- - - - - - - - - - - - - - - - - - - - - - - - - - -------------------------
----~-
-----------
CALIFORNIA STATE U1UVERSITY 1 NORTHRIDGE
44N EDUCATIONAL
PROGRfu~
IN MYOCARDIAL INFP.RC'!'ION
A project submitted in partial satisfaction of the
requirements for the degree of Master of Public Health in
Community Health Education
by
Una Sue Sinsheimer
June, 1976
-------- --------·-------
----~--
..
--- ----
--~------
----
---
-- ---- - ----------- -----
.
--------
--·-
------··------------·-·----·-·---··--·-·------·--- ---·------ -------------- ---···-----·----
--·--·~--~-----·-----------~
The Project of Una Sue Sinsheimer is approved:
California State University, Northridge
ii
ACKNOWLEDGMENTS
Many individuals have contributed to the fulfillment of this
study.
I wish to thank each of the following:
The Medical Center of Tarzana Hospital for providing the
opportunity to implement this program.
Colleen Blair, Director of Nursing Service and Ellen Nazarian,
Supervisor of the Intensive Care Units for their consultation and
support.
My professors at CSUN, especially G. Krishnamurty, Dr. P. H.
and Walleed Alkhateeb, M.P.H. for their advice and guidance.
Appreciation to Robin Grant, M.P.H. for being my friend and
consult a...11.t .
A special thanks to my family and friends for their encouragement and support.
iii
TABLE OF CONTENTS
Page
APPROVAL . . . . .
ii
ACK..~OW"LEDGMENT S
iii
viii
LIST OF TABLES .
ABSTRACT
.........
ix
Chapter
1.
INTRODUCTION
1
PURPOSE OF THE STUDY
DEFINITION OF
TER\~
3
ORGANIZATION OF THE R&\UUNDER OF THE STUDY
2.
4
REVIEW OF LITERATURE
5
THE NATURE OF MYOCPEDIAL INFARCTION .
5
Definition
5
Etiolog-J
5
Risk Factors
6
Treatment • • •
7
METHODOLOGY OF PLANNING PATIENT
EDUCATIONAL PROGRM!S • . . .
Consideration of the Patient
8
Consideration of the Family .
8
Program Content . •
8
Educational Methods .
9
1
J.
7
9
1
1
1
I
1
I
I
1
I
1
I
I
I
I
I
I
I
I
11ETHODS AL\JD M..I\.TERIALS--PATIENT EDUCATIONAL PROGR.tillJf
iv
I
10
12
Page
Chapter
LLvUTATIONS OF THE STUDY .
12
ASSUMPTIONS OF THE STUDY • .
12
APPROVAL FOR RESEARCH
13
THE SETTING
14
THE DEFINITIVE OBSERVATION UNIT
14
STUDY SAMPLE •
15
THE QUESTIONNAIRE
17
DATA COLLECTION
17
STATISTICAL ANALYSIS OF DATA •
17
JUSTIFICATION OF PROGRAM CONTENT .
18
Unit 1:
.~atomy and
Unit 2:
Pathology of Myocardial Infarction
20
Unit 3:
The Healing Process . .
20
of the Heart .
19
CURRICUL1JM DESIGL"l--PATIENT EDUCATIONAL PROGRAT\.Jl .
20
TEACHING AIDS
28
FORlvfS
4.
Physiolo~J
....
. • . . .
' '
,
30
DISCUSSION OF RESULTS--PATIENT EDUCATIOHAL PROGR..Arvl . •
32
PRETEST .A.."TD PO·ST TEST P..ESULTS
32
CUR.>i.ICULUM DESIGN
34
. . • .
Summary
38
TEACHING AIDS
38
The Self-Instructional Manual
The Heart Model
. . . . . . ., . . . . . . . .
38
39
Prescription for Physical Activity . . • .
39
Guidelines for Resuming Physical Activity
40
v
Page
Chapter
5.
METHODS Al\l'D MATERIALS--NURSE EDUCATIONAL PROGRAM .
LIMITATIONS OF THE STUDY .
42
ASSUMPTIONS OF THE STUDY .
42
THE STUDY SAMPLE . .
43
QUESTIONNAIRE
43
DATA COLLECTION
43
STATISTICAL Al\l'ALYSIS OF DATA •
44
JUSTIFICATION OF PROGRAM CONTENT .
44
Unit 1: Anatomy of the Coronary Arteries;
Pathology of 1~ocardial Infarction
44
Unit 2: PlaD~ing Physical Activity
for the Patient . . . . . . . . .
45
Unit 3:
Evaluating the Patients' Learning
Envirorunent
. . . . . . . . . . . . . .
Methods of Instruction
45
Unit 5:
Charting Procedure
46
46
DISCUSSION OF RESULTS OF NURSE EDUCATIONAL PROGR...A.M .
54
PRETEST Al\l'D POST TEST RESULTS
54
CURRICULIDJ1 DESIGN
56
57
Summai""J
LEJuli.NING OPPORTUNITIES . .
7.
45
Unit 4:
CURRICULillA DESIGN
6.
42
57
Sillv'IMARY, CONCLUSIONS, AND RECOMMENDATIONS
S1JMMARY:
PATIENT EDUCATIONAL PROGRAM:
CONCLUSION:
SUMMARY:
.
66
PATIENT EDUCATIONAL PROGHAt\1
67
NURSE EDUCATIONAL PROGRMA
CONCLUSIONS:
66
• . .
NURSE EDUCATIONAL PROGRI.\.M
vi
67
67
Page
Chapter
68
RECOMMENDATIONS .
BIBLIOGRAPHY
69
.APPENDICES
74
A.
Patient Test
76
B.
Patient Interview Questionnaire
I"'Jq
c.
Results of the Patient Interviews
81
D.
A Self-Instructional Manual:
84
E.
The Heart Model
100
F.
Prescription for Physical Activity
102
G.
Guidelines for Resuming Physical Activity
105
H.
Prescription for Patient Education-Nzyocardial Infarction • . . .
107
I.
Patient Education Progress Notes
109
J,
Comparison of Responses to Pretest and Post Test
Questionnaire Items by Individual Patients
in the Patient Educational Program • . . • .
111
K.
Nurse Test •
llJ
L.
Criteria for Evaluation of a Patient
Teaching Session • . • . . . . . •
ll6
Comparison of Pretest and Post Test Questionnaire
Items by Individual Participants in the
Nurse Educational Program . . . . • • . • . • •
118
M.
Myocardial Infarction
vii
I
;
LIST OF TABLES
Page
Table
1.
Demographic Profile of Patients Studied in
the Pilot Patient Educational Program .
2.
Individual Patient Scores on the Pretest
and Post Test . . . • . • . . . • • . .
3.
Comparison of responses to pretest and post test
questionnaire items by individual patients
in the Patient Educational Program . . . •
112
4.
Results of Objectives Established for Concept #l
Curriculum Design--Patient Educational Program
35
5.
Results of Objectives Established for Concept #2
Curriculum Design--Patient Educational Program
36
Results of Objectives Established for Concept #3
Curriculum Design--Patient Educational Program
37
7.
Individual Nurse Scores on the Pretest and Post Test
55
8.
Comparison of pretest and post test question..naire
items by individual participants in the
Nurse Educational Program . • .
• . . .
119
9.
Results of Objectives Established for Concept #1
Curriculum Design--Nurse Educational Program
58
10.
Results of Objectives Established for Concept #2
Curriculum Design--Nurse Educational Program
....
.
59
Results of Objectives Established for Concept #3
Curriculum Design--Nurse Educational Progra~
.....
60
12.
Results of Objectives Established for Concept #4
Curriculum Design--Nurse Educational Program
.....
61
13.
Results of Objective Established for Concept #5
Curriculum Design--Nurse Educational Program
.....
62
6,
11.
viii
16
........
33
.ABSTRACT
.AN EDUCATIONAL PROGRAM IN MYOCARDIAL INFARCTION
by
Una Sue Sinsheimer
Master of Public Health
June, 1976
This study had a twofold purpose.
develop, implement,
~~d
The first purpose was to
evaluate a patient education program designed
to increase the patient 1 s knowledge of myocardial infarction and its
treatment.
and evaluate
The second purpose of the study was to develop, implement,
a.Tl
educe.tion program for the nurses who would be teach-
ing the patients.
This prograJn was designed to assist the nurses in
both identifying the patient 1 s educational needs and utilizing and
evaluating appropriate learning opportunities.
The study sample for the patient education program consisted
of eight patients admitted to the Medical Center of Tarzana Hospital
with the diagnosis of myocardial infarction.
A pretest--educational activity--post test research design
was used for the study.
A questionnaire was designed to measure the
patients 1 knowledge of the disease process and treatment.
A statis-
tical analysis of the mean test scores showed a significant increase
in knowledge at the • 05 level.
Based on these results the author concluded that the patient
education program vras successful in increasing the patient 1 s k:nowl-
ix
·-------~---------
--------------------------------------------------------------
edge of disease process and treatment.
The teaching aides - a self
instructional manual and a prescription for physical activity - were
evaluated by the patients and the author and were found to be effective teaching materials.
The study sample for the nurse education program consisted
of ten staff nurses of the Definitive Observation Unit of the Medical
Center of Tarzana Hospital.
The pretest--educational activity--post test research design
was utilized.
A questionnaire was designed to measure the nurses
knowledge of disease process and methodology in education.
A sig-
nificant difference in the mean test scores showed a significant
increase in knowledge at the ,05 level.
The nurses were also ob-
served in patient teaching sessions, and all were able to perform
satisfactorily.
--------------------------------------·--------------------------------------·
X
.-------------·-------------------·
---------------
Chapter 1
INTRODUCTION
Care of the patient who has suffered a myocardial infarction
has undergone great change in the last decade,
Advances in medical
technology have led to more sophisticated methods of diagnosis and
treatment.
More lives are being saved and the quality of patient care
has been improved.
Hospitals are attempting to meet the total needs of the
myocardial infarction patients and their families,
The kind of ex-
periences a patient will have during his/her hospitalization can
result in the development of a positive frame of reference which
help to contribute to positive attitudes, motivations, and behavior
necessary for his/her successful treatment (Jew, 1975:1.)
Patient education has been found to be a very
aspect of patient care.
import&~t
Planned educational experiences dealing
with exercise, diet, drugs, and modes of life
style have resulted in
positive effects on recovery and rehabilitation.
(Duncan, 1973,
Kelsey, 1973, Woodward, 1972)
The instruction of the patient has traditionally been
carried out by the physicianj however, the ainount of time a physician
has to spend with the individual patient has been significantly
decreased.
Nurses and para-medical personnel working with the
physician have begun to assume the responsibilities of patient
education.
The professional nurses licensure states that a nurse
1
2
--·-·-------- - - -
has the right and duty to provide the information a patient needs to
maximize his chances of achieving restored health.
508)
(Duncan, 1973:
A survey of nurses in a community hospital revealed a willing-
ness to assume teaching responsibilities, but a perceived lack of
knowledge in educational methodology.
This project was developed to meet the need for an educational program for the myocardial infarction patients in a community
hospital and to prepare nurses to assume the responsibility of patient
education.
PURPOSE OF THE STUDY
This pilot study was developed with a twofold purpose.
The
major goal was to develop an educational program to assist the myocardial infarction patient and his/her family in increasing their
knowledge of the nature of myocardial infarction and its treatment.
The secondary goal was to develop an educational program to
assist the patient educators (nurses) in both identifying patients'
educational needs and utilizing and evaluating instructional methods.
J
- · - - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - -------------------------;
DEFINITION OF
TER~
The following definitions were decided upon for this study:
Primary patient care:
The concept of patient care in which a
admitting nurse has responsibility of evaluating patient needs, and
designing a plan of care to meet these needs.
Patient education:
Educational experiences planned for the
patient by professional personnel which will enable the patient to
have a better understanding of disease process and treatment including:
diet, medications, and physical activity.
Treatment:
Refers to anything done to a patient for purposes
of cure, prevention of disease,
Curriculum design:
~~d/or
the relief of symptoms.
Refers to the outline of a course content
including objective, learning opportu..~i ty, and evaluation method.
Prescription:
A written direction for a therapeutic measure
to meet the needs of an individual patient.
4
ORGANIZATION OF THE REMAINDER OF THE STUDY
Chapter 2 reviews the literature found relating to the nature
of myocardial infarction and methodology of planning patient educational programs.
Chapter 3 discusses the methods and materials used in planning
and evaluating the patient educational program.
The discussion of results of the patient educational program
is the main emphasis of Chapter 4.
Chapter 5 discusses the methods and materials used in planning
and evaluating the nurse educational program.
Chapter 6 reviews the results of the nurse educational program.
Chapter 7 includes the researcher's conclusions and recommendations.
A bibliography and appendix provide appropriate reference to
the text of the study.
----~-----~----------------------------
-------- ---- ----------
-~-----------------
Chapter 2
REVIEW OF LITERATURE
The purpose of this chapter is to present a brief review of
the need for planned educational experiences for myocardial infarction
patients.
The search of the literature was made in two areas:
(a) nature of myocardial infarction and (b) methodology in planning
patient education.
The nature of myocardial infarction discusses
the etiology of the disease, the risk factors, and treatment.
Methodolo~J
in planning patient education discusses four areas of
consideration in program planning - the patient, the family, the
progra~
content, and the educational method.
THE NATURE OF TvriOCARDIAL INFARCTION
Definition
MYocardial infarction is the process by which the myocardial
tissue (heartmuscle) is destroyed in regions of the heart that are
deprived of their blood supply.
This ischemia (decrease in blood
supply) is due to an obstruction of the corona~J arte~J.
(Brunner,
1972:373)
Etiology
Atherosclerosis is the principal cause of the obstruction of
the coronary artery.
Atherosclerosis is a degenerative process of
the vessel wall which causes the wall to become thickened and
5
6
narrowed.
As a result of these changes, the blood flow becomes
obstructed which in turn leads to tissue death.
Friedberg, 1966)
(Brunner, 1972,
Coronary artery disease (atherosclerosis of the
coronary arteries) is the number one health problem in the United
States.
The American Heart Association statistics show approximately
four million people have coronary artery disease and in 1973 approximately 684,000 people died of myocardial infarction.
(American
Heart Association, 1976)
Risk Factors
During the last twenty years, medical researchers have
developed a coronary profile.
This profile describes characteristics
which have been consistently observed in people with coronary artery
disease.
The criteria for high risk are:
(1) male, aged forty or
older; (2) high blood cholesterol; (3) hypertension; (4) obesity;
( 5 ) fa'Ilily history of heart disease; ( 6) cigarette smoker; and
(7) stocky body build.
(Friedberg, 1966:646)
Not every potential patient displays all the criteria of the
profile; however, the more risk factors an individual possesses the
greater the chance of developing coronary artery disease.
factor not included in the profile is emotional stress.
One risk
This is not
a primary factor, but there is a feeling among some researchers that
emotional stress does contribute to the occurrence of myocardial
infarction.
(Friedberg, 1966)
Not all patients with coronary artery disease have a myocardial infarction.
An insufficient
corona~J
itself as a syndrome known as angina pectoris,
blood flow may manifest
This syndrome is
7
- - - - - - - - - - - - - - - - -----------
----------~-------
--------------------------
featured by pain in the anterior chest without significant tissue
damage occuring; however, as the obstruction progresses, the
decrease in blood supply may lead to myocardial infarction.
(Brunner, 1972, Friedberg, 1966)
Treatment
Myocardial infarction can be treated.
After the initial
damage, the goal of medical management is to minimize muscle damage
until the destroyed tissue has been replaced by scar tissue;
~~d
a
collateral circulation (additional blood supply to the injured area)
has been established.
This process takes from six to eight weeks.
(Kogan, 1971:253)
Medical management is designed to relieve pain, rest the
myocardium, and prevent complications.
Once healing has occurred,
the treatment is centered on increasing physical activity.
1971:254)
(Kogar1,
This is done in accordance with the individual's tolerance.
Approximately eighty percent of the first time myocardial infarction
patients can return to previous levels of activity.
METHODOLOGY OF
P~~NING
(Friedberg, 1966)
PATIENT EDUCATIONAL PROGRkVB
The American Hospital Association and The American Medical
Association, among others, consider patient education to be
integral part of patient care.
~~
(American Hospital Association, 1972,
American Medical Association, 1975)
Patient education has been shown to be responsible for:
(1) fewer readmissions; (2) increased knowledge of disease and treatment; and (J) increased compliance to treatment.
(Rosenberg, 1971,
8
--·---~·--···-·--··------~--------------~-~-~
-------- - -
~--
~---
----------------------------
Woodward, 1972, Davis, 1969)
There are four areas of consideration in planning patient
educational programs: (1) the patient; (2) the family participation;
(3) the program content; (4) educational
methodolo~J.
(American
Public Health Association, 1972, Baden, 1972, Clark, 1972, Rosenberg,
1971, Schlesinger, 1973, Tyzenhouse, 1973)
Consideration of the Patient
The patient Bill of Rights states that the patient has the
right to: know the etiology of the disease and methods of treatment,
and to participate in the medical management of his/her disease.
(American Hospital Association, 1973)
Davis states that an individual
is responsible for his/her own health care, and a program of education
may assist him/her in accepting this responsibility.
(Davis, 1969)
Consideration of the Family
The second area of consideration, inclusion of the family in
the program plarilling, is emphasized throughout the literature. Family
cohesiveness has been associated with increased levels of compliance,
while family discord has been closely associated with noncompliance.
(Davis, 1969)
Several articles reviewed stated that the family's
support and cooperation reinforced the success of the educational
program.
(American Public Health Association, 1972, Baden, 1972,
Duncan, 1973, Kelsey, 1973)
Progra.-rn Content
The third area of consideration in program
program content.
plar~ing
was
The literature search was directed toward educa-
9
tional programs for the postmyocardial infarction patient.
programs reviewed were divided into two parts:
and methods of treatment.
etiology of disease
The etiology of disease included, heart
function and pathology of myocardial infarction.
treatment entailed:
The
The discussion of
diet, medication, physical activity, and
reduction of risk factors.
Educational Methods
The fourth area of consideration in program planning was
educational methods.
Several methods were found to be effective.
The methods most frequently discussed in the literature was group
meetings.
(Baden, 1972, Duncan, 1973, Kelsey, 1973, Woodward, 1972)
These groups incorporated people with similar medical problems
(Sirr~onds,
1973) or families of patients with similar medical problems.
(McGann, 1976)
The purpose of the groups was to provide educational
experiences which increased knowledge of disease and treatment.
(SiwE<onds, 1973, McGruLD, 1976)
The team approach to patient education has also been frequently used.
Rosenberg defines the team as:
the doctor, nurse,
social worker, dietician, and other allied health professionals.
(Rosenberg, 1971)
Schlesigner expanded the definition to include
the patient as a member of the
tea~.
The team utilizes conferences
to evaluate patient needs and plan a comprehensive program of treatment and education.
(Rosenberg, 1971)
One of the newest methods of teaching is programmed instruction.
A study by Clark and Bayley found programmed instruction to
have several
advar~ages:
(1) it actively involves the learner;
10
( 2) the patient can work at his own pace; ( 3) it may be used with
the family; (4) it can be used at any convenient time; and (5) it
allows the teacher to be available for additional duties.
In the
study, the programmed text was given to the patient to go through
and then the nurse returned to review and discuss the contents with
the patient.
(Woodward, 1972; Kelsey, 1973; Boden, 1972)
The one-to-one method of teaching is not discussed as frequently as the other methods; however, it has been shown to be more
effective.
In a study comparing one-to-one, an audiovisual presenta-
tion, and a
progrruR~ed
text, each containing the same content, the
one-to-one had a significant increase in knowledge compared to the
others.
The one-to-one methods was also rated by the participants
as creating more interest in the subject matter.
(Alkateeb, 1975)
The selection of an educational method is dependent upon
several variables.
The Committee on Educational Tasks in Chronic
Disease made. the following statement regarding the process of selecting educational methods:
Selecting educational methods that are appropriate for the
learning content involves
• identifying each patient's flow
pattern through the facility; the different staff members who
will be involved in his care; and the number of other patients
with similar conditions. (American Public Health Association,
1972:11)
S1JMMARY
Myocardial infarction is the process by which heart muscle is
destroyed.
The principal cause of myocardial infarction is atheros-
clerosis, which is a degenerative process of the artery wall.
Researchers have developed a cardiac profile which describes the high
11
risk patient as:
male, aged forty or older, high blood cholestrol,
hypertension, obesity, family history of heart disease, cigarette
smoker, stocky body build.
Medical treatment of myocardial infarction is designed to:
relieve pain, rest the myocardium, and prevent complications.
Patient education is considered an integral part of patient
care.
Four areas of consideration in planning patient education
programs are:
the patient needs, the family participation, the
program content, and program methodology.
Several educational methods have been found to be effective.
They are:
group meetings, team approach to care plans, prograrmned
instruction, and the one-to-one method.
The selection of an educational method is dependent upon:
patient flow patterns, staff members involved in the program, and
the number of patients with similar conditions.
Taking into account the areas of consideration discussed in
the literature and the process of selecting educational methods, the
author concludes that a
progra~ed
instruction with the nurse acting
as a resource person would be th€ appropriate method to be used for
this project.
----- --~
~----~~-------- ---~---~--- -~
--- - ---------~-
--~--
- - - - -------- ---- ------------·-----
Chapter J
METHODS AND MATERIALS--PATIENT EDUCATIONAL PROGRAM
The purpose of this study was to determine if a selfinstructional manual, a heart model, a prescription of physical
activity, and a guideline for resuming physical activity were effective in increasing the patients' knowledge of disease process and
treatment.
In order to test the effectiveness of these teaching aids an
experiment was designed using the pretest--educational activity--post
test method.
The patients were tested using the instruments described
in this chapter.
LDV:ITTATIONS OF
T~~
STUDY
This study was limited to a selected population of patients
admitted with the diagnosis of acute myocardial infarction to the
Medical Center of Tarzana Hospital.
the
n~~ber
The sample size was limited to
of patients admitted between January 1, 1976 and March 1,
1976.
The patients had to be able to read English and their participation in the program had to be sanctioned by the ad..rnitting physician.
ASSUMPTIONS OF THE STUDY
For the purpose of the study it was assumed that:
1.
The participants read the self-instructional manual as
12
13
---~---·---------------------------------------------~-----------
directed.
2.
The contents of the manual were written in such a manner
that the patient could understand what was written.
3.
The nurse instructors reviewed with the patient the con-
tents of the prescription for physical activity as directed.
4.
The contents of the prescription were written in a manner
that was easily understood.
5.
The items of the questionnaire were written in a manner
that was easily understood.
6.
The patients answered the questionnaire without assistance
from the nursing staff and without the use of the teaching materials.
APPROVAL FOR
RESE~~qcH
The author is a staff nurse at the Medical Center of Tarzana
Hospital.
The nursing service department of the hospital had ex-
pressed an interest in developing a patient educational program for
myocardial infarction patients.
A meeting took place between the
author, the Supervisor of the Intensive Care Units, and the Director
of Nursing Service.
The possibility of developing a patient educa-
tional program was discussed and it was decided that a program was
feasible.
A series of events took place before the author presented the
proposed program to the nursing supervisor and the Director of Nursing Service.
These events are discussed in this chapter under
Justification of Program Content.
The program was approved by nursing service with a request to
14
have the medical director of the coronary care unit review the
material.
He examined the program and made two suggestions for change
in the content.
These changes were made.
The program was then taken to the Internal Medicine Committee
of the hospital.
The author presented a..n outline of the program to
the committee and each member was given a copy of the selfinstructional manual and the prescription for physical activity to
review.
The committee approved the program and also supported the
changes the medical director had suggested,
The chairman of the
Internal Medicine Committee presented the program to the Executive
Medical Committee for final approval which was obtained.
THE SETTING
The group of subjects selected for the study were patients of
the Medical Center of Tarzana Hospital.
acute, general, private hospital.
It is a two hundred bed,
It has a staff of 450 physicians
whose philosophy is to provide the opportunity for education, research,
development and application of scientific principles as they relate
to quality patient care.
The medical center has an ongoing relationship with the Los
Angeles Valley College; California State University, Northridge; the
University of Southern California; and the University of California
at Los Angeles.
THE DEFINITIVE OBSERVATION UNIT
The patients participating in the study were selected from
15
the Definitive Observation Unit.
This is a twenty three bed special
care unit for subacutely ill patients.
prima~J
The staff of the unit utilize
care philosophy to evaluate patient needs and provide a plan
of care to meet these needs.
The post myocardial infarction patients spend approximately
seven to ten days in this unit.
During this period they begin ambula-
tion and are observed for their tolerance of activity.
The primary care philosophy of this unit is suitable for a
patient educational program for the following reasons:
1.
The nurse is assigned to the patient for his/her total
stay in the unit so there is time to establish rapport.
2.
.An educational program can be planned and implemented by
the same individual.
3.
The nurse has fewer patients to care for than on other
nursing units, so she has the time to devote to the program.
STUDY SMAPLE
The total sample for the pilot program was eight patients.
The demographic information the author felt was necessary to
obtain from the participants was the educational level, age, occupation, and past medical
histo~J
related to a heart problem.
The age, occupation, and medical history are part of the
patients' medical record.
They were asked their level of education.
The demographic data is presented in Table 1.
Of the eight patients who participated in the pilot program,
there were six males and two females.
They were from forty six to
I
Table l
Demographic Profile of Patients Studied in
the Pilot Patient Educational Program
Subject
Sex
Age
Occupation
Level of
Education
History of
Heart Disease
l
M*
55
businessman
college
none
2
M
57
electrician
high school
none
3
M
62
production
supervisor
high school
none
4
M
46
private
detective
high school
none
5
M
50
businessman
college
none
6
M
65
factory worker
high school
none
7
F**
65
store clerk
high school
none
8
F
55
housewife
high school
none
*M is the symbol for male
**F is the symbol for female
1-'
0'
17
------------
sixty five years of age.
The minimal educational level was high
school graduation and they had occupations which
wife to a businessman.
r~~ged
from a house-
None of the study samples had had a previous
history of heart disease.
THE QUESTIONNAIRE
A pretest - post test questiorillaire was used to measure the
participants' knowledge and attitude regarding myocardial infarction
and its treatment.
The questionnaire consists of twelve multiple choice and six
true/false questions.
The content of the questions is discussed in
the curriculum design.
Appendix I is a copy of the questionnaire.
DATA COLLECTION
The admitting physician of each prospective subject was
approached when the patient was admitted to the Definitive Observation
Unit.
If the physician consented to have his patient involved in the
study, the patient was then approached,
Once consent was given the
pertinent demographic information was obtained from the patient and
the pretest was given.
The post test was administered no sooner than one day after
completion of the educational program..
It was administered as close
to the day of discharge as possible.
STATISTICPL
ili~ALYSIS
OF DATA
At test was used to analyze the data from'the questionnaire.
18
This test was chosen because of the small sample size and the criteria
for assumptions of normality and homogeneity of variance were met by
the data.
(Kerlinger, 1964)
JUSTIFICATION OF PROGRAM CONTENT
The literature review revealed several studies which described
the content of myocardial infarction patient educational programs but
none of these documented a justification for the content.
In planning
a program, the author felt it was necessary to consider what the
patient wanted to know about the disease and treatment.
To evaluate
these patient needs, an interview questionnaire was designed.
(Appendix B)
The author interviewed seven postmyocardial infarction patients
with the purpose of: ( 1) determining what they knew about their disease and its treatment, (2) if they felt they had sufficient knowledge
of these two areas, and ( 3) what information they felt should be included in a patient educational program.
To briefly SlJI!llilarize the results of the interview: (l) they
possessed limited knowledge of the disease process and treatment (diet,
medication, exercise); (2) they wanted more information about these
subjects; and (J) the suggested content areas were: disease process,
guidelines fo.r exercise, diet, programs for weight reduction,
emergency care classes, and consultation in dealing with stress.
(Appendix C contains The Results of the Patient Interviews)
Upon evaluation of these results, the author drew the following conclusions:
19
l.
two of the areas of need--diet and medication--were
v'/
presently being discussed with the patients on an informal basis by
the nurses and dieticians.
2.
programs in emergency care and reduction of stress were
not suggested by the majority and could be considered for future
prograrrmri.ng.
3,
The areas that needed immediate attention were
diseas~
-...,.
process and guidelines for exercise therapy.
The nursir:.g service department agreed with the author's
evaluation.
It was decided that disease process and guidelines for
exercise therapy would be the contents of the pilot program.
The subject areas were complex and a decision had to be made
as to how much information the patients need to know.
The medical
director of the coronary care unit was consulted regarding this.
He stated that from his experience the majority of patients need a
simple explanation of the disease and treatment; complex explanaticns
are confusing and unnecessary for insuring patient
compli~~ce
to
treatment.
With the doctor's suggestions in mind, and the content defined,
the author developed the three units of the curriculum design.
The
justification of each 1lll.it will be discussed separately.
Unit 1:
Anatomy and Physiology of the Heart
It is necessary to have a knowledge of the function of an
..
\/
/
organ in order to understand the pathology of the disease process. ·
This unit was developed to provide the patient with this information.
The discussion was limited to anatom..i.cal parts involved in the disease
20
process.
Unit 2:
Pathology of Myocardial Infarction
This unit addressed itself to cause and effect of the disease
process.
This was discussed in terms relating to the anatomy and
physiology presented in Unit 1.
Unit J:
The Healing Process
This unit was designed to assist the patient in understanding
the relationship of the healing process to the treatment regimen.
To
accomplish this, the process was discussed in terms of length of time
as well as physiological process.
The criteria for selection of the learning opportunities used
in the
curricul~m
design were:
simplicity of presenting the subject
matter, economics of materials, whether or not the methods had been
shown to be effective by others, availability of audiovisual teaching
aids, and the patient flow pattern in the nursing unit,
CURRICULU11 DESIGN -- PATIENT EDUCATIONAL
PROGRru~
A curriculum design for an educational program is based upon
concepts.
To present the concepts in an organized manner, behavioral
objectives, learning opportunities, and methods of evaluation are
established for each concept.
The following section defines the objectives, learning
opportunities and methods of evaluation as they relate to the three
concepts (units discussed under justification of program) established
for an educational program for myocardial infarction patients.
21
---~-~--~--
--
~-------
Concept #1
----~----
-
---~----~-------
---
---------- -- -----
~--
-
~--- ---~--
-----
Knowledge of the anatomy and physiology of the heart is
essential in understanding the pathology of myocardial infarction.
Objective 1:1: The patient will be able to describe the
composition of the structural tissue of the heart.
Learning Opportunity 1:1:1:
A.
Participant is asked to locate his heart by
placing his hand on his chest.
B.
Reads statement of heart structure and function.
Content 1:1:1:
The heart is a muscular organ and it
pumps blood.
Evaluation 1:1:1:
Given a list of body tissues} the
patient will select the tissue which composes the heart wall.
(Test question #1)
Objective 1:2:
~~d
The patient is able to describe the size
shape of the human heart.
Learning Opportunity 1:2:1:
Patient is asked to make
the comparison of the heart to man's clenched fist in terms of size
and shape.
Content 1:2:1:
Diagrams of a heart and a man's fist.
-Evaluation 1:2:1:
Given a list of objects, the
patient will select the one which is most similar to the size and
shape of the heart.
(Test question #2).
Objective 1:3:
The patient is able to identify the left
and right pumps of the heart (on a model) and describes the
of each.
f~~ction
22
Learning Opportunity 1:3:1:
A.
The manual guides the patient in locating the
anatomical parts of the heart.
B.
Patient reads statement of the function of each
part.
Content 1:3:1:
blood to the body.
Left side is the main pump; pumps
Right side is the smaller pump; pumps blood to
the lungs.
Evaluation 1:3:1:
A.
Given a list of body functions, the patient will
select the statement which correctly describes left heart function,
(Test question #3)
B.
Given a list of body functions, the patient will
select the statement which correctly describes right heart function.
(Test question #4)
C.
The nurse will observe the patient locating the
left and right pumps on the heart model.
Objective: 1:4:
The patient will be able to identify
the heart, arteries, and veins as the major components of the circulatory system.
Learning Opportunity 1:4:1:
describe parts on a
diagr&~,
then label the diagram.
Content 1:4:1:
atory system and their
Read statements which
Three major components of the circul-
fu_~ctions.
Evaluation 1:4:1:
A.
The patient will correctly label the diagram.
2J
B.
Given a list of anatomical structures, the
patient will select the three major components of the circulatory
system.
(Test question #5)
C.
Given a list of vessels, the patient will select
the vessel which transports oxygen.
Objective 1:5:1:
(Test Question #6)
The patient will be able to palpate
his (her) radial pulse.
Learning Opportunity 1:5:1:
Patient reads page 4 of
the manual which is a programmed exercise.
Content 1:5:1:
Instructs patient in the method of
palpating a radial pulse.
Evaluation 1:5:1:
A.
Patient demonstrate palpation of the radial
pulse with 100 percent accuracy,
B.
Given a list of anatomical structures, the
patient will select the location of the radial pulse.
(Test question
#7)
Objective 1:6:1:
The patient will be able to define the
lungs' functions in relation to the circulatory system •
. Learning Opportunity 1:6:1:
A.
The patient is asked to inhale and exhale,
B.
Reads statement of lung function in relation to
circulation.
Content 1:6:1:
The lungs are an exchange system.
They take in oxygen, release carbon dioxide.
24
-- ----- -- ---------------------------------------------- -- ---· --- ----------~--·. ----· -- --------------
Evaluation 1:6:1:
-
-- ..-
--------------------··
Given a multiple choice, the
patient will select the statement which correctly describes lung
ftU~ction.
(Test question #8)
Objective 1:7:
The patient can describe the flow of
blood through one circulatory cycle.
Learning Opportunity 1:7:1:
A diagram of the cir-
culatory cycle.
Content 1:7:1:
Shows organs and arrows indicating
the path of blood flow.
Evaluation 1:7:1:
The patient can verbally describe
the flow of blood through one circulatory cycle.
Concept #2
Knowledge of the pathophysiological changes of coronary
artery disease is essential to ur.derstanding the pathology of myocardial infarction.
Objective 2:1:
The patient will be able to identify the
three coronary arteries (on a model) and describe their function.
Learning Opportunity 2:1:1:
A.
three
corona~J
The manual guides the patient in locating the
arteries,
B.
Reads statement of the three arteries' function
in relation to heart tissue.
Content 2:1:1:
The location and function of the three
main coronary arteries,
Evaluation 2:1:1:
A.
The nurse will observe the patient locating the
three arteries on the heart model.
25
----
--------~------~~-------
B.
-~------------
-~-
---------- ---- -- --- ---------
-- -- ---------
----~
Given a multiple choice, the patient will select
the answer which correctly describes the function of the coronary
arteries in relation to heart model.
Objective 2:2:
(Test question #9)
The patient can describe the anatomical
and physiological changes which take place in the heart as a result
of Coronary
Arte~J
Disease.
Learning
A.
Opport~~ity
2:2:1:
Manual guides patient in observing a cross
section of a coronary artery on the heart model.
B.
Patient reads statement of changes that take
place in the artery.
Content.2:2:l:
changes of Coronary
Arte~J
Description of the pathological
Disease.
Evaluation 2:2:1:
A.
Given a multiple choice, the patient will select
the adjective which correctly describes the texture of a diseased
artery.
(Test question #10)
B.
Identify a diseased
arte~J
from
diagra~s
in the
manual.
Concept #3
To understand treatment of myocardial infarction, it is
essential to be knowledgeable of the pathology which occurs and the
healing process which follows.
Objective 3:1:
The patient will be able to describe the
major pathological change which takes place when a person has a
myocardial infarction.
26
Learning Opportunity 3:1:1:
Patient reads description
of the event of myocardial infarction.
Content:
Description of the process of myocardial
infarction.
Evaluation 3:1:1:
A.
Given a list of statements which describe path-
ological body changes, the patient will select the statement which
correctly describes the event of myocardial infarction,
(Test
q_uestion #11)
B.
Given a list of terms, the patient can correctly
define the term myocardial infarction.
Objective 3:2:
(Test question #12)
The patient will be able to describe the
healing process in terms of scar formation and collateral circulation,
Learning Opportunity 3:2:1:
Reads statements des-
cribing the parts of a diagram, then labels the diagram.
Content 3:2:1:
Scar formation and collateral
circulation.
Evaluation 3:2:1:
A.
Patient correctly labels the diagram.
B.
Correctly answers T/F statement regarding:
1)
the formation of scar tissue.
(Test
2)
the development of collateral circulation
3)
the time span of the healing process,
q_uestion #IJ)
(Test q_uestion #14)
q_uestion #15)
(Test
27
Objective 3:3:
The patient will recognize that he (she)
will be able to resume most of their former physical activities.
Learning Opportunities 3:3:1:
A.
The patient and nurse discuss the prescription
for physical activity.
B.
Guidelines of the physical activity prescription
reviewed with the patient.
Content 3:3:1:
Doctor outlines physical activities
the patient may participate in.
Evaluation 3:3:1:
A.
Test question #16, #17:
Patient correctly
answers the T/F statements on this subject.
B.
Nurse subjective evaluation of attitude.
Objective 3:4:
The patient will recognize that return
to physical activity will be a gradual process.
Learning Opportunity 3:4:1:
A.
Patient reads discussion of this subject in the
B.
Nurse discusses this subject when reviewing
manual.
prescription of physical activity.
Content 3:4:1:
A.
Relationship of healing to physical activity
B.
Doctor outlines physical activities patient may
discussion.
participate in.
28
-~--------------
------~----
------------ - - -
----~--------·--- ----·~-----··---··---
----------------------·--------~
Evaluation 3:4:1:
A.
Test question #18, the patient correctly answers
T/F statement on this subject.
B.
Nurse subjective evaluation patient attitude.
TEACHING AIDS
Four
program:
teachi~~
aids were utilized in the patient education
(l) a instructional manual, (2) a model of the heart,
(J) a prescription for physical activity, and (4) a guideline for
resuming physical activity,
The self-instructional manual was designed by the author to
provide the patient and family with learning opportunities that
would:
(1) be an accurate source of information, (2) involve them
in the learning process, and (3) allow them to work at their own
rate.
The manual is a thirteen-page booklet that utilizes diagrams
and a model of the heart to guide the patient in learning
the heart,
physiolo~J
~~atomy
of
of systemic circulation, pathology of myo-
cardial infarction, and the healing process following infarction.
(See Appendix D )
The manual was tested on former patients and reviewed by
professional medical personr.el.
Revisions were made as a result of
suggestions given by both groups.
The manual and heart model are brought to the patients'
bedside by the attending nurse.
The patient is given the opportunity
to go through the manual by himself or herself or with family.
29
---------------~-------
------- ---------
-~---
- - ------- -- --
---------
-----------------
The nurse returns to answer questions and discuss the contents of
the manual.
Following the program the patient is invited to keep
the manual as a resource.
The heart model is approximately twice natural size and revalves on a wooden stand.
It is dissectable into five pieces to
show detailed internal structure.
Appendix E contains a picture and
a more detailed description of the model.
The prescription for physical activity was designed by the
author to provide the patient and family with a written outline of
the physical activity prograJn, prescribed upon discharge from the
hospital.
The prescription classifies daily physical activities into
the following eight categories:
( 1) personal hygiene, ( 2) household .
activity, (3) activities outside the house, (4) job-related activities,
(5) recreational activities, (6) entertainment, (7) sexual activity,
and (8) exercise regimens.
The first seven categories are further
defined by when the activity may be resumed and any stipulations
the physician wishes to put on the activity.
The eighth category,
exercise regimens, is more specific; it is divided into definitions
of the activity, when it may be begun, and the length of time (or
distance) in which it must be completed.
The prescription was
evaluated by former patients as to clarity of content.
(See Appendix
F)
The patient was interviewed by the nurse to determine what
his activities were before the myocardial infarction and what
questions the patient had regarding physical activity.
This inforrna-
30
------
~--
- - -------------------- -- - - - - - ---·--- .. ·-----·-----------
-
.
----------- -----------------~---------------------
tion was discussed with the physician before he filled out the
prescription.
After the prescription was completed the nurse dis-
cussed the contents with the patient.
The fourth teaching aid--guidelines for resuming physical
activity--is attached to the prescription.
It is a list of
suggestions for reducing stress during physical activity and it is
also a guide to assist the patient in recognizing the signs and
symptoms of physical stress.
(See Appendix G)
FORMS
The following section describes the forms which were utilized
by nurses
&~d
physicians to record certain information into the
patient chart.
..,
A prescription for the patient educational program was
developed for two purposes.
The first purpose was to provide a form
on which the physician orders the patient's educational program.
The second purpose was to provide a form to document completion of
the physician's orders.
The prescription is a single sheet of paper which is divided
into two sections.
In the first section the physician specifies
which component(s) of the program he wants the patient to receive and
when the program is to be initiated,
In the second section the nurse
documents when the program has been completed.
The components of the
program have been divided into eight behavioral objectives.
The nurse
documents with her signature and the date when each of the behavioral
objectives have been completed by the patient.
(See Appendix H)
Jl
The patient education progress notes is a standard nursing
record form upon which the nurse records patient behavior in relation
to the patient education program.
(See Appendix I)
Chapter 4
DISCUSSION OF RESULTS--PATIENT EDUCATIONAL PROGRAM
The purpose of this portion of the study was to evaluate the
effectiveness of utilizing a self-instructional manual, a heart model,.
a prescription for physical activity and a guideline for resuming
physical activity in increasing the patients' knowledge of myocardial
infarction and its treatment,
The eight patients who participated in the study were selected
on the basis of their diagnosis.
The specific background information
on the patients is discussed in Chapter J,
The patients were individually pretested, completed the
educational activity, and post tested,
PPETEST AND POST TEST RESULTS
In order to determine if there was any gain in knowledge the
pretest and post test scores were compared,
The mean score on the
pretest was 11.5, the mean score on the post test was 15.J.
The
difference of J. 8 points was significant at the ,05 level.
Table.2 is a list of the individual patient scores.
All
participants increased their pretest scores by one to seven points.
Table J in Appendix J shows responses to individual
questionnaire items.
There were no test items in which the patients
consistently had incorrect responses,
The patients had the most
incorrect responses to questions on function of the right and left
pumps of the heart, and the amount of time that is needed to return
32
Table 2
Individual Patient Scores on the Pretest and Post Test
Pretest*
mean
t value
*
**
***
Post Test**
14
16
ll
15
13
17
9
15
ll
14
9
14
13
14
12
17
ll. 5
15.3
4.75***
The maximum possible score on the pretest was 18
The maximmn possible score on the post test was 18
t snore significant at . 05.
w
w
34
----·---·--------~------~-------------~~-----
-
---
---------- - - - - -
~--
---- --
----------------~-~--
to previous physical activity levels.
CURRICULUM DESIGN
This section directs its discussion to the contents of the
curriculum design.
The curriculum design for the Patient EducatioLal
Program was based on three concepts.
1.
Knowledge of the anatomy and physiology of the heart is
essential in understanding the pathology of myocardial infarction,
2.
Knowledge of the pathophysiological changes of coronary
artery disease is essential to understanding the
pat~olo~J
of myo-
cardial infarction.
3.
To understand treatment of myocardial infarction, it is
essential to be knowledgeable of the pathology which occurs and the
healing process which follows.
Objectives which required the patients to demonstrate
knowledge, an attitude, or psychomotor behavior were established for
each of these concepts.
Seven objectives were established for
Concept #1, two objectives were established for Concept #2, and four
objectives were established for Concept #3.
The results of the methods used to evaluate these objectives
and the author's comments have been arranged in table form to simplify
the discussion.
Table 4 are the results of the objectives established
for Concept #1.
Table 5 are the results of the objectives established
for Concept #2, and Table 6 are the results of objectives established
for Concept #3.
Table I,
Results of Objectives Established
for Concept Ill Curdculum l:O,slgn--Pattent Educational Program
fiesuJt.s
Pre
Objective
Evaluation MeU10d
1:1
Describe the structural tissue
of the heart
Test question Ill
1:2
Descdbe the sl.ze and
shape of the heart
Test question #2
1:3
ldentlfy and define the
function of the heart pumps
A.
B.
C.
l: ~
Identify the components of
the circulatory system
A.
B.
C.
1:5
Palpation of a radial pulse
A.
B.
1:6 Define the function of the
Test question HJ
Test question 14
Identify pumps on
the heart model
Labeling a diagram
Test question 115
Test question 1/6
Dcmtmstration of
technique
Test question II?
Test question 118
Test~
8
Post
TestH
Nur·se Observation
Comment
6
Ob,Jective J.:l was met.
8
Objeetive 1:2 was met
J
I,
2
7
When 1111 methods of
evaluation were reviewed
collectively the
objective l.:J was met
8 patients identlf1ed correctly
5
5
8 patients correet.ly labeled the diagram
Objective 1:4 was met;
question 116 needs further
evaluation
8
Objectlve 1:5 was met
8
6
0
6
6
'1
pt~tients
demonst.raterl correct technique
ObjP.ctive 1:6 was met
l1wgs
1:7
Describe the flow of blood
Verbally describe
8 patients d"scribed correctly
ObjectivP. 1:7 was met
The maximum correct answers on thP. pretest ls 8.
**
The maximum correct answer·s on the post test ls 8.
w
\Jl
Table 5
Results of Objectives Estt<blished
for Coneept #2, Curriculwn Design--Patient ~:ducutional Program
Objective
2.1
2:2
Identify the coronary arteries
and dtlscribe their function
Pathological changes of
coronary artery disease
Evaluation Metho<l
A.
Identify arteries
on a heart model
B.
Test question #9
A.
Label a diagram
B.
Test question 1110
HesuHs
Pre
!'ost
Test* TeotH
4
6
Nurse Observation
Con•nent
8 patients correctly identified the arteries
Objective 2:1 was met
8 patients correctly labeled the diagram
Objective 2:2 was met
7
'l
The maximum correct answers on the pretest is 8
H
The maximum correct answers on the post test, is 8
w
fJ'
Tnble 6
Hesults of Ol.J.Iectlves Establl.Rhed
for Concept IIJ, Curriculum Desl.gn--Pati.enl. Educational Program
Objective
Evalulltlon Met.hod
--3:1 Pathological change of
H.,sul to
Pre
Post
TestK Test. X*
NtLrse Observa t l.on
Conuuent
-----
A.
Test question 1111
6
8
B.
Test question 1112
5
6
A.
Lobel a dlagnun
ObJective 3:1 was met
ucyocardial infarction
):2
J :J
3 :L,
Describe the healing process
Recognize abHity to resume
fonner acl.ivit1es
Recognize the return to
activity is a gradual process
8 patlents labeled diagram correctly
B. Test question #1)
4
l:l
c.
Test qLLesUon 1114
8
8
D.
Test. question 1115
7
8
A.
'Ies t ques Lion # 16
I,
6
B.
Test question #17
7
8
c.
Nurses 1 subJ ee-L i ve
evalua.t ion of
pntl<mt. attitude
A.
Test question #JB
B.
Nurses' subjective
evaluation of paLlent
att.Hude
Objective 3:2 was met
Object.ive J:J was met;
question 1116 needs
further evaluation
8 patients demonstrttted proper attitude
8
Objective J:l, was met
8
8 pat.leut;s demonstrated proper attitude
The maximum score on the pretest is 8.
**
The maximum score on the post test is 8.
w
-..,J
38
Summary
Test questions and the nurses' observation of the patient
labeling diagrams, identify parts of the heart model, and demonstrating psychomotor skills were used to evaluate the patients' ability
to meet the objectiYes,
The tables show that all the objectives
under each of the concepts were met.
The combined results of the
various evaluation methods were used to draw these conclusions,
TEACHING AIDS
This section will discuss the patients' and the author's
subjective evaluation of the teaching aids.
The Self-Instructional Manual
This teaching aid was well-received by the participants and
their families, and the post test results demonstrated that it was
instrumental in increasing knowledge.
'1
-·
The contents and vocabula~J appeared to be appropriate,
The
participants displayed no difficulty in comprehending the information
and, in fact, demonstrated enthusiasm,
The participants stated that
the diagrams and illustration helped them in understanding normal and
abnormal functions,
The author observed that the contents of the manual stimulated
the participants to ask additional questions regarding disease process
and treatment.
The review sessions provided the opportunity for
interaction between the nurse, patient, and family.
The learning opportunities which discussed
puw~
action
39
(1:3:1, 1:4:1) need further evaluation.
The sample of participants
discussed in this paper is small; therefore, the project will be
continued and the contents and learning opportunities will receive
further evaluation.
The Heart Model
The model provided multiple learning opportunities:
it
enhanced the contents of the manual; it allowed the learner to be
physically involved in the learning process; and it stimulated
questions related to material not covered in the manual, but important to the patient.
The author observed that the participants were pleased to
manipulate this structure because it had previously been
int~Dgible.
They knew it was the most important organ, but they had had little
concept of its structure,
Many of them requested that the model be
left at their bedside so they could review the contents of the
manual at their leisure.
The author feels that this is an effective teaching aid and
it has potential beyond its use in this particular patient educational
program.
Prescription for Fb..ysical Activity
The purposes of the project were to evaluate whether this
teaching aid met the patients expressed needs, and to evaluate the
patients' attitude towards complying to the physical activities
prescribed.
The participants demonstrated a positive attitude toward the
40
prescription.
They stated that the categories outlined the scope of
their activities and the format for exercise was easily understood.
Difficulties were encountered when the physicians filled out
the prescription,
Several demonstrated a lack
·~-----··~-
the
purp()s~..
of~l.l,!ld~rstanding
.--·
of
k
of the prescription, even though a brief inservice on
its use was provided to a representative committee.
Generally, they
did not write specific instructions and they did not utilize the
format for the exercise regimen,
The nursing staff of the definitive
observation unit was aware of the problem and increased its efforts
to be in attendance when the physicians wrote the prescription.
This
approach was initiated as this paper was written so the author is
unable to evaluate it at this
tL~e.
The post test results indicate that the participants
demonstrated a positive attitude towards resuming physical activity.
The nurses' discussions with the patients regarding the prescription
were most useful in cultivating this attitude.
The author concludes that the prescription
lS
potentially
an effective teaching tool but the teamwork of the physician
~~d
the
nurse is needed to implement it.
Guidelines for Resuming Physical Activity
As stated earlier, this teaching aid was developed as a
resource sheet to be used in conjunction with the prescription for
physical activity.
It is the author's observation that it is an
effective resource material,
The patients felt the contents were
informative and would be useful as they began resuming activity.
·
41
The contents of the sheet are not comprehensive, and as the
program continues to be evaluated additions can easily be made.
Chapter 5
METHODS AND MATERIAlS--NURSE EDUCATIONAL PROGRAIVI
The purpose of this study was to determine if
progra~
fu~
educational
for patient educators was effective in aiding them in
identifying patients' needs, utilizing insturctional methods, and
evaluating instructional methods.
In order to test the effectiveness of the program an experiment was designed, using the pretest--educational activity--post test
method.
The patient educators were tested using the instruments
described in this chapter.
LIMITATIONS OF THE STUDY
This study was limited to a selected population of staff
nurses of the Definitive Observation Unit,
The
s&~le
size was
limited to those who volunteered for the program.
The nurses participating in the program had to have had prior
experience in the nursing care of myocardial infarction patients.
ASSUMPTIONS OF
T~~
STUDY
For the purpose of the study it was assumed that:
1.
The participants would attend all eight class sessions.
2.
The participants would read all
J.
The content of the classes and the reading assignments
assig~~ents.
were presented or written in a manner that was easily understood.
42
43
4.
The items of the questionnaire were written in a manner
that was easily understood.
5.
The nurses answered the questionnaire without assistance
from other resources.
THE STUDY S.At'v!PLE
The target group for this educational program was ten
registered nurses.
They were all females who had been primary care
nurses a..Tl average of two years.
The educational backgrou..n.d of this
group ranged from an Associate of Arts to a Bachelor of Science
degree in Nursing.
They had all taught patients in informal settings,
but only three had participated in any orga..Tlized patient education
programs.
The nurses with teaching experience had been involved in
diabetic and well baby educational programs.
QtJESTIONN.i\_IRE
A questionnaire was developed to measure the participants'
knowledge of myocardial infarction and methods of instruction.
The
questionnaire consisted of nine short answer questions which are
listed in Appendix J,
DATA COLLECTION
The nurses were pretested at the beginning of the educational
program.
class.
The post test was administered upon completion of the final
44
STATISTIC)~
ANALYSIS OF DATA
A t test was used to statistically analyze the data from
the questionnaire.
The t test was chosen because of the small sample
size and the criteria for assumptions or normality and homogeneity
of variance were met by the data.
JUSTIFICATION OF
PROGRM~
CONTENT
A search of the literature, completed June 1975, failed to
identify any literature dealing with curriculum design for a program
which prepares staff nurses to be patient educators.
There were
articles which listed patient educators 1 duties, but none of the
articles described preparation for said duties.
Due to the lack of resources the author decided to evaluate
the target group 1 s educational needs and with this information in
mind, develop a curriculum design.
~~
tile prospective program participants.
informal survey was made of
The survey revealed a need
for: ( 1) review of the anatomy of the heart, ( 2) review of the
pathology of myocardial infarct ion, &"'l.d ( J) learning how to use
teaching tools effectively.
The author used the results of the survey and her own evaluation of the nurses 1 educational needs to pl&"'l. the five units of the
curriculum design.
Each of these units will be discussed separately
below,
Unit 1:
Anatomy of the Coronary Arteries; Pathology of
Infraction
~trocardial
45
The nurses had a basic knowledge of these subjects so the
learning opportunities would be geared toward review rather than
introduction of new information.
Unit 2:
Planning Physical Activity for the Patient
The inclusion of this unit in the curriculum design was a
result of
evaluatL~g
the nurses 1 needs and the patients 1 needs (via
surveys of both groups ) .
The nurses expressed a need to be more knowledgeable regarding ph_ysical activity for the coronary patient.
to know
11
The patients wanted
how much they can do without hurting their heart, 11
The content of the unit was thus directed towards helping
a patient plan activities based on the guidelines the physician has
given,
Unit 3:
Evaluating the Patients 1 Learning Environment
This unit was planned to meet what the author felt was an
imbalance in nursing preparation due to differing educational backgrounds of the target group,
The author, being a nurse, is aware
that some nurses are very astute at evaluating patients 1 learning
needs and others appear to have a limited awareness of these needs.
The content thus covered the psychosocial factors as well
as the physical factors which influence the learning environment.
Unit 4:
Methods of Instruction
The survey of the participants demonstrated a need to know
methods of instruction.
knowledge of
11
They stated that they were limited in their
how to teach, n
Several teaching tools had been
46
-----~--~--~-----~-------~-----------------------------------------------·---
-------
-----~-
------------- -------. --·- -- ----------------------------- ---·-
developed for the nurses to use in the patient educational program.
The purpose of this unit, therefore, was 'to teach the nurses how to
utilize these tools.
Several additional methods of instruction for
the nurses to use to supplement the teaching tools were also discussed.
Unit 5:
Charting Procedure
This unit was included to meet the legal requirements of
the patient educational program in that, a record of all patient
activities must be kept as a part of the patients' charts.
The
nurses were adept at recording patient behavior as related to
nursing care, but it was
necessa~J
to introduce certain forms that
would be used to record patient educational activities.
Therefore,
the content of the unit covered purpose of the forms and the procedure for recording patient behavior.
The criteria for selecting the learning opportunities used
in the curriculum design were:
1.
economics
2.
if it involved the student in the learning process
3.
if the method had been shown to be effective by previous
investigators
4.
the author's evaluation of her ability to utilize a
specific learning opportunity.
CURRICULG~
DESIGN
This section discusses the objectives, learning opportunities,
and methods of evaluation as they relate to the five concepts (units
discussed u...11der justification of program) established :for an educa-
47
tional program for patient educators (nurses).
Concept #1
Knowledge of the
~natomy
of the heart is essential in
understanding the pathology of myocardial infarction.
ObJective 1:1:
The nurse will be able to identify, on a
heart model, the three major coronary arteries.
Learning Opportunity 1:1:1:
A physician or nurse
specialist lecture "Anatomy of the Coronary Arteries. 11
Content 1:1:1:
Anatomy of the three major coronary
arteries and their branches.
Evaluation 1:1:1:
A.
Given a diagram of the heart, the nurse will identify
the three major coronary arteries.
B.
(Test question #1)
Given a model of the heart, the nurse will identify
the three major coronary arteries.
Objective 1:2:
The nurse will be able to identify the area
of patient's infarction site on a heart model.
Learning Opportunity 1:2:1:
specialist lecture
11
A physician or nurse
Iviyocardial Infarction Sites. 11
Content 1:2:1:
location and the affected
The six most common infarction sites:
corona~;
artery.
Evaluation 1:2:1:
A.
Given a list of six sites of myocardial infarction,
the nurse will be able to identify what coronary was affected.
(Test question #2)
B.
The nurse will be observed in a patient teaching
session, and will correctly identify (on a heart model) the patient's
48
- - - . · - - - ---
--- -------·-------------------- ----·- --------·--------
site of infarction.
Concept #2
A prescribed program of daily activity is beneficial for
the patient:
guidelines and precautions must be taken to make the
activity safe.
Objective 2: l:
The nurse will be able to assist the patient
in planning a physical activity program which meets the criteria set
by the physician.
Learning Opportunity 2:1:1:
A physician lecture-discussion
"Physical Activity of the Post Myocardial Infarction Patient"
Content 2:1:1:
A.
Current thoughts on increasing activity of the post
myocardial infarction patients.
B.
Review of criteria for judging the patients' ability
to resume sexual activity.
C.
Precautions to be taken by patients when participating
in physical activity.
Learning Opportunity 2:1:2:
R., and Ernest H. Friedman.
Reading - Hellerstien, Herman
"Sexual Activity and the Post Coronary
Patient," Archives of Internal Medicine, Vol. 125, June 1970
pp 996-999.
Content 2:1:2:
Research on physical stress during sexual
activity.
Learning Opportunity 2:1:3:
J. Stichman.
Reading- Schoenberg, J., and
How to Survive Your Husband's Heart Attack.
New York:
McKay, 1974, 56-64.
Content 2:1:3:
Wives of myocardial infarction patients
49
give their view of how the male patient adjusts to resuming sexual
activity.
Learning Opportunity 2:1:4:
"Exercise after Myocardial Infarction:
Reading - Hellmuth, G,A.
American Family Physicians,
VIII, No. 4 (1973), 94-104.
Evaluation 2:1:
A.
List at least three precautions, the patient should
take when resuming daily physical activities.
B.
List at least three precautions the patient should
take when resuming sexual activity,
C.
(Test question #4)
List at least one criteria used to judge when a
patient is ready to resuine sexual activities.
D.
session.
(Test question #J)
(Test question #5)
Observation of the nurse in a patient teaching
(Appendix L:
Criteria for Evaluation of a Patient Teaching
Session)
Concept #J
Knowledge of the psychosocial factors which iDSluence
myocardial infarction patients is essential in planning for individual
patient needs.
Objective 3:1:
The nurse will be able to identify the psycho-
social factors which influence the patients' adjustment to hospitalization and will develop a teaching plan to meet these needs.
Learnir~
11
Opportunity J:l:l:
Nurse:
The Hospitalized Patient--1Nhat Influences Him 11
Content 3:1:1:
A.
family
B.
patients' attitude toward health
Lecture-discussion-
50
C.
work orientation
D.
religion
E.
ethnic background
F.
medical history
G.
patient-doctor relationship
H.
economics
Learning Opportunity 3:1:2:
Reading - Purtilo, Ruth.
The Allied Health Professional and the Patient.
Saunders, 1973.
Philadelphia:
W, R.
p. 60-63.
Evaluation 3:1:
A.
The nurse will list and describe four psychosocial
factors which influence a patient's hospitalization,
(Test question
#6)
B.
Observation of nurse in a patient teaching session.
Objective 3:2:
The nurse will identify factors which will
facilitate a positive learning environment.
Learning Opportunity 3:2:1:
Nurse lecture-discussion -
"Factors to be considered when evaluating patients educational needs"
Content 3:2:1:
A.
emotional state
B.
physical comfort
C.
education
D.
physical limitations
E.
what patient wants to know
F.
age
Evaluation 3:2:
A.
The nurse will list and describe at least five factors
to be considered when evaluating the patients' educational needs.
(Test question #7)
B.
Observation of the nurse in a patient teaching
session,
Learning Opportunity 3:2:2:
Content 3:2:2:
Problem Solving Exercise
The group responsibilities:
A.
define a teaching problem.
B.
develop a list of approaches to the problem.
C.
identify specific learning opportunity to be insti-
D.
identify the principle(s) of learning that justifies
tuted.
the approach.
Evaluation 3:2:
Individual participation within the
group.
Concept #4
Learning opportunities assist the learner in attaining
desired outcomes.
Objective 4:1:
The nurse will use the information discussed
in the principles of learning to select learning opportunities which
meet the individual patient's needs,
Learning Opportu_nity 4:1:1:
Under supervision of the
instructor, the nurse reads a list of principles of learning.
Content 4:1:1:
the text:
List of the principles of learning from
Fader, J. T. and G. T. Dalis,
and Application.
Health Instruction:
Theory
2d. ed. Philadelphia: Lea and Febiger, 1974, 56-67.
Evaluation 4:1:
I
52
A.
Given an example of a learning opportunity, the nurse
will list at least one principle of learning which applies to that
method.
(Test question #8)
B.
Observation of the nurse in a patient teaching
session,
Learning Opportunity 4:1:2:
exercise.
Group problem solving
See Learning Opportunity 3:2:2.
Objective 4:2:
~fuen
the patient demonstrates a need for
alternative learning opportunities, the nurse will be able to select
the appropriate alternative methods.
Learning Opportunity 4:2:1:
Nurse lecture-discussion:
nFour Learning Opportunities"
Content 4:2:2:
Text.
of Patient Teaching in Nursing.
Redman, Barbara Klug.
St. Louis:
The Process
C. V. 1bsby, 1972, 91-119.
Methods A.
diagrams, illustrations
B.
analogies
C.
formulation of rule or principle
D.
case study
Evaluation 4:2:
A.
The nurse will list the two learning opportunities.
Test question #9)
B.
Observation of nurse in patient teaching session.
Objective 4:3:
The nurse will recognize the importance of
providing meaningful learning opportunities to meet the patients'
needs.
53
--~---~----~-~----·------~----
------
~----~------~---------- -----~----
Learning Opportunity 4:3:1:
_________
.,
Nurse-lecture discussion -
"Four Learning Opportunities"
Content 4:3:1:
See Objective 4:2
Evaluation 4:3:1:
Observation of the nurse in a patient
teaching session.
Concept #5
A medical record is a communication of essential factors
for the purpose of maintaining a history of patient behavior over a
period of time.
Objective 5:1
The nurse will describe, in measurable terms,
patient behavior which is relevant to the educational program.
Learning Opportu_rlity 5:1:1:
Nurse lecture- "Record
keeping for Patient Education Programs 11
Content 5:1:1:
A.
Introduction of forms:
Patient Education Prescription Sheet and Patient
Education Progress Notes.
B.
Purpose of forms, nurse responsibilities in charity.
C.
Procedure for
Evaluation 5:1:1:
chartL~g
of patient education program.
Given a situation, the nurse will
accurately record the pertinent facts of the patient behaYior
(relevant to the educational program).
I
Chapter 6
DISCUSSION OF RESULTS OF NURSE EDUCATIONAL PROGRMA
The second purpose of the pilot study was to evaluate the
effectiveness of an educational program in aiding patient educators
in
identifyi~~
patient needs, utilizing and evaluating learning
opportunities.
The participants of the study were selected on a volunteer
basis.
The study sample consisted of ten registered nurses.
The study
sa~ple
classes and post tested.
in Table 7.
was pretested, completed eight educational
The individual nurse scores are listed
The highest possible score on the test was thirty points.
PRETEST AND POST TEST RESULTS
Comparison of individual scores revealed that all the nurses
scored better on the post test by three to seven points.
The dif•
ference in the means of 5.2 points was significant at the .05 level.
Table 8 in Appendix M shows responses to individual questionnaire items.
The table indicates that question #3 had only five
correct responses on the post test.
This was enough of a consistent
incorrect response to warrant a review of the question.
The nurses
had the most incorrect answers to questions on precautions to be
taken when resuming physical activity and methods of instruction.
They had the most correct answers to questions on identifying learning opportunities, identifying myocardial infarction sites, and
54
Table 7
Individual Nurse Scores on the Pretest and Post Test
Pretest*
mean
t value***
*
**
***
Post Test**
23
30
23
29
23
30
24
27
26
29
20
26
17
20
21
27
27
28
24
28
22.2
27.4
3.85
The maximum possible score on the pretest was 30
The maximum possible score on the post test was 30
t score significant at .05
VI
VI
56
criteria for resuming sexual activity.
CURRICULUM DESIGN
The statistical analysis of data showed a significant increase in knowledge; however, the objectives of the author were not
met,
The author established a criteria of 100 percent accuracy in
answering the test questions, and not all nurses were able to meet
this requirement.
The author evaluated the situation and decided
to establish a second method of evaluation and then review the results of both methods,
Observation of the nurse in an actual patient teaching
session was the second method.
Criteria was established for this
observation and is seen in Appendix L.
The curriculum design for the Nurse Educational Program was
based on five concepts:
1.
Knowledge of the anatomy of the heart is essential to
understanding the
2.
patholo~J
of myocardial infarction.
A prescribed program of daily activity is beneficial for
the patient:
guidelines and precautions must be taken to make the
activity safe.
3.
Knowledge of the psychosocial factors which influence
myocardial infarction patients is essential in planning for individual
patient needs.
4.
Learning opportunities assist the learner in attaining
desired outcomes.
5.
A medical record is a communication of essential factors
57
for the purpose of maintaining a history of patient behavior over a
period of time.
Objectives which required the patients to demonstrate
knowledge or an attitude were established for each of these concepts.
The results of the objectives will be discussed in a table form as
they were treated in Chapter 4.
Tables 9,10,11,12, and lJ will
discuss Concepts 1,2,3,4, and 5 respectfully.
Swnmary
The tables show that all the objectives established for each
of the concepts were met.
It was; however, necessary to review all
methods of evaluation for each objective before making a decision.
The test questions were not answered with 100 percent accuracy but
the observation of the teaching session showed that the nurses were
able to perform at a satisfactory level.
LEARNING OPPORTUNITIES
The curriculum design was evaluated by a questionnaire and
observation of the nurse in a teaching session.
The post test
showed an increase in knowledge and the criteria set for the objectives were met.
What remains to be evaluated are the learning
opportunities and their content.
Learning Opportunity 1:1
1:2
(lecture: Coronary Arteries)
(lecture: Infarction Sites)
These lectures were well-received,
The lecturer invited
questions, so there was interaction between the lecturer and the
participants.
The content of the lectures were up to date and the
Tahle 9
Results of Objectives F.stobll.shed
for Concept #1, Curriculum Des.lgn--Nurse Educational Program
Results~
Pre
Objective
1: l
ldentifica tion of
the coronary arteries
Evaluation Method
Test question Ill
Test
9
Post
Test
*
IdentHication of
myocardial infarction
sites
Test quesLlon 1/2
Comment
Objective 1:1 was met
7
All JO nurses correctly identified the art
arteries
Ident.iflcatJon of the
arteries on the heart
model
1:2
Ol.>servat1on
2
Identifl.eation of
sites on the
heart model
Objective l :2
9
In indlv:f.dunl teaching session the nurse
could correctly identify infarction sites.
The maximum correct responses on the pretest and post test ls 10.
\.J1
CQ
'I'~ttd.e
10
HesuHs of' ObJectives Established
for Concept #2, Curricultun Design--Nurse EdtJcatlonal Program
flesults*
Pre
Post
Test
Te"t
Objedl ve
Evoluat.lon Method
2:1
Test quest.lon 1/J
2
5
Test question II~
8
9
'fest question /15
J
8
As siting the patient i.n
plruming physical activity
Observat !<)II of o
teaching session
ObservaLI.on
Conunent
Objective 2:1 was met
All mll'Aes pP.rt'orllled sat.:l.sfact.orily
The I!IRXim•un correct responses on the pretest. and post t.est l.s 10.
IJ
"
Taule 11
Hesults of Objectives Established
for Concept 1/J, Curriculum D•,sign--Nurse F;ducational Pr(>grAm
Besults*
Objec:t.ive
Evaluation Method
J: 1 Identification of
Test questJon 1/6
psychosocial factors that
influence the patient
3:2
ldenti fie at ion of factors
which faciliLate a
positive learning environment
Pre
Test
3
Post
Test
Observation of a
teachl.ng session
Comment
Objective J:l was met
8
All nurses performed satisfactorily
Observat lon of s
tencldng session
Test ques tl on #7
Obs(;rvation
6
Objective 3:2 wAs met
'7
All nurses performed Ratisfadorily
Maximum con·ect responses on the pretest and post test. is l 0.
0"
0
Table 12
[{esults of Oh,jecli ves E:Htebli.shed
fo1' Concept #1., Cnrt'icul•un lleslgn--Nurse Educational Program
Results~
Objective
Evaluation Melhod
Pre
Post
Test
Test
Observ11tlon
Comment
-------------------~
:1
Selecting learning opportunities
Test question /18
8
10
Observat.lon of a
teach1ng sesslon
4:2
Selecting alternative
leamlng opporLtmitles
Test question
0
1/'J
All nurses performed satisfactorily
Object! ve 4:1 was met
All nurses performed satisfactorily
Objective 4:2 was met
All nurses performed satisfactorily
ObJective 4:3 was met
6
Observation of a
teaching staff
4 :J
Recognition of the i.mportance
of providing meaningful
learning opportunities
Observatlon of a
teachl.ng session
---------Maximum correct responses on the pretest and post test is 10.
0'
1-'
Table lJ
Results of ObJect:! ve Established
for Concept #5, Cut·riclllum Design--Nurse EducaLional Program
Objective
Evaluation Method
5:1
Given a situation,
record patient
behavior
Recording patient behavior
on a medieal record
H.esults
Pre
Post
Test
'!'est
Observation
All nurses performed eatiRfact.orlly
Comment.
Objective 5:1 was met
0'
N
63
information was presented at the nurses' level.
The author concludes
that these learning opportunities were worthwhile and valuable.
Learning Opportunity 2:1
(lecture-discussion:
Physical
Activity of the Patient)
This learning opportunity was a group discussion with the
physician acting as a resource person.
The content was up-to-date
and the information was directed toward how the nurse may assist the
patient,
The nurses stated that they liked the format because it
allowed them active participation.
Learning Opportunity 3:1:1
(discussion:
The Hospitalized
Patient What Influences Him/Her)
The participants were receptive to the learning opportunity
but felt the content did not contain new information, leading to
boredom.
The author feels the content is valid and should be in-
cluded in nurse education curriculum, but this particular target
group may have been misjudged.
The learning opportunity needs
further evaluation.
Learning Opportunity 3:2:1
(lecture-discussion:
Factors To
Be Considered when Evaluating Patient Needs)
The format and content were new information and were wellreceived.
The learning opportunity appears to have been successful
because all students were able to accurately assess patient needs in
the teaching sessions.
Learning Opportunity 4:1:1
(Principles of Learning -
introduction)
The content was acceptable, but the learning opportunity did
-~-
------- - -------
--
-~
~
--~--------·-
-·----------
-----~~-----
·--
-·-- ---- ---
.
- ------ - ··-··--------·----·- -----------------------------
64
. not allow for individual participation.
during the presentation.
The nurses appeared bored
The content is worthwhile but different
learning opportunities must be utilized.
Learning Opportunity 4:1:2
(Problem-Solving Exercise)
This exercise was most productive in involving the participants in a learning experience.
There was interaction between the
group members and everyone contributed.
Learning Opportunity 4:2:1
(lecture-discussion:
Four
Learning Opportunities)
.Again, the target group was receptive to the information, but
the format limited participation by all group members.
The author
is satisfied that the content met the group's needs, but the learning
opportunity needs to be reevaluated.
Learning Opportunity 5:1:1
(lecture:
Record Keeping)
The learning opportunity and the content were satisfactory.
The lecture method allowed for the presentation of a volume of
material.
The group was invited to ask questions so there was some
interaction allowed.
The content was developed to meet the needs of
specific target group, perhaps other patient educational programs
would not have this need.
Learning Opportunity 2:1:2
2:1:3
2:1:4
3:1:2
(These were the Reading
Assignments)
The nurses did not read the articles assigned.
They stated
that they forgot about the assignment and/or they did not have time
to read them.
The author consulted the director of inservice education and
65
------------------------------------------------
she stated that this was a problem she had with other nursing educational programs,
The author suggests a further study is needed to
assess methods to motivate nurses.
Chapter 7
SUMMARY, CONCLUSIONS, .AND RECOMMENDATIONS
The pilot study had a twofold purpose:
(1) to develop and
evaluate a educational program for myocardial infarction patients, and
(2) to develop and evaluate an educational program for the patient
educators.
The review of literature discusses the nature of myocardial
infarction and the methodolosJ of program planning,
The nature of
myocardial infarction reviewed etiology, risk factors, and methods
of treatment.
The review of literature in methodolos.f of program
planning found four consistent areas of consideration:
(1) the
patient, (2) the family participation, (3) the program content, and
(4) educational methods,
SUMMARY:
PATIENT EDUCATIONAL PROGR/IM
The patient educational program utilized a
questioD~aire
taining twelve multiple choice and six true/false questions.
con-
The
content of the questioDnaire was taken from the four teaching aids
utilized in the program.
post test,
The questionnaire was used as a pretest and
The educational program consisted of the patients reading
a self instructional manual and the patient educators reviewing with
the patient, the prescription for physical activity and the guidelines for resuming physical activity.
The mean scores on the pretest and post test were calculated
66
6'/
and compared.
CONCLUSION:
PATIENT EDUCATIONAL PROGRMA
Based on the correct responses on the pretest and post test
by the patient group, the following conclusions were reached:
1.
The patients had increased their knowledge of myocardial
infarction and its treatment after reading the self instructional
manual and reviewing the prescription for physical activity and the
guidelines for resuming physical activity.
2.
The self instructional manual, heart model, prescription
for physical activity, and the guidelines for resuming physical
activity were effective methods of teaching the nature of myocardial
infarction and its treatment.
Sffiv1MARY:
NURSE EDUCATIONAL PROGRAM:
The nurse educational program utilized a questionnaire containing nine short answer questions.
The content of the questionnaire
was taken from the content of the learning opportunities presented in
the curriculum design.
post test.
The questionnaire was used as a pretest and a
The educational program consisted of eight class periods,
utilizing a variety of learning opportunities.
The mean scores on the pretest and post test were calculated
and compared.
CONCLUSIONS:
NURSE EDUCATIONAL PROGR.Mf
Based on the correct responses on the pretest and post test
68
by the nurse group, the following conclusions were reached:
1.
The nurses had increased their knowledge of identifying
patient needs, utilizing and evaluating instructional methods after
attending the eight classes of the educational program.
2.
The learning opportunities presented in the educational
program were effective methods of teaching the identification of
patient needs, utilization and evaluation of instructional methods,
RECOMMENDATIONS
The following recommendations are made for the patient
educational program:
1.
Future studies should be done to test the effectiveness
of these methods of patient teaching as compared with other methods.
2.
The future educator should develop an inservice program
for physicians to acquaint them with the program and their responsibilities in it.
J.
The evaluation of the program should be expanded to in-
clude measurement of the patient 1 s knowledge post discharge.
The following recommendations are made for the nurse educational program:
1.
Future studies should be done to test the effectiveness
of the content and learning opportunities of the curriculum design
as compared with other programs.
2.
The learning opportunities should be expanded to include
methods which would promote more group interaction.
BIBLIOGRAPHY
69
70
BIBLIOGRAPHY
BOOKS
Brunner, L. S., and others. Textbook of Medical Surgical Nursing.
2d ed. Philadelphia: J, P. Lippincott, 1972.
Friedberg, C.
1966.
Diseases of the Heart.
Philadelphia:
W. B. Saunders,
Fodor, J. T., and G. T. Dali. Health Instruction: Theory &~d
Application. 2d ed. Philadelphia: Lea &~d Febiger, 1974.
Hochbawn, G. M. Health Behavior.
Publishing Co., Inc., 1970.
Belmont, Calif.:
Wadsworth
Kerlinger, F. N. Foundations of Behavioral Research.
Holt, Rinehart and Winston, Inc., 1964.
Kogan, Benjaw~n A., ed. Readings in Health Science.
Harcourt Brace Jovanovich, Inc., 1971,
Means, R. K. Methodology in Education,
Merrill Publishing Co., 1968.
New York:
New York:
Columbus, Ohio:
Purtilo, Ruth. The Allied Health Professional
Philadelphia: W, B. Saunders, 1973.
fu~d
Charles E.
the Patient.
Redman, Barbara Klug. The Process of Patient Teaching in Nursing.
St. Louis: C. V. Mosby, 1972.
Schoenberg, J., and J. Stichman. How to Survive Your Husband 1 s
Heart Attack. New York: McKay, 1974.
71
,-------------------------------··--~---·------------~--~--~-----.-~------.
PERIODICALS
Alkateeb, W., C. J. Lukeroth, and M. Riggs. "A Comparison of Three
Educational Techniques Used in a Venereal Disease Clinic,"
Public Health Reports, XC (March-April, 1975), 159-64.
AJ:y, R. E.
"Patient Education Program Answers Many Unanswered
Questions," Hospitals. XL (November 16, 1966), 159-64.
Baden, C. A. "Teaching the Coronary Patient and His Family,"
Nursing Clinics of North America, VII (September, 1972),
563-649.
Bowen, R. G., R. Rich, and R. M. Sclotfel\].t. "Effects of Organized
Instruction for Patients with the Diagnosis of Diabetes Mellitus,"
Nursing Research, XIV (Winter, 1962), 151-59.
Cain, H. D., and others. "Graded Activity Programs for Safe Return
to Self-Care after ~Jyocardial Infarction, 11 Journal of the
American Medical Association, CLXX'VII (July 15, 1961), 101-02.
Clark, C. M., and Bayley, E. W. 11 Evaluation of the Use of Programmed
Instruction for Patients Maintained on Warfarin Therapy, 11
American Journal of Public Health, LXII (August, 1972), 1135-39.
D1.lllca.71, J. M., A. Grandbouche, and G. Moody. "A Program for the
Teaching of Cardiovascular Patients," Heart and Lung, II
(July-August, 1975), 508-11.
Epstein, F. H. nintroduction to Coronary Heart Disease," Preventive
Medicine, I (1972), 23-26.
Hellerstien, Herman R., and Ernest H. Friedman. 11 Sexual Activity
and the Post Coronary Patient, 11 Archives of Internal Medicine,
CXJ0! (June, 1970), 996-99.
Hell:nuth, G. A. 11 Exercise after lv.fyocardial Infarction, 11 American
Family Physicians , VII I, No. 4 ( 1973 ) , 94-104.
Kelsey, H., and V. L. Beamer. nA Post-Hospital Health Education
Program," Heart a.fld Lilllg, II (July-August, 1973), 512-14.
Linehan, D. T. 11 'Nhat Does the Patient Want to Know, 11 American
Journal of Nursing, LXVI (May, 1966), 1066-70.
McGann, M. 11 Groun Sessions for the Families of Post-Coronary
Patients, 11 Supervisor Nurse, VII (Febr\l.ary, 1976), 17-19.
72
:Mullen, P. D. "Health Education for Heart Patients in Crisis, 11
Health Service Reports, LXXXVIII (August-September, 1973),
669-7.3.
Pohl, M. L. "Teaching Activities of the Nursing Practitioner,"
Nursing Research, XIV (Winter, 1962), 4-11.
Powell, A. H., and E. H. Winslow. "The Cardiac Clinical Nurse
Specialist, 11 Nursing Clinics of North America, VIII (December,
1973), 723_;733.
Rosenberg, S. G. "Patient Education Leads to Better Care for Heart
Patients," HSMHA Health Reports, LXXXVI (September, 1971),
793-802.
Schlesigner, A. D.
"Health Education," Hospitals, XLVII (April 1,
1973)' 137-40.
Simmonds, S. K. 11 Education and the Hospital," Hospitals, XLVII
(March 1, 197J), 54-60.
Tyzenhouse, P, S. "W..yocardial Infarction--Its Effect on the Family,"
American Journal of Nursing, LXXIII (June, 1973), 1012-1.3.
Woodward, G. M. , and M. R. Gauthier, nHospi tal Education Program
Following Myocardial Infarction," Canadian Medical Journal, CVI
(March 18, 1972), 665-67.
73
----------·----·----~
---------------------
----- -------------
-------·--------~
UNPUBLISHED SOURCES
American Medical Association. "Statement on Patient Education."
Report to the Board of Trustees, New York, June, 1975.
American Public Health Association. Public Health Association
Section, "A Model for Planning Patient Education," Report of
the Committee on Educational Tasks in Chronic Disease, 1972.
Davis, M. S, "Documenting the Need. 11 Strategies for Patient
Education. Second Invitational Conference on Patient Education.
American Hospital Association, October 6-8, 1969.
Jew, Priscilla. "Evaluation of a Patient-Teaching Guide. rr
Unpublished Master's thesis. California State University,
Northridge, 1975.
Simmonds, S, K. 11 Focusing on the Issues. rr Strategies for Patient
Education. Second Invitational Conference on Patient Education:
American Hospital Association, October 6-8, 1969.
74
APPENDIX A
PATIENT TEST
75
76
-------~-------·------~----~- ----------~- ------------~-------------
PATIENT TEST*
1.
The wall of the heart is made of:
a.
b.
c.
d.
2.
Your heart is approximately the same size as, and similar in
shape to:
a.
b.·
c.
d.
J,
from the l1IDgs and pump it to the body
from the body and pump it to the 11IDgs
from the heart and pump it to the l1IDgs
the lungs
receive the blood
receive the blood
receive the blood
pump the blood to
from the 11IDgs and pump it to the body
from the body and pump it to the lungs
from the heart and pump it to the lungs
the lungs
heart, arteries, veins
arteries, veins, lungs
heart, lungs, veins
arteries, heart, lungs
The vessels that carry oxygenated blood are:
a.
b.
c.
d.
7.
receive the blood
receive the blood
receive the blood
pump the blood to
The circulatory system is made up of:
a.
b.
c.
d.
6.
grapefruit
man's fist
pear
woman's fist
The f1IDction of the right side of your heart is to:
a.
b,
c.
d.
5.
a
a
a
a
The fu_Tlct ion of the left side of your heart is to:
a.
b.
c.
d.
4.
epithelial tissue
connective tissue
muscle tissue
fatty tissue
capillaries
venules
veins
arteries
Your radial pulse is located:
a.
b.
c.
d.
in the middle of the wrist
between your wrist and the elbow
directly below the thumb
below the index finger
77
8.
The function of the lungs in the process of circulation is to:
a.
b.
c.
d.
9.
soft
widened
narrowed
hard
A heart attack takes place when:
a.
b.
c.
d.
12.
aorta
coronary arteries
coronary veins
ventricles
Coronary Artery Disease means the vessels have become:
a.
b.
c.
d.
11.
blood with oxygen
carbon dioxide
of breathing circulates the blood
blood with oxygen and remove the carbon dioxide
The vessels that supply the heart muscle with oxygen are:
a.
b.
c.
d.
10.
supply the
remove the
the motion
supply the
there is too much fat in the blood
there is a decrease in the blood supply to the heart muscle
the blood becomes thick
there is a decrease in the blood supply to the lungs
The medical term for heart attack is:
a.
b.
c.
d.
cor pulmonal
myocardial infarction
pulmonary edema
congestive heart failure
READ THE FOLLOWING STATEMENTS .AND DECIDE IF THE STATE.t\ilENT IS TRUE OR
FALSE.
13.
14.
15.
16.
The heart is capable of developing a new blood supply
to the injured area
True
False
The heart muscle heals by forming scar tissue over
the injured area
True
False
The healing process following a heart attack takes
several weeks to be completed
True
False
After a heart attack a patient will very likely not
return to his previous level of physical activity
True
False
78
17.
18.
*
After a heart attack one's sex life has to be greatly
reduced
True
False
It is important for the healing process of the heart
to gradually increase physical activity
True
False
The post test consisted of the same questions arranged in a
different order.
APPENDIX B
PATIENT INTERVIEW QUESTIONNAIRE
79
80
--------------------------------------------------------------------~
PATIENT INTERVIEW QUESTIONNAIRE
Name:
Age:
Address:
Phone No.:
Occupation:
Diagnosis:
Physician:
1.
2.
J.
When you were discharged from the hospital did you receive a
prescription for medication?
a,
Did you receive instruction regarding the medication?
b.
Do
you think you need to know more about the medication?
Were you discharged with a prescription for a diet?
a.
Did you receive instruction regarding the diet?
b.
Do you think you need to know more about the diet?
What can you tell me about what happens to your body during a
heart attack?
a.
Where did you acquire this information?
b.
Would you like to know more about heart attacks?
4.
Did you receive any instructions about resuming sexual relations?
Was the information specific enough?
5.
Did you receive instruction regarding ambulation at home?
a.
Was this information explicit enough?
b.
Would you have liked more information?
6,
What was the most important thing for you to know when you left
the hospital?
7.
W'nat information do you think should be included in an education
program for heart patients?
APPENDIX C
RESULTS OF TI-iE PATIENT INTERVIEWS
81
82
---------··--·-·-----------
RESULTS OF PATIENT INTERVIEW QUESTIONNAIRE
A total of seven patients were interviewed~
Question l.
Received prescription
for medication
yes
no
7
Received instruction
yes
7
0
no
0
Has enough information
yes
no
3
4
Question 2.
Received prescription
for die
yes
no
7
Received instruction
Has enough information
yes
no
yes
no
4
3
2
5
0
Question 3.
Patient statements in regard to pathology of myocardial infarction
3 subjects stated - arteries get plugged
1 subject stated - arteries get plugged and muscle dies
1 subject stated - the heart is a pump and the muscle dies
2 subjects did not know
Patients acquired this information from:
doctor
nurse
other
3
1
1
All wanted more information
Question 4.
Received instruction regarding
sexual activity
Was the information specific
enough
yes
no
yes
no
5
2
5
2
Question 5.
Received instruction
regarding ambulation
yes
no
-- ______ _:)
Was the information
specific
yes
no
----~-------- - ----------- _1_ - - 6
Has enough information
yes
2
no
5
83
Question 6.
What was the most iJnportant thing for you to know when you left the
hospital?
6 subjects stated activity
1 subject stated diet
Question 7.
PrograJn suggestions in order of priorities
Exercise
Heart pathology
Diet
Weight reduction
Emergency procedures
Reducing stress
APPENDIX D
A SELF-INSTRUCTIONAL MANUAL: MYOCARDIAL INFARCTION
84
85
PATIENT EDUCATION ?ROGRfu"l
;,!YOCARDIAL DTFA.RCTION
Una Sinsheimer, 1975
86
-------~
-----------·
------------·-··----------~------------~----
--·-----------
-~---------
------- ----------·-----------·
DITRODUCTION
This is a. self-instructional manual w·hich 'ilill guide you in learning
ho~.,
a nor:nal heart functions and 'ilha.t changes take place when you have a. heart
atta.c..l<..
You 'ilill be asked to i;ake part in a. 'fa.riety of exercises such as:
labeling diagrams, filling in blanks, and identii"Jing parts of a heart model.
The model of the heart has been brought to your bedside, along with this
manual.
There
~e
The manual •rill ask you to handle the model and identi:'y its parts.
diagrams to help you with identification, but
you have any
difficulty, please a.sk. your nurse for assistance.
The answers to the ques-cions of the
the information asked.
exer~ises
.a.re
~r:.n.ted
directly Oelow
Check your answers before going ·:m to the next iJa.ge.
If your answer is incorrect,
~sk
your nurse for assistance.
87
PLACE YOUR H.:'..ND OTIR YOT.J'R EEA..qT
Do you feel it beating?
The heart is a muscular organ and 'Nith each
beat it is pumping blood to your body.
Tux:1 to page 2
88
The !J.uma.n heart is approximately the saJ!I.e
size as your fist and it is similar in
shape.
Turn to page 3
89
There are a. special group of Yessels •.;hich :o.oYe the blood throug,.'l the
body.
These •ressels along •..rith the heart make up the CirculatOr'] System.
FIGURE I.
CIRCULATORY
IS A DUGRAH OF THE
SYSTEM.
£ach of ths following statements
describes some part of the system.
Read the statamenta and ~atch the
underlined words with the blanks
in the diagram.
l.
The organ that ?UMPS the blood
is called the
hea~~.
2.
~e
Yessels that carr; blood
to the body are called ~~~eries.
3.
The vessels chat return the
blood to the heart are called
~
a.
heart,
b. ·reins,
Turn to page 4
c. arteries
90
-----~----
---------
--------~
~nen
heart.
---- ----------- ---·
----·------------~·-·
a doctor or nurse take your pulse they are feeling each beat of your
A pulse :nay be felt seYeral places on your body, but the easiest place
to feel it is at the
:\
i .
:?I:JurtE II.
Turn to page 5
T~ist.
l.
Place the tips of tha first 3 finge~s
of your right h~~d on the inside of
youx left 't~rist.
2.
~Tow
3.
Press your ~in~ers lightly against
t.he ;oone tl1at :!.s ther9. 1ou ·Hill
feel a rhythmic pul3ation against
yoUJ: fingers. ·rsrs IS THE 3EATDTG
OF YOUJ:\ H:EA.'ZT.
move the finge~s of "']Our r'!.ght
hand so they a.r~ on the :;>art of your
·~ist which is below your thumb.
See ?!:3-tJP.E II.
91
Look at the heart model in front of you.
It is a duplicate of a human
hea..-t, out is built on a larger than life scale.
T:1.e heart has 2 sides,
and each side is a pump.
Open Latch A on tr.e heart :nodel.
See the FIGURE III.
?IGtJFE I:::I.
The pink
~d
ca.l.led the
blue
c~Vity
t~~ck
~u...ntps.
and strong, its
Turn to page 6
le!~ ~~·
It is
It is the :1a..in -cumo of the ':1ea..rt, -and it is
Lef'~ 7ent~icle.
the bigger of the two
is
you are looking into is the
The :nuscle surrounding the left Yentricle
~ction
is to pump the blood to the body.
92
Open Latch 3 on the heart model.
See FIGUBE
?IGUPE
~his
rl.
cavity i3 the right ·rentricle of :gump.
smalle~
rv.
Aa you can see, it is a. little
than tne left ventr!cl: and the muscla wall is
has tte job of
:9~ing
the blood to the lungs,
of oxygen for tCe body to use.
Turn to 9a.ge 7
~<'There
it
thi~~er.
~icks
TI~is
side
up a supply
93
TAKE A DEEP 3F.EATH
E:ach time you. inhale, you. a..re bringing oxygen into your l'..mgs.
l:!Oif EN'.Jl.LE
lfuen you. exhaJ.e you. a..re blo•.;ing ou.t carbon dioxide.
THE LUNGS .'L'\E Ali EXCH.ANGS 3'ISTEH
They
r~ceive
the oAfgen the body needs
~o
:~ction
and :hey
carbon dioxide tD.at :..s left af-4;c!" the body uses the OAJgen..
~emove ~he
94
FIGURE V is a diagram of tae heart a.nd lungs.
~~dicate
Study the
the path the blood takes to
dia~am ~~d
ma~e
The ar!"ows in the diagram
a complete circulation.
trace the flow of-blood.
<!('-\"'co 1\
"":J,c..<.lQC...
K,.:<"-'r
c, •.
c.~
J
:Tow that you
circu.la:ces.
~ave
studi~d
the diagr.s.m., desc!"ibe in a fe-r.v
~Nards
l"'.~.ow
the blood
95
Close Latches A and B on the heart model.
faces you.
~otice
Turn the model so the left side
the red vessels :na.rked I and !!.
See F!GT3RE 'T!.
FIGLSE 7!.
?IGUT\E 't!II.
~TofN'
tu1.·n the heart model to -:he !"ight side.
bcttoc of the ventricle, it is marked
T:totice the
~ed
YesseJ. on the
These a.re the C:O.RONF2Y ." ~'l'E.R.IES.
'E.1.ey a.re a s-pecial group of arteries that bring a blood supply to the heart
muscle.
Turn to page 10
96
Open Latch A.
As you lift the piece of the
vessel is cut in two.
See E'IGURE VIII.
~odel
away, you will see that the
This is a vein, but it ·..rill demons-
trate the anatomy of the corona.I"'J a.rtery.
F:GUFE VI!!.
Arteries are similar to a. :::ose.
~be
Olue circle on
~he
m.odel. i.s the wall of
the hose and the red dot represents the amount of space the blood has to flow
tl:'.rough.
These ;;mall vessels a.re responsible for nourishing the hea.rt muscle
with oxygen.
They are the Yessels that are affected
attack.
·-rurn to 9age U
~>~hen
you ha.ve
9.
heart
97
·-~~---~-------·--------------·-------~-------· --~-----------------·---~~-----~-----------
Coronary
-~-tarias
·------------------------------------·
become diseased when products of the blood settle on
the sides of the artarJ wall and causes it to become narrowed.
~·ihen
happens the heart !!!USCle doesn't receive its full supply of OX'Jgen.
this
This
cond.id.i ton is known as CORONlUtY A.?.TERY DISEASE.
3elow a.re two aide .,rl.eTKS of
orJgen to the
-3.
Clea..~
co~ona.ry
muscle a.nd the muscle is
heart attacl-t is called
:3. ~~!yocar'iia.l
you \fOuld find that:
Nyocardia.l
heart muscle
Infarction
So the tarm :•lyocardia.l I:::lfarction
'!'u.rn to page 12
artaries.
Circle the one
in.jure~...
:nfarction.
In
~hat
medi~al
If this term is
has
tcr:n.L."'1olog:r
1;a.~en
apart,
98
--------·-----·--·------------------ ----------------------~--------------------·
FIGURE rA is a diagram
myocardial infarction.
of the changes that take place when a person suz'fers a
The statements below the diagram describe these changes.
Read the statements and identity the parts of the diagrsm.
l.
The b.ea.rt m.uscle is in.jured· rt~hen the a:rte!""'J becomes narrowed and there is
a decrease in
~he
supply of OJC'fgen.
(Identi~f
the narrQwed coronary
arta~J)
2..
I'he L1..jured hear"t. :rruscle hea.ls ·oy forming a scar over the
affac~ed
area..
(identif'y the in.jured area.)
3.
The a.rterJ r-emains narrowed ar"ter the :o.yocardial infarction so the heart
!l!Uscle still ioes not recei're enough oxygen.
s~er
'1~o
compensate for this, the
branches of the corona..r:r arteries get larger 9.!ld develop
Cra.nc!les to nourish the a.rea of in.jury.
circulation.
·rr. is
ne~-r
is called colla.tera.J.
(Identify the collateral circulation)
99
The scar formation and the collateral circulation take several weeks to
fully de•relop.
During this time the heart needs to rest, so you
to reduce the amount of work it has to do.
The doctor
·~ll
rt~ill
have
help you plan
activities so this healing will take place.
This completes this part of the education program.
unclear about any of the
eX!Jlanation.
info~ation,
If you are still
please ask your nurse for a further
APPENDIX E
THE HEART MODEL
100
101
SECTION 5
biological training aids
8390: DURABLe Heart.
Made of unbreakable, semi-flexible plas·
tic, approximately twice natural size: revolving on round wooden stand. 16"
high including stand. The model is dis·
sectlble into S pieces to show detailed
internal structure In both the atria and
ventricles. The bicuspid. tricuspid and
both semilunar valves are shown in
closed position as three dimensional
structures visible from above and below.
The Bunola of His is included. The coronary and great vessels with many of their
ramoficatlons are reproduced. Descend·
ing aorta. esophagus and trachea are
~resent. The distribution of the vagus and
sympathetic nerves is shOwn in detail.
Suoolied with descriptive ~~ey containing
118 ·references to model.
25
Heart
Models
Clay Adams~,_.
.:' ::
t- . ~:: \ _
OivtStOn ot
9i!Cton. OtCktnson ;,:nd [email protected]
?arSIOCany, ~- ,i. 07054
~
'
APPENDIX F
PRESCRIPTION FOR PHYSICAL ACTIVITY
102
lOJ
APPENDIX F
?RESCRIPTION fOR
ACTIVITY
?E..,SO~fAL
P~"YSICAL
TO 3EGIN
?rlGi:ENE
s~~wer:r4;0a~n~ng
wasi.:i~ :-~ai:
DA!~Y
AC':IV'IT"'!--!:CUSEHOLD
;;ooA::....'l.g' ::ea.l.s
:vashing
2.i.gt~
'.:!:.~:!'.es
hcuse
~2.e3....~..g
P~s:-essicn:
:novies
ou-c ~c
·ii:-~er
J:OSSIZS/?,ZC?.!.A,TICN
SEXU.A.r.:. ACT7.V7.7!
AC:'IV!TY
SUGGEST!CNS/
STIPUUTIONS
104
------------~---------------·~------~----
- - - - - ---·----- -~~
----- - - - - ------------~---~---
PRESCRIPTION OF ?HYSICAL .l.CTI'l!TY
TYPE OF !XERCISE
new
OFnN
DIST.4NCE
·:o
BEGIN
--------------·------- - -
.APPENDIX G
GUIDELINES FOR REStJMING PHYSICAL ACTIVITY
105
106
-----
--------------·-·-------------------··-----------------·-------------------
GUIDELINES FOR RESUMING PHYSICAL ACTIVITY
General Information
1.
~fuen
walking, walk on a level
desired.
2.
Walk slowly and comfortably.
3.
Never exercise if you feel fatigued.
4.
Never exercise within one hour of completing a meal.
5.
If exercising in the afternoon, do so after a rest period.
pl~ne,
and take rest periods as
Sexual Activity
1.
Do not have sexual relations when you are fatigued or following a
heavy meal.
2.
A position in which you have to support the least amount of body
weight is best.
3.
Rest afterward; do not immediately resume any strenuous activity.
Warning Signs of Physical Stress
1.
Development of
jaw or ear.
2.
Confusion, dizziness, light-headedness
3.
Persistent occurrence of irregular heartbeats
4.
Persistent fatigue
5.
Nasea
6.
Shortness of breath
7.
Rise in a pulse rate above
~~y
chest pain or pain referred to the arm, teeth,
-~-
APPENDIX H
PRESCRIPTION FOB. PATIENT EDUCATION--.MYOCARDIAL INFARCTION
107
108
---------------------------------------------------
?RESCF~PTION
-~-
---
-- ------ -----------
?OR ?A:I1NT EDUCATION
* MYOCARDIAL
i:NFAECTIIJN
~
Instruction ~aj begi~ -------------Es~ima~ed
date of discharge --------------
Self ir.st :-uct. i
~nal
::anual
;Jh.ysice.l ac~ivi"":ty
__:::alcula"':ing ;ul.se :-a":ce
---?:-esc:-i;~ion :'c-::
?lan=~ng =edica~ion ;~es
----rnfc~ation ~ggardL~g d~~ action, apecifj·~-------------------------------------------------~~:o~ation ~ega~dL~g 3iCe effe~~3, 3pec!fy
~c
Jieticim
·r:.si:
~3.t:!.ant
L~for.nat~~n,
-----Additiona:
speci:y
Sig!led: ___________________________ M.D.
:.
?a~ie~t is able ~o e~la~~ ~he ~~cess of sjs~ama~ic
·.!i.:-~ula::. !.on.
2.
?at.ier..t is abl~ ~o :.dent if:'! :he !'"1.gn-r:. sr..d :ef~ sides
...~he ~ea.~ a..~d C.~fi...."l* ~lle .:"' 1..!!i.C-ci::n ·-::f ;acb..
~f
3.
?::."tient. is
ab~e ~o
axp2.ain the £' 1J.l"'.c'tion
~f ~rjgan
t:=ansporY.
~.
?ati~nt
~x;lain
o.
is ~ble to ~der.~ify :he
their ~~cti~~.
?atient is s.ble to
infarction a.T"J.d :he
descri~e ~he
cor~n~J ~eriss ~d
e,ren-..:: cf' cyocard.ial
heali-~ ~recess
that fcll::ws.
7.
Ps:r:.!er.r.t is 'ibla :;o ir..tarpret -:::.e a.c-ci ·ri ty orders
out1.ined by· -:.he :;>hJsi·:!ia..."l.
8.
Additional
~d~cation
::ems.
9.S
Da~e:
--------
APPENDIX I
PATIENT EDUCATION PROGRESS NOTES
109
110
.\IOTE PROGAESS OP CASE, COMPI_ICATIONS, CONSUL T,.l,iiONS. CHANGE IN OIAGNOSIS,
CONOITION ON OISCHARGE,INST'AUCTIONS TO PAiiENT.
O'ATE
(
(_
MEDICAL CENTER of TARZANA
18321 Clark Street • Tarzana, California 91356
Telephone (213) 881-0800
?ATIENT :::OiJC.ATICN ?!l.OGBESS o!OTES
!~1-09 8173
322~
liolt=··--··~
..
APPENDIX J
C01@ARISON OF RESPONSES TO PRETEST AND POST TEST
QUESTIONNAIRE ITEMS BY INDIVIDUAL PATIENTS
IN THE PATIENT EDUCATIONAL PROGRAM
111
112
Table 3
Comparison of responses to pretest and post test
questionnaire items by individual patients
in the Patient Educational Program
Patient
2
1
p
Question r
e
#
p
b
s
p
t
0
s
t
5
4
p
r
e
p
0
s
t
p
r
e
p
0
s
t
p
0
s
t
8
7
6
p
r
e
p
r
e
p
0
s
t
p
r
e
p
0
s
t
p
r
e
p
0
s
t
1.
2.
+
+
+
+
+
+
-
+
-
+
+
+
+
+
-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
3.
+
+
+
+
+
+
-
+
+
+
-
+
+
+
+
4.
+
+
+
+
+
+
-
+
+
+
+
+
+
+
- -
- +
- -
- -
5.
- - -
-
6.
+
+
+
-
+
-
+
- -
-
+
+
-
+
-
-
- - +
7.
- - -
-
+
-
+
+
+
+
+
+
+
+
+
+
+
+
-
+
+
+
+
+
+
-
+
-
+
-
+
+
+
+
+
+
+
+
+
+
-
- - -
+
+
- -
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
-
+
+
+
+
+
+
+
+
+
+
+
13.
+
+
+
-
- -
+
-
- - -
+
-
+
-
+
+
+
+
+
+
+
14.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
15.
+
+
+
+
+
+
+
+
+
+
-
+
+
+
+
+
16.
-
+
- -
-
+
-
+
+
+
+
+
+
+
+
+
17.
+
+
-
+
+
+
+
+
+
+
+
+
+
+
+
+
18.
+
+
+
+
- -
+
+
+
-
+
-
+
+
+
+
8.
9.
10.
11.
12.
+
3
p
r
e
+
+
indicates a correct response
indicates an incorrect response
+
+
+
+
+
APPENDIX K
NURSE TEST
113
114
-------------------·-------~---------·---
----
---------------~--~~----
---------
NURSE TEST
l.
Identify and label
~he
coronarJ arteries as seen in :he
diagram bel-:Jw.
2.
:;fat~h "the ;b.y3ical. 3i:e -:f :he r!lYOCardial
artery ·jvhi~b. would ~e :)CC~uded.
A-."lter:.or
:.rr
Poste!"icr :..£!
!.n.:~:.r~-.;!.cr:. 7Ti~b.
A.
3.
righ~
ccronarJ
-pos~erior
left
Postsriolaters.l MI
--·--
:..::e
corcn~J a~~er;,
~.terior
left
~r:e!j~,
bra..Tlch
descending
br~~ch
:orcna~J ar~erJ,
-:ircumflex ':)ra."lch
115
--~------------------------·
J,
List and desc~ibe at least J precautions a patient should take
when resumL~g 9hysical activity.
4.
List and describe J precautions a patient should take •Nhen
resumi."lg sexual ac-ci ,r._ ty.
5.
Discuss when sexual acti 'Tity may be resUJ:led,
6.
Describe 4 psychosocial factors which influence a patient's
~act.ian to hospitalization.
7.
Describe 5 factors ~o
lea~L~ abilities.
8.
~e
In the patient teaching
closed f'!.st.
consi1ered when a'traluating
~~ual ~he
patient's
heart is compared :a a
lfnat iVCUld be -che reascn tor using this
1
tea.~hir~?
9.
~he
List or gi. ve m exan:pla of ::""cu:- :1ethods ::1f te.s.cb.ing.
~~~rs
~e-t;hod
·:lf
.APPENDIX L
CRITERIA FOR EVALUATION OF
A PATIENT TEACHING SESSION
116
117
----------------------------~---------- ------~---------·----~------~-------·-----~
CRITERIA FOR EVALUATION OF
A PATIENT TEACHING SESSION
l.
Has the nurse investigated what type of infarction the patient
has suffered?
2.
Has the nurse investigated what information the doctor has given
the patient?
3.
Has the nurse investigated the psychosocial factors which may
positively or negatively influence the patient.
4.
Does the nurse continually evaluate the teaching session
make adjustments when needed?
5.
Does the nurse accurately answer the patient's question and/or
seek resource material to answer the question?
6.
Does the patient appear to be satisfied with the teaching
session?
7.
Is the charting of the patient behavior in keeping with procedure?
8.
Is the patient behavior accurately recorded?
~~d
APPENDIX M
COfu~ARISON
OF PRETEST AND POST TEST
QUESTIONNAIRE ITEMS BY INDIVIDUAL PARTICIPANTS
IN THE NURSE
EDUCATION.fo~
118
PROGF.At\1
119
--·------------------ - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - -----
- ------~- - - - - -
Table 8
Comparison of pretest and post test
questionnaire items by individual participants
in the Nurse Educational Program
Nurse
p p
r 0
e s
t
4
p p
r 0
e s
t
5
p p
r 0
e s
t
6
p p
r 0
e s
t
-
+ +
+ +
+ +
-+ -+ -+
-
+ +
-
J,
-
+
--
- -
--
+
-
-
4.
-+
+ +
+
-
+ +
5.
-
-
+ +
6.
+ +
+ +
-
7.
+ +
8,
9.
r 0
e s
t
8
p p
r 0
e s
t
p p
r 0
e s
t
10
p p
r 0
e s
t
+
-
+ +
+ +
--
+
-
+
+ +
-
+
- -
+
+ +
-
-
+
- -
+ +
-+
+ +
+ +
+ +
+ +
+ +
-
+
-
+
-
+ +
-
+
- -
-
+
-
+
+ +
+ +
+ +
--
-
+
-
+
+
+ +
-
+
+ +
+ +
+ +
+ +
-
-
+
-
-+
- -
-+ - + -
1
2
3
Question
#
p p
r 0
e s
t
p p
r 0
e s
l.
+ +
+ +
2.
+
+
+
t
+
+
+
+
indicates correct response
indicates incorrect response
7
p p
+
+
9
- --
-- -+
-
-
+ +
+ +
--
+ +
+ +
-
+
+ +
- -
--
-
+
---------