. Vol. 2, No. 3. May-June 1973.
4.
Coronary Artery Disease. A Monograph., Warner-Chilcott
Laboratories. Morris Plains, New Jersey, 1972.
5.
Coronary Risk Handbook.
Association. 1973.
6.
Fodor, John T. and Dalis, GusT., Health Instruction:
Theorv and Apolication., 2nd Edition, Philadelphia:
Lea and Febiger, 1974.
7.
Fors, S. and Kreuter, M. "Heart Health Education in the
Patient Care Setting", Proceedings of the ASHA. Fiftysecond Convention. October 14, 1978.
ff.
Foxworth, Gwendolyn D. "Rehabilitation of Hospitalized
Adults After Open-Heart Procedures:
The Team Approach",
Heart and Lung, Vol. 7. No. 5, September-October 1978.
9.
Friedman, Meyer. Pathogenesis of Coronary Artery Disease,
New Yor: McGraw-Hill, 1969.
New York: American Heart
10.
Girdano, Daniel and Everly, George.
Controlling Stress
and Tension: A Holistic Approach. Englewood Cliffs:
Prentice-Hall. 1979.
11.
Gordon, Gerald. Role Theory and Illness: A Sociological
Perspective.
New Haven: College and University Press. 1966.
12.
Guyton, Authur C., Textbook of Medical Physiology. 5th
Edition. Philadelphis: W. B. Saudners Co., 1976.
13.
Harvey, W. Proctor. et. al., ed. The Yearbook of Cardio1ogy--1980. Chicago: Yearbook Medical Publishers, 1980.
14.
Heartbook--A Guide to the Prevention and Treatment of
Cardiovascular Diseases. American Heart Association,
New York: E. P. Dutton, 1980.
37
135
15.
Hurst, John w., ed. The Heart: Arteries and Veins. 4th
Edition., New York: McGraw-Hill, 1978.
16.
Me Intosh, Henry C. ed., Diet and Heart Disease. Baylor
College of Medicine: Cardiology Series MonOgraph. Vol. 2,
Part II., 1978.
17.
Moriyama, Iwao, et, al. Cardiovascular Disease in the
United States. Cambridge: Harvard University Press, 1971.
18.
Naughton, John P. and Hellerstein, Herman. ed., Exercise
Testing and Exercise Training in Coronary Heart Disease.
New York: Academic Press. 1973.
19.
Ross, R. s.
"The Problem of Ischemic Heart Disease:
Current Approach and Implications for Curriculum Design".
Johns Hopkins Medical Journal. May 1976.
20.
Shafer, Kathleen. H. et.al., Medical-Surgical Nursing.
St. Louis: C. V. Mospy Company. 1975.
21.
Sinsheimer, Una Sue. "An Educational Program in Mvccardial Infarction". (Masters Thesis, California State
University, Northridge, 1976).
22.
Weinberg. A. et. al. " A Curriculum Effort in Cardiovascular Disease Prevention" Health Education. Vol 6.,
No . 1 0 , 19 7 9 .
23.
World Almanac and Book of Facts--1980 Edition. Source:
National Center for Health Statistics. U.S. Department
of Health, Education and Welfare.
24.
Zohman, Lenore R. and Tobis, Jerome S. Cardiac Rehabilitation. New York: Grune and Stratton. 1970.
38
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138
INSTRUCTION SHEET
FOR
COUNTING YOUR OWN PULSE
SONE HEART HEDICATIONS REQUIRE PERIODIC ADJUSTMENT
IN DOSAGE. TO HELP YOUR DOCTOR DETERMINE WHEN A
CHANGE IN DOSAGE IS NECESSARY, YOU MUST RECORD
YOUR PULSE RATE AND RHYTHM BEFORE YOU TAKE YOUR
PRESCRIBED DOSE.
DURING RECOVERY FROM A HEART ATTACK, THE PULSE RATE
IS ALSO USED AS A MEASURE OF THE HEARTS ABILITY TO
MEET THE BODY'S NEED FOR OXYGEN-RICH BLOOD AS YOUR
ACTIVITY LEVEL IS INCREASED.
REME:f-1BER: : : : : : : : :
1.
GET A CLOCK OR WATCH WITH A SECOND HAND AND
PLACE IT WHERE YOU CAN SEE IT EASILY.
2.
SIT DOWN AND REST FOR FIVE MINUTES BEFORE
TAKING YOUR PULSE---IF YOUR PULSE RATE IS
BEING USED TO MONITOR YOUR EXERCISE TOLERANCE,
TAKE YOU PULSE BEFORE. DURING AND AFTER THE
ACTIVITY.
3.
PUT THE FLESHY PART OF YOUR FINGERTIPS ON THE
OPPOSITE WRIST, IN THE GROOVE JUST BELOW THE
BASE OF YOUR THUMB.
4.
PRESS LIGHTLY, MOVING YOUR FINGERTIPS ALONG THE
GROOVE OF YOUR WRIST UNTIL YOU FEEL YOUR PULSE.
5.
WITH YOUR FINGERTIPS (NEVER YOUR THUMB), COUNT
YOUR PULSE FOR ONE FULL MINUTE.
NOTE WHETHER
IT IS REGULAR OR IRREGULAR.
6·.
WRITE YOUR PULSE AND RHYTHM ON THE RECORD SHEET
ON THE REVERSE SIDE OF THIS PAPER.
7.
TAKE YOUR PULSE AT THE SAME TIME EACH DAY.
IF YOUR PULSE RATE FALLS BELOW________JMIN., OR
IS ABOVE.________-JMIN., OR IF IT SEEMS IRREGULAR,
DO NOT TAKE YOUR MEDICATION
--~-
CALL YOUR DOCTOR
AT ONCE ----TELL !liM YOU PULSE RATE
.
139
-
PUL.SE RATE RECORD
Date
Time
Rhythm
Rate
PULSE RATE RECORD
Date
Time
Rhythm
Rate
I
.,
I
I
I
'
-
140
Patient instruct~ons
EVERY MEDICATION HAS BOTH ADVANTAGES AND
DISADVANTAGES.
YOU CAN PLAY A PART IN YOUR
OWN HEALTH BY LEARNING AS MUCH AS YOU CAN ·
ABOUT THE MEDICATIONS YOU ARE TAKING.
HERE ARE SOME THINGS YOU SHOULD KNOW ABOUT
ANY MEDICATION . . . . • . . . . . . . . . . • . • . . . . . . • . ·•.
1.
TAKE YOUR MEDICATION ONLY AT THE TIME AND IN THE
AMOUNT PRESCRIBED BY YOUR DOCTOR.
2.
IF YOU MISS TAKING A PILL, NEVER CORRECT THE ERROR
BY DOUBLING UP ON THE NEXT DOSE.
3.
NEVER STOP TAKING YOUR MEDICATION WITHOUT THE
CONSENT OF YOUR DOCTOR.
4.
~EVER,
5.
NEVER, TAKE YOUR MEDICATION IN THE DARK. ALWAYS
CHECK THE LABEL FIRST.
6.
CARRY A LIST OF YOUR MEDICATIONS AND THE DOSE
YOU ARE TAKING IN YOUR WALLET.
7.
TAKING VITAMINS ARE NOT NECESSARY, BUT WILL NOT
HARM YOU OR INTERFER WITH YOUR MEDICATIONS .....
EXCEPT, IF YOU ARE ALSO TAKING A BLOOD THINNING
MEDICATION.
8.
REMEMBER .... ALWAYS TAKE THE RIGHT AMOUNT
AT THE RIGHT TIME
AS INSTRUCTED BY YOUR DOCTOR
9.
AVOID ALCOHOL,
RUN OUT OF YOUR MEDICATION.
WHEN A FEW
PILLS REMAIN, HAVE YOUR PRESCRIPTION REFILLED.
IT MAY CAUSE UNPLEASANT SIDE EFFECTS.
KEEP ALL MEDICATION OUT OF THE REACH OF CHILDREN
141
;-IF.DICATION NA.NE:
DIGOXIN
(DIGITALIS)
DESCRIPTION:
ROUND WHITE SCORED TABLET {0.25 mg)
ROUND YELLOW SCORED TABLET {0.125mg)
WHAT IT DOES:
HELPS YOUR HEART BEAT STRONGER,
SLOWER AND MORE REGULARLY.
REMEMBER:
TAKE DIGOXIN AT THE SAME TIME EACH
DAY TO MAINTAIN A CONSTANT LEVEL IN
YOUR BODY.
CHECK YOUR PULSE BEFORE TAKING THIS
MEDICINE ... IF IT BECOMES VERY SLOW
CALL YOUR DOCTOR.
(SEE RATE BELOW).
DIGOXIN MAY CAUSE YOU TO LOSE TOO
MUCH POTASSIUM, ESPECIALLY IF YOU
ARE ALSO TAKING A DIURETIC.
UNUSUAL THIRST OR FEELINGS OF
WEAKNESS MAY BE EARLY SIGNS THAT
YOU NEED MORE POTASSIUM.
YOU MAY
BE ADVISED BY YOUR DOCTOR TO EAT
FOODS HIGH IN POTASSIUM, SUCH AS:
BANANAS
ORANGE JUICE
ORANGES
NUTS
GRAPEFRUIT
PRUNES
DRIED BE.ANs·
GREEN VEGETABLES
IT MAY ALSO BE NECESSARY FOR YOUR
DOCTOR TO ADJUST YOUR DOSAGE FROM
TIME TO TIME.
CALL YOUR DOCTOR,
IF . . . . . . . . l.
YOU HAVE LOSS OF APPETITE.
2.
YOU HAVE NAUSEA, VOMITING OR
DIARRHEA.
3.
YOU HAVE UNEXPLAINED DROWINESS,
OR WEAKNESS.
4.
YOU HAVE HEADACHES.
5.
YOU HAVE BLURRED, YELLOW, GREEN
OR FLICKERING VISION.
YOU FEEL DEPRESSED {DOWN IN THE DUMPS).
6.
7.
YOUR PULSE RATE IS BELOW_________
BEATS PER MINUTE.
142
~IEDICATION
NAt-IE:
HYDRODIURIL (HYDROCHLORTHIAZIDE)
DESCRIPTION:
AVAILABLEIN DIFFERENT SIZES, SHAPES
AND COLORS, DEPENDING ON THE BRAND
NAME AND THE MANUFACTURER.
WW\.T IT DOES:
HELPS GET RID OF THE EXTRA WATER IN
YOUR BODY AND HELPS REDUCE THE WORK
LOAD ON THE HEART.
REMEMBER:
YOU CAN EXPECT TO URINATE (PASS YOUR
WATER) MORE OFTEN THE FIRST FEW DAYS
AFTER STARTING THIS PILL.
TO AVOID
UNNECESSARY TRIPS TO THE BATHROOM.
DURING THE NIGHT ... TAKE YOUR PILL
IN THE MORNING OR BEFORE 6:00 P;M.
WEIGH YOURSELF DAILY AT THE SAME TIME
YOU MAY BE ADVISED BY YOUR DOCTOR XO
EAT FOODS HIGH IN POTASSIUM, SUCH AS:
GRAPEFRUIT
NUTS
BANANAS
MOLASSES.S
PRUNES
ORANGE JUICE
GREEN
DRIED BEANS
ORANGES
VEGETABLES
CAT I
YO fiR
Dili.:TDB-,
IF . . . . . . . 1.
2.
.1
YOU HAVE EXCESSIVE WEAKNESS, TIREDNESS,
DIZZINESS OR FAINTING.
YOU EXPERIENCE FREQUENT LEG OR
STOMACH CRAMPS OR· BACK PAIN.
3.
YOU HAVE EXCESSIVE THIRST.
4.
YOU GET A FLUTTERING OR POUNDING IN
YOUR CHEST, SHORTNESS OF BREATH,
SWELLING OF HANDS, FEET OR ANKLES.
5.
YOU NOTICE A WEIGHT GAIN OF MORE
THAN 2 LBS. A DAY OR 5 LBS. A WEEK.
6.
YOU GET AN UPSET STOMACH THAT LASTS
24 HOURS OR MORE .
143
NED ICATION
NA.~!E:
INDEROL
(PROPANOLOL)
DESCRIPTION:
PEACH
GREEN
( lOmg)
(40mg)
1--IHAT IT DOES:
SLOI-/S THE HEART RATE AND LOWERS
THE BLOOD PRESSURE.
REi'1El'!BER:
DO NOT STOP TAKING THIS MEDICATION
UNLESS TOLD TO DO SO BY YOUR DOCTOR.
BLUE
(20mg)
YELLOW
(80mg)
STOPPING THE MEDICATION SUDDENLY
MAY CAUSE SERIOUS SIDE EFFECTS.
AVOID EXCESS ALCOHOL.
·
NAY HIDE THESIGNS AND SYMPTONS OF
LOW BLOOD SUGAR.
DIABETICS SHOULD
ESPECIALLY CAREFUL.
..
CALL YOUR DOCTOR:
IF . . . . . . . . . . . 1.
YOU HAVE WHEE ZING, SHORTNESS OF
BREATH OR A NEW COUGH.
2.
YOU HAVE DEPRESSION,
WEAKNESS.
3.
YOU HAVE ANKLE SWELLING.
4.
YOU HAVE ~/EIGHT GAIN
IN ONE DAY).
5.
YOU
6.
YOU HAVE A SKIN RASH.
7.
YOU HAVE DIARRHEA OR CONSTIPATION.
8.
YOU HAVE A PULSE RATE LESS THAN
HAVE~
__/MIN.
FATIGUE OR
(MORE THAN 2 lbs.
SLEEPLESSNESS~
144
~!EDICATIO~
t-;A.\IE:
ISORDIL (ISOSORBIDE DINITRATE, SORBITRATE)
DESCRIPTION:
AVAILABLE IN DIFFERENT SIZES SHAPES AND COLORS,
DEPENDING ON THE BRAND.
COMES IN THREE FORMS
OF PILLS.
2.
CHEWABLE (ONLY FORM SUPPLIED BY VA)
SUB-LINGUAL (UNDER THE TONGUE)
3.
SWALLOI~ABLE
1.
IY1-l.-\T IT DOES:
HELPS TO PREVENT ANGINA (CARDIAC CHEST PAIN)
BY DILATING THE BLOOD VESSELS AND BRINGING
~lORE
HAS
RE~l91BER:
BLOOD AND OXYGEN TO THE HEART MUSCLES.
SLOI~ER
ONSET OF ACTION BUT ACTION LASTS
LONGER THAN NITROGLYCERIN.
DO NOT TAKE THIS TO RELIEVE CHEST PAIN ONCE
IT HAS STARTED.
IF CHEST PAIN OCCURS ANYWAY, THEN
TA~E
NITRO-
GLYCERIN.
~~y
CAUSE: HEADACHE AND DIZZINESS.
AVOID ALCOHOL
CHEW CHEl'IABLES THOROUGHLY BEFORE SWALLOWING.
CALL-YOUR DOCTOR;
IF ....... .
1.
YOU
2.
YOU HAVE FLUSHING OF THE SKIN.
3.
YOU HAVE DIZZINESS, WEAKNESS, FAINTNESS.
4.
YOU HAVE NAUSEA OR VOMITING.
K~VE PERSISTfu~T ru~D
SEVERE HEADACHES.
145
1-!EDICATION NA!-!E:
LASIX
(FUROSEMIDE)
DESCRIPTION:
WHITE SCORED ROUND::TABLET.~-. (40mg)
WHITE OBLONG TABLET
(20mg)
WHAT IT DOES:
HELPS GET RID OF THE EXTRA WATER IN
YOUR BODY AND HELPS REDUCE THE WORK
LOAD ON YOUR HEART.
RENEMBER:.
YOU CAN EXPECT TO URINATE(PASS YOUR
WATER) MORE OFTEN THE FIRST FEW DAYS
AFTER STARTING THIS PILL. TO AVOID
UNNECESSARY TRIPS TO THE BATHROOM
DURING THE NIGHT •.. TAKE YOUR PILL
IN THE MORNING OR BEFORE 6:00 P.M.
WEIGH YOURSELF AT THE SAME TIME DAILY.
YOU MAY BE ADVISED BY YOUR DOCTOR TO
EAT FOODS HIGH IN POTASSIUM, SUCH AS:
GRAPEFRUIT
NUTS
BANANAS
ORANGE JUICE
PRUNES
MOLASSES
ORANGES
DRIED BEANS
APRICOTS
GREEN VEGETABLES
CALL YOUR DOCTOR,
IF . . . . . . . . . l.
YOU BECOME VERY WEAK OR DIZZY.
2.
YOU GET AN UPSET STOMACH, DIARRHEA
OR MUSCLE CRAMPS LASTING 24 HOURS
OR MORE.
3.
YOU HAVE TROUBLE HEARING OR YOUR
EARS START TO RING.
4.
YOUR EYES GET BLURRY.
5.
YOU BECOME VERY SHORT OF BREATH
OR NOTICE MORE SWELLING IN YOUR·
LEGS AND ANKLES.
6.
YOU NOTICE A SKIN RASH OR ITCHING.
7.
YOU NOTICE A WEIGHT GAIN OF MORE
THAN 2 LBS. A DAY OR 5 LBS. A WEEK.
146
MEDICATION NAME:
NITROBID (NITROGLYCERIN OINTMENT)
DESCRIPTION:
WHITE OINTMENT SUPPLIED IN A TUBE
WITH MEASURING PAPER.
WHAT IT DOES:
LONG-ACTING PREVENTION OF CHEST
PAIN (ANGINA) .
REMEMBER:
STORE IN A COOL PLACE
REMOVE OLD OINTMENT FROM SKIN BEFORE
RE-APPLYING.
MEASURE DIRECTLY FROM THE TUBE ONTO
MEASURING PAPER. QO NOT RUB THE
OINTMENT INTO THE SKIN.
CHOOSE AN AREA OF THE SKIN WHICH IS
MOSTLY HAIR-FREE--CHEST WALL, ABDOMEN,
ANKLE, THIGH OR FOREARM. SECURE PAPER
WITH TAPE. ROTATE SITE EACH APPLICATION.
HEADACH, DIZZINESS OR A FLUSHED WARM
FEELING IN YOUR FACE ARE FAIRLY COMMON
WITH THIS OINTMENT.
THESE EFFECTS USUALLY
DISAPPEAR IN A FEW WEEKS.
CALL YOUR DOCTOR:
IF . . . . . . . . l.
YOU DEVELOP UNUSUALLY SEVERE HEADACHES.
2.
YOU BECOME UNUSUALLY DIZZY.
3.
YOU DEVELOP A RASH AT THE SITE OF
THE APPLICATION OF OINTMENT.
147
HEDICATION N.l',NE:
NITROGLYCERIN
DESCRIPTION:
COMES IN DIFFERENT STRENGTHS:
(1/100)
(1/150)
{1/200)
-(1/400)
EACH STRENGTH IS THE SAME SIZE AND COLOR.
SMALL WHITE TABLET, SLIGHTLY BIGGER THAN
A PINHEAD.
WHAT IT DOES:
RELIEVES CHEST PAIN BY BRINGING MORE
BLOOD AND OXYGEN TO THE HEART MUSCLE.
RENEI-!BER:
TAKE A TABLET AS SOON AS THE PAIN STARTS.
LET THE TABLET NELT UNDER YOUR TONGUE.
MAY CAUSE A DROP IN BLOOD PRESSURE, SO
SIT DOWN OR LIE DOWN WHEN TAKING EACH
TABLET.
CARRY TABLETS WITH YOU AT ALL TIMES.
STORE IN ORIGINAL BROWN BOTTLE, TIGHTLY
CLOSED. REMOVE COTTON FOR EASY ACCESS.
GET A FRESH SUPPLY EVERY THREE MONTHS.
FRESH TABLETS PRODUCE A SLIGHT BURNING
SENSATION UNDER YOUR TONGUE.
TO PREVENT CHEST PAIN---TAKS l\. TABLET
FROM THREE TO FIVE MINUTES BEFORE ANY
ACTIVITY WHICH PRODUCES CHEST PAIN.
MAY TAKE UP TO THREE NITROGLYCERIN FOR
EACH EPISODE OF CHEST PAIN (ONE EVERY
5 MINUTES).
C.".LL YOUR
DOCTOR
IF ........ l.
2.
YOUR CHEST PAIN DOES NOT GO AWAY
AFTER THREE TABLETS.
YOU HAVE UNUSUALLY SEVERE PAIN OR
SEVERE HEADACHES OR FAINTING.
148
1-IEDIC.:I.TION
N.~l-!E:
NOR PACE
(DISOPYRN1IDE)
DESCRIPTION:
A WHITE AND ORANGE (lOOmg) OR
BROWN AND ORANGE (150mg) CAPSULE.
\iH.'I.T IT DOES:
PREVENTS EXTRA HEART BEATS AND HELPS
YOUR HEART MAINTAIN A REGULAR RHYTHM:
!l.fl-1E1·18ER:
MUST BE TAKEN AT REGULAR INTERVALS
AS PRESCRIBED BY YOUR DOCTOR.
IT MAY CAUSE YOU TO HAVE A DRY MOUTH.
THIS IS A NORMAL EFFECT OF THE
MEDICATION.
CALL YOUR DOCTOR:
IF._ . . . . . . ;.
L
YOU HAVE DIZZINESS OR FEEL FAINT.
2.
YOU GET A FLUTTERING OR POUNDING
IN YOUR CHEST.
3.
YOU GET SEVERE CONSTIPATION OR
DIARRHEA.
4.
YOU HAVE DIFFICULTY URINATING.
5.
YOU HAVE BLURRED VISION.
6.
YOU BEGIN TO HAVE SHORTNESS OF
BREATH, SWELLING OF ANKLES,
HANDS OR FEET.
149
MEDIC.\TION NAl'IE:
POTASSIUM SUPPLEMENT
DESCRIPTION:
MAY BE EITHER A LIQUID OR POWDER,
WHICH MUST BE MIXED WITH A FULL
GLASS OF WATER OR FRUIT JUICE.
MAY ALSO BE GIVEN AS A PEACH COLORED
PILL CALLED SLOW-K.
WHAT IT DOES:
POTASSIUM IS AN IMPORTANT CHL~ICAL
IN THE BODY WHICH HELPS THE MUSCLES,
INCLUDING THE HEART MUSCLES,
CONTRACT SMOOTHLY AND PROPERLY.
REHE~!BER:
PEOPLE WHO ARE TAKING DIURETICS
(WATER PILLS) MAY BECOME LOW IN
POTASSIUM. AND MUST RELACE THIS
LOSS.
SOME PEOPLE WILL NEED TO TAKE
POTASSIUM AS A MEDICATION.
YOU MAY BE ADVISED BY YOUR DOCTOR
TO EAT FOODS HIGH IN POTASSIUM,
SUCH AS:
BANANAS
ORANGE JUICE
ORANGES
APRICOTS
GRAPEFRUIT
NUTS
PRUNES
· MOLASSES
DRIED BEANS'
GREEN VEGETABLES
CALL YOUR DOCTOR,
IF . . . . . . . . . l.
YOU NOTICE LOSS
0~
APPETITE.
2.
YOU HAVE ABDOMINAL PAINS,
VOr-tiTING OR DIARRHEA.
NAUSEA,
3.
YOU HAVE DIZZINESS OR WEAKNESS.
4.
YOU HAVE NUMBNESS OR TINGLING IN
YOUR ARMS OR LEGS.
5.
YOU K~VE UNSUAL TIREDNESS OR
DEPRESSION.
150
MEDICATION N.'V-!E:
PROCARDIA
DESCRIPTION:
ORANGE CAPSULE
WHAT IT DOES:
DILATES (WIDENS) THE BLOOD VESSELS
WHICH SUPPLY OXYGEN TO THE HEART
MUSCLE AND HELPS TO DECREASE ANGINA
(CHEST PAIN) •
RENH!BER:
DO NOT STOP TAKING THIS MEDICATION
UNLESS TOLD TO DO SO BY YOUR DOCTOR.
(NIFEDIPINE)
(lOmg)
HAVE YOUR PRESCRIPTION REFILLED
SO YOU WILL NOT RUN OUT OF THIS
DRUG OR MISS A DOSE.
STOPPING THE MEDICATION WITHOUT
THE SUPERVISION OF YOUR DOCTOR
CAN CAUSE SEVERE CHEST PAIN.
IF YOU HAVE CHEST PAIN WHILE TAKING
THIS DRUG, YOU SHOULD TAKE YOUR
~ITROGLYCERIN AS DIRECTED BY YOUR
DOCTOR, IN ADDITION TO THIS MEDICATION.
MAY CAUSE DIZZINESS, SO WHEN YOU GET
OUT OF SED, GO UP AND DOWN STAIRS, OR
Cf:IANGE POSITIONS. t•!OVE SLOHLY.
LIE
DOWN AT THE FIRST SIGN OF DIZZINESS.
CALL YOUR
DOCTOR
IF . . . . . . . l.
YOU HAVE SHORTNESS OF
BREATH.
2.
YOU HAVE SWELLING OF FEET OR ANKLES.
3.
YOU HAVE DIZZINESS OR LIGHTHEADEDNESS.
4.
YOUR HAVE BLURRED VISION.
151
(PROCAINAMIDE)
(LONG ACTING PROCAINAMIDE)
MEDIC."-.TION N.'\I·!E:
PRONESTYL
PROCAN-SR
DESCRIPTION:
YELLOW (SOOmg)
GREEN (250mg)
FILM-COATED TABLETS
WH.li.T IT DOES:
PREVENTS EXTRA HEART BEATS AND HELPS
YOUR HEART MAINTAIN A REGULAR RHYTHM.
REMEMBER:
TO BE EFFECTIVE THIS DRUG MUST BE
TAKEN AT REGULAR INTERVALS.
CALL YOUR DOCTOR.
IF . . . . . . . . l.
YOU HAVE SORENESS OF YOUR MOUTH,
THROAT OR Gill·!S.
2.
YOU HAVE AN UNEXPLAINED FEVER.
3.
YOU DEVELOP SY!-1PT0.:1S OF UPPER
RESPIRATORY INFECTION SUCH AS
SORE THROAT:. OR HEAD COLD.
4.
YOU HAVE A THlir1PING OR
POUNDING IN YOUR CHEST.
5.
YOU HAVE SEVERE NAUSEA,
OR DIARRHEA.
6.
YOU DEVELOP PAIN IN YOUR JOINTS
OR MUSCLES.
VOMITING
152
1-tEDICh.TION N.Z.J.!E:
QUINIDINE
(QUINIDINE HYROCHLORIDE)
QUINIGLUTE (QUINIDINE GLUCONATE)
DESCRIPTION:
QUINIDINE---WHITE SCORED TABLET (200mg)
QUINIGLUTE---LARGE WHITE TABLET (324mg)
WITH "CLOCK" FACE
tlHAT IT DOES:
HELPS YOUR HEART BEAT MORE REGULARLY
REMEMBER:
TAKING YOUR PILLS WITH NEALS WILL
HELP TO DECREASE STOMACH UPSET.
SURE TO GET MORE PILLS BEFORE
THE BOTTLE IS EMPTY SO THAT YOU
DO NOT MISS A DOSE.
~E
C~LL
YOUK
DOCTOR.
IF . . . . . . . 1.
YOU HAVE DIARRHEA,
VONITING.
NAUSEA OR
2.
YOU HAVE BLURRED VISION.
3.
YOU HAVE RINGING IN YOUR EARS.
4.
YOU GET A_RASH AND/OR A FEVER.
5.
YOU HAVE A PULSE RATE BELOW_____
OR AN IRREGULAR PULSE.
6.
YOU FEEL FAINT, DIZZY OR PASS OUT.
153
-------------~.a
-· .;./ f-:---=-,
~
I--:........
r -. -.. . ._
!-~--
~
- .·....,
-
J
-~
Ii=" YOU H.'-.VE CHEST .?."-.I~, SHORT!'E:SS OF BREATH OR DIZZINESS,
\·;'iAT YOU ;._RE uOING ;._NO RESTIF YOUR DOCTOR f:!AS
G:::~:::F.ED NITrtOGLYCEP.IN FOR CHEST PAIN---TAKE YOUR
r-;C:!)ICI:<E A.KD LIE !)Q",>'N FOR 15 MINUTES. Wl-iEN YOUR PAIN
p_.;s STCPFED, YOU MhY CONTINUE WHAT YOU \-.'ERE DOING BUT
AT A SLOWER PACE.
~TO?
C~~L
YOUR DOCTOR IS YOUR HAVE:
1.
PAIN OR CHEST DISCOMFORT THAT DOES NOT GO
;>..1\AY WHEN YOU TAKE YOUR MEDICATION OR WITH
15 MINUTES OF REST.
2.
CHEST PAIN THAT BEGINS TO Al'/AKEN YOU AT NIGHT,
OCCURS WHEN YOU ARE RESTING OR INCREASES IN
SEVERITY OR FREQUENCY.
3.
SHORTNESS OF BREATH WHICH IS NOT RELATED TO
ACTIVITY.
YOU MAY EXPECT A LITTLE SHORTNESS
OF BREATH \-/HEN DOING SOME ACTIVITIES-
4.
DIZZINESS.
5.
FAINTING.
6.
NAUSEA OR VOMITING.
7.
UNEXPLAINED SWEATING.
8.
A VERY SLOW OR A VERY FAST HEART BEAT Tf-l~T DOES
NOT SLOW DOWN TO YOUR NORMAL RANGE WITH A SHORT
PERIOD OF REST.
IF YOU CANNOT GET IN TOUCH WITH YOUR DOCTOR OR
THE REH.'\BILITATION OFFICE, HAVE SOMEONE DRIVE YOU
TO THE HOSPITAL EMERGENCY ROOM.
ALSO-----REMEMBER TO REPORT---ANY SIDE EFFECTS LISTED
ON YOUR MEDICATION INSTRUCTION SHEETS.
SctJHDOSctH
flST
8NIHJV3~
155
INTERVIEW GUIDE
PURPOSE: The Interview Guide will serve as a tool for the
assessment of educational/learning needs on admission and
prior to instruction and; for evaluation of learning outcomes.
1.
Question:
Can you tell me in your own words what happens
to the heart when a heart attack occurs?
Answer:
Should include a statement. such as; there is
a complete blockage of an artery that furnishes the
heart muscle with blood and oxygen and a small area of
muscle tissue of the heart dies from this lack of oxygen.
2.
Question:
Tell me in your,own words
place in the damaaed heart muscle.
:how healing takes
Answer:
Should include statements. such as; healing
starts immediately after a heart attack and the heart
muscle heals much like any other damaged tissue.
Scar
tissue gradually replaces the damaged tissue.
3.
Question:
How long does it take for the heart to heal
after a heart attack?
Answer:
4.
6-8 weeks. ·
Question:
What is the purpose of restricting your
activity after a heart attack?
Answer:
Should include statement. such as; a damaged
heart cannot pump blood as easily; by restricting activity
the heart muscle is required to do less work during the
healing process.
5.
Question:
What can the pulse rate tell us?
Answer:
Should include statements, such as; the pulse
rate measures exercise tolerance after a heart attack. A
rapid heart beat means the heart is having to work harder
and this can put a strain on the damaged heart muscle.
Changes in heart rate can also identify early signs of
medication side effects.
156
6.
Question:
What changes in heart rate should you report
to the doctor?
Ans•..:er:
Should include all of the following--increased
heart rate that does not return to normal following a
rest period; a very slow heart rate; an irregular heart
rate or skipped beats; fluttering or pounding feeling in
your chest.
7.
Question:
Tell me what medications you will take at home.
How much vou are to take?
How often and what the medication does for your heart?
Answer: Acceptable if the patient refers to and shows
copies of the medication handout sheets; refers to list
of "Medications I Take" or can recall from memory.
8.
Questions:
If you have chest pain, what should you do?
Answer:
Should include statements, such as; Stop what
I'm doing and rest--Put a nitroglycerin under my tongue
and sit or lie down for 5 minutes.
If chest pain continues I will take 2 more nitroglycerin tablets, 5 minutes
apart.
9.
Question:
What action should you take if your chest pain
is not relieved by nitroglycerin and lasts longer than 15
minutes.
Answer:
Should include statements, such as; Call my doctor;
Have someone drive me to the hospital emergency room.
10.
What symptoms have you been instructed to report
Question:
immediately?
Answer:
Should include at least 4 of the following
statements: 1) Chest pain lasting longer than 15 minutes or
if it occurs when your resting; 2) Increased shortness of
breath; 3) Dizziness or fainting; 4) Unexplained weakness;
5) Very fast or very slow heart rate; 6) Unexplained
sweating or cold clammy feeling to skin; 7) Indigestion
that doesn't go away.
ll.
Question:
Will you show me how you will count your pulse?
Answer:
Patient should demonstrate ability to could own
pulse with no more than a (+) or (-) 4 variance, when
valjdated by the instructor.
15
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172
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YEAR:
DATE
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STAGE
I
DATE
T
0
.w.EDICATIOl'f Al'lO TREATwEHT
•
l. Complete bedrest, partial personJ
H
al care, bedside co~~ode.
2. Sit 45° as tolerated.
D
"'UR'§[l" INITIALS
I
H
I
D
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I
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l. Cooplete bedrest vith bedside
H
STAGE
cou~ode.
.
May sit in chair 10-15 min. b.i.d~
2.
II
as tolerated (asJist in sitting.!
and transferr1ng •
_
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H
supervision of P.T.
q.i.d. 10 times.
I
7. Deep breathing lOX b.Ld.
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l . Bedside co=ode; oay sit in chair"
20-30 minutes b.i.d. as tolerated"".
STAGE
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ill
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5. Patient does 30 seconds of step-l"
ping in place vith supervision ofo
P.T.
6
STAG I
IV
Df"~n hrP<J.t.h\no-
lOX b l ,d
I
E
1. Bathroom privileses, Sit in lounJ:
chair as tolerated. Encourage si~~
ting at bedside for meals.
2. Deep breathing lOX b.i.d.
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3. Supervised A.R.O.M. to all ex{re~eties supine in_bed 3X daily
~eart rate not to 1ncreaJe more
an 15 beats per minute.
4. Active flexion of ankles q.i.d.
I
I
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E
6. Patient does active ankle flexio
I
I "I I
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3. Dangle legs on side of bed 1 tin~~
4. Passive range of motion to all
0
extremeties 3X once per day.
5. Stand at bedside for 1 min. vith
I
I
E
3. Passive range ol mot1on to all
extremeties 3X once per day,
4. Patient does active flexion of
ankles q.i.d. daily, 10 repetitions.
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CONTINUING MEDICATION
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MONTH(Sl:
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Supervised active ranee of rnoti~tH
STAGE
to all extreneties 3X once daily
surine.
.io
IV
lj_ Pa ient does 1 minute of steppin~
CONT.
in place vith supervision of .TIE
3.
.
·I
I
5. Patient does active ankle r.IOtion~H
b.i.d. (20 rotations).
0
.
IE
~-
Ha~nroom
STAGE
pr~v~~eges.
;:,~t
~n
lounge chair e.s tolere.ted.
Encourage sitting at bedside for
meals.
v
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E
conpletes active range o~ H
motion to all extre~eties IX tvi
~er da
Once sucervised(~ith
0
.T.
nee unsuFei-vised.
Heart
rate not to increase more than l~E
beats/per minute.
3. Deep breathing lOX b.i.d.
H
4. Ambulation in hallvay lrith super [J
vision at: P.T. lX per day 90
feet/min. f."or 2-5 minutes.
Continue e.ct:ivities 1, 2, .3 in
HI
Stase V.
2 • Suoervised active exercises in0
elUde uocer and laYer extrer.-:.etieS
5X once·uaily.
2.
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Pat~ent
0.
E
r
STAG
VI
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3. Ankle rotations
b.Ld.
0
E
~H
Ambulation in hall·.;ay 2X daily
0
vith supervision by P.T ..
GOAL:
180 ft/2 ~in .. (2 c:ets). One •.talk! E
v-i+h
<:;n~.o-·
• ~; f"\n
lr-;..-.o.
STACi
~·
VII
.--<. . . . . . . . . .
t
once vith
P.T. and once unsupervised. GOAL
180 ft/2min. (2 mets) valk times
2-5
£1'11~, ,,. op•c~ b•ln-·
minutes.
.... Tti(NT 10f!NTIII"IC.ATI0N- TAI(.ATINC, J"ACII,.ITV- '"""'"0 .. 0
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~t:COR'O
CONTINUING MEDICATION
AND TREATMENT
VA J"OA"'"
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Continue 9.c-r.ivities 1, 2. 3 in
14
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Star;e V.
Actl'le exercises t·.rice ~ Once vi tho
." supervision or P. T. and once vith
out for t·..ro minutes.
IE
3. Arnbulation in hallvay
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(20 rota
tions).
lj_ Deep breathing lOX b.i.d.
5.
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10-2970
1oTOC• O"' VA •0"'""'" IO.nJ"ICII
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174
MOHTH(S)~
YEARo
:
(A ,. .. ,,. • •
-.u '"''''•'
•n,,._d_
C:~E
0.4Tf:
~ f--r--~-.---.--.--.--.--r--~-.--.--.--.-~
w.EOIC.lTIOH AHO TR.EAT"'-EHT
~-~_J
OAT~
·~~lo t""nlry to ,..,..,..,,,. tlt•t rl ll.e• b.-r,.. rou~rtlr u,.,..
R£l"F:RSE !.IDE FOH tnENTIJ."ICATION OF 1'-"ITIAU.J
1. Continue activities 1, 2, 3 in
STAGE
Stage V.
Pat1ent does ovn active exercise
VIII 2. tw1ce
daily withovt supervision
l2 minute session}.
__
_L__J __ _
~~L-•~U~••~.~.~.\~.-,T-O~.L-S~J_'--L-_L__J_~L--j
N
0
3. Ambu1ation in hallway without
N
sunervision ror 5 ~in. 2X day.
Nurse .consent nrior to valk is
0
liandatory.
·
4. With P.T. sunervision, patient
E
valk« clcnm ;J.fliP"ht.<; of.-stails
and tal~es elevator u;>.
N
].. Continue activities 1, 2, 3 in
STAGE
Stage V.
o
Pat 1 en t does ovn active exercise j''-+--+--1f--+---t---+---cr--t---t---+--t--+--+--t---J
2.
IX
2X daily vithout supervision.
E
N
3. Ambulation in hallway 2X daily
with minimal supervision.
5-10
0
min. in duration •
Nurse consent r--t---+---f--+---+--+---f--t---+--+--t--+--+--t---J
prior to valk is mandatory.
E
1
4.
H
Patient valks dovn and up 1
flight (9 stairs dovn/9 stairs
up) once vith supervision.
ll
;N
5. Possible discharge graded ex e r- 1
t---!--+--+--+---t--t--+--+---!--t--+--i!--+~+--l
cise tolerance test which
o
inc 1 ud e s i ndi vidual home e xe r cis ef-E-+---fj--+-+--+--t--+--+--t--+--+--!--+-+--1
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sT•G
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1 • Con t in ue activities 1 , 2 , 3 in !f-+---t---f--+--+---t---ci---+--+---t---J--+---!--1---1
Stage V.
io
2 • ~ ~t! e ~ t. -~~~ ~ .. ~ ~ .. ~c : i ~:; : ~e rc is e s!:--E+---t--,i--+--+---t--ii---t--+---t--1--+---!--f---j
1
1
3. Honit~red exercise session sunerlH
vised by P. T.
Session to last
15-25 minutes, oC slov valking.
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175
1/.EDICAl
RECC~D
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Init.,H•v•;:.
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NUr!SING ·
·-:Jv'
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ON i\DMISSION, \·:HEN PATIENT'S CO!'WITION PJ,S ST.?,BLIIZED:
L
.ln.l .... ~c.tec:
A
Ex!Jlcin to patiEnt and f2.mily v;hy he/she is in Intensive
Caz-e.
2.
Explain
a.
b.
c.
d.
the purpose of :
Cardiac t-loni torOxygen and Nasal Cannula.
Intravenous ther2py.
Diagnostic Tests {Chest Xray,
Ekg,
B
I
Blood)
3.
Explain nurse call system.
4.
Explain visiting regulations to patient and family.
5.
Instruct patient to report chest pain or shortness of
breath immediately.
6.
Explain necessity of activity restriction and activity
progression.
7.
Explain the healing process.
8.
Explain the average length of stay in CCU is 5 days.
PRIOR TO TRANSFER TO THE WARD:
10.
Explain changes in environment and staffing ratios when
transferred to ward.
11.
Explain stage of activity level at time of transfer.
12.
Explain that same doctor WLll follow patlent on ward.
13.
Explain av~rage length of stay in hospital is 10 days
to 2 weeks.
INSTRUCTIONS:
Enter your lnitials in column A and 8 when accomplished.
Identify initials at top of page.
A=subject matter given to patient bv nurse.
B=subiect matter can be reoeat,d bv. patient.
·c-"---·-···•
ORIENTATION CHECKLIST
CARDIAC R EP.AB F!"OGR.~.:1
SU?PLEMENT
DHI~ED
DATA BASE
v" ,.c., ....
oc,.. ., ••
l0-7973g
176
I
OK 1·Rt-.KSFER. TO THE Wl>.RD:
d:a +- C>
1.
Explain the nurse call syster.:.
2.
Re-inforce the need to call nt!rse and rt:~·O:!:"t chest
pain or shortness of breath ir."-;,ad i a tel y- G:'?:-":lcSIZE:
a. Use call light/intercom to sio!1al nurse.
b. DO NOT l·:hLK to nurses station if having c!":est
pain ..
3.
B
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Explaln contents of or1ent2tlon hancouL
sheet a!1ole~ve with patient.
Krite Head Nurse's narne on
sheet.
4.
Explain physical layout of •:arci and location of
bathrooms and showers.
(~ay \•ant to defer until ambulatory)
5.
Explain and re-inforce necessity of activity
restrictions and activity progression during
healing process.
6.
Place appropriate Cardiac Rehab Calendar in
patient's room and explain how this will keep
him informed of his activity level.
7.
Explain purpose and location of 2.ppointment
board.
8-
Ask patient i f he has any medication, such as
nitroglycerin, in his possession.
E1·1PH.'\SIZE:
I
THAT FOR STAFF TO ACCURATELY t·lONITOR HIS
RECOVERY ... HE MUST NOT TAKE ANY MEDICATION
OTHER THAN NHAT IS GIVEN TO HI1·1 BY THE
NURSING STAFF.
I
Explain that after transfer from ccu to ·..:C~rd.
some patient's feel anxious or depressed.
These feelings are normal and will usually
pass as activity is increased.
I
9.
A
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INSTRUCTIONS: Enter your initials in Column A and
3 ·..;hen
accomplished.
Identify initials in space to right.
In
it~
Sicnature
A=subject matter given to patient by nurse.
B=subject matter can be repeated by patient.
ADRESSOGRAPH
ORIENTATION CHECKLIST
Ci'I.ROIAC REHAB PROGRAM
..L
{C/u~d
177
'lJ
SUPPlEMENT DEFINED OATA BASE
MEDICAL RECORD
SUPPLEJo,IEHT TO
•
onf, oneJ
PART
0
I
On
0•11
I
Ov
Ov•
SERVOCE
CARDIAC REHABILITATION PROGRAM TEACHING RECORD SUHNARY--NURSING COMPONENT
Following instruction.
the patient is able to:
OUTCOME CRITERIA
L
2.
DatF'
Taugnt
Use own pulse rate to
activity.
4.
Use activity chart to identify
own prescribed level.
Instructor
Sianature & Comment
I
State in own words the meaning
of a heart attack.
Explain the healing process in
own words.
3.
5.
Date
Net
rnon~tor
State name, purpose, and
de sage for each prescribed
discharge_ medication.
6.
State the correct use of
nitroglycerin.
7.
Recall the signs and symptoms
=equiring prompt medical
attention.
8.
State a plan of action to be
followed if chest pain lasts
lonaer thanlS ~inutes.
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Additional learning n e e d s : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1.
2.
3.
4.
SIGNATURE:
R .I'll.
lCO<Oit .. . _ - ,.. ........
.r,
CARD CAC REII.\B PROGR\~1
TEACHING RECORD SU~·rl\RY
SUPPLEMENT
DEFINED
DATA BASE
133-82 (665/119)
~~;~::: 10-797 8g