THE RAINBOW CLINIC

TRIAGE EDUCATION

FLIPBOOK:

PROMOTING HEALTH LITERACY IN OUTPATIENT SPECIALTY CLINICS:

NURSING EDUCATION TO ADDRESS NURSE SENSITIVE INDICATORS AND

IMPROVE INTERDISCIPLINARY CARE COORDINATION.

• Define health literacy

• Discuss the scope of the issue

• Discuss current Nurse Sensitive Indicators for Ambulatory Care

• Key strategies to address improving health literacy and implementing NSIs in the Rainbow clinic

HEALTH LITERACY The IOM defines health literacy as “the

degree in which individuals have the capacity to obtain, process and understand basic health information and services to make appropriate health decisions.”

Health literacy includes: print literacy, oral literacy, E-health literacy and numeracy (numbers, dosages…)

SCOPE OF THE ISSUE Half of adults in

United States lack proficiency in basic reading or math skills (above 8th grade level).

Adults over the age of 65, racial and ethnic minorities, and low income status are the most at risk for low health literacy

WHAT CAN WE DO? Health literacy is

integral part of nursing practice.

It is an essential part of health communication, patient engagement, patient empowerment and can have a significant impact on health outcomes

The VA is dedicated to promoting health literacy within the organization

Veterans Health Library Easily understood patient

education info in multiple languages on understanding diagnosis, preparing for tests or procedures and managing ongoing health that help the patient make informed decisions regarding care.

MyHealtheVet Refill prescriptions Monitor personal health

data Food and activity

journals BP and Pain logs

Monitor own self-entered health record

Send secure messages to primary team

View lab work results View appt information

Krames online--CPRS

WHAT IS THE QUALITY IMPROVEMENT GOAL?

Create a culture of nursing driven education and care coordination.

Performance Improvement to address NSIs in Ambulatory care

To promote patient engagement, improve patient adherence to treatment plan, identify at risk veterans and promote collaboration of care

MEASURE/INDICATORVeterans with appointments in the Rainbow clinic

8E/W/N areas will be assessed utilizing a standardized triage process to address current Nurse Sensitive Indicators established by the ANA and AAACN Task force:

• Medication Reconciliation• Pain assessment and follow-up• Smoking Cessation• Depression Assessment conducted• Controlling High Blood Pressure• Hospital Re-admissions• Patient Education

MEDICATION RECONCILIATION Your Provider will perform a medication reconciliation with you for

each appointment Take the time to learn about your medicine. For instance, why are you taking

it? What does it do? Work with your doctor or other health care providers to get the answers you need

Medicines have brand names and generic (chemical) names. When a medicine is first made, it is sold only under its brand name. Later, it can be made and sold as a generic. Generic medicines cost less than brand-name medicines and most work just as well. Most people can use the generic medicine instead of the brand-name medicine, unless their doctor says otherwise.

Name of medicine

Taken for: Dose: Time(s) to take it:

TAKING AN ACTIVE ROLE IN YOUR MEDICINES Ask Questions About Your Medicine

What is the name of the medicine? Why do I need to take it? When should I take it? How should I take it: with water? with food? on an empty stomach? How much do I take? What do I do if I miss a dose? What side effects could it cause and which ones should I call the doctor

about? Are there any foods or medicines I should avoid while taking this medicine? Will this drug change how my other medications work?

Take an Active Role Fill all your prescriptions at the same pharmacy. This keeps your medicine

history in one place. Talk to the pharmacist. Make sure you understand how to take each medicine.

Ask for a fact sheet about each one. Tell your doctor and pharmacist about all the prescription and over-the-

counter medicines you take. This includes vitamins, nutrition or health supplements, alcohol or other drugs, and herbal remedies.

Tell your doctor and pharmacist if you have any medical conditions or allergies to any medicine or food, or if you are pregnant or breastfeeding.

Keep a list of all your medicines. Use the sample to the right as a guide for the type of information needed.

MEDICATION SAFETY Safety tips

Have a routine for taking each medicine. Make it part of something you do each day, such as brushing your teeth or eating a meal.

When you go to the hospital or your doctor’s office, bring all your current medicines in their original boxes or bottles. If you can’t do that, bring an up-to-date list of your medicines.

Don't stop taking a prescription medicine unless your doctor tells you to. Doing so could make your condition worse.

Don't share medicines. Let your doctor and pharmacist know

of any allergies you have. Taking prescription medicines with

alcohol, street drugs, herbs, supplements, or even some over-the-counter medicines can be harmful. Talk to your doctor or pharmacist before using any of these things while taking a prescription medicine.

MEDICATION SAFETY TIPS CONT. When filling your prescriptions, try using the same pharmacy

for all your medicines. If not, let the pharmacist know what medicines you are already on.

Keep medicines out of the reach of children and pets. Don't use medicine that has expired or that doesn’t look or

smell right. Get rid of it properly. To find out the right way to get rid of medicine:

Call your city or county government’s household trash and recycling service and ask if a drug take-back program is available in your community.

Call your local pharmacy and ask the right way to get rid of the medicine.

Go to www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653 to learn how to get rid of medicines safely.

Medicine that comes in a container for a single dose should be used only 1 time. If you use the container a second time, it may have germs in it that can cause illness. These illnesses include hepatitis B and C. They also include infections of the brain or spinal cord (meningitis and epidural abscess).

PAIN ASSESSMENT

Measuring Your Pain A pain scale helps you rate pain intensity. In the scale, 0

means no pain, and 10 is the worst pain possible. A pain scale is used only to measure how your pain changes

for you not to compare your pain with someone else’s pain. You should rate your pain every few hours. You may feel some pain even with medicines. It is important to tell your health care provider if

medicines don't reduce the pain. Be sure to mention if the pain suddenly increases or changes.

PAIN ASSESSMENT AND FOLLOW-UP

COMMUNICATING ABOUT PAIN Your role

Tell your health care provider about the pain and your health problems. Be sure to:

Mention all the medicines you take. This includes any you buy over-the-counter and any herbs, teas, or vitamins you take.

Mention any pain relief techniques you use, like massage or meditation.

Measure pain as directed by your health care provider.

If your health care provider asks you to, keep a diary of your pain, the treatments you are using and how well they work. You may also be asked to describe how strong your pain is on a scale of zero to 10. Zero is no pain and 10 is the worst pain you can imagine. Be prepared to do this for your health care provider.

Follow your treatment plan as directed by your health care provider. Tell your health care provider how your treatment is working.

As pain is reduced, you’ll feel better. Less pain means less stress on your body and mind.

Your health care provider’s role Your health care provider will help

you understand and manage pain. You will be told about your pain control options. These will most likely include medicines. Options like physical therapy and acupuncture may also help.

Note for family and friends It may be hard to understand how

your loved one feels. But the pain he or she has is real. You may not be able to stop the pain. You can help in other ways, though. Spend time with your loved one. This helps distract from the pain. And help him or her take medicines on time and in the correct amount.

COMPLEMENTARY CARE FOR PAIN: You may find pain relief with complementary care. Look for a

licensed or certified professional. And tell your health care professional that you are using complementary care. Massage can increase circulation and relaxation. This can help

relieve stress and pain. Biofeedback therapy uses instruments to measure the body's

physiological activity, like heart rate and muscle activity. This information is used to help a person learn to control certain functions, such as relaxing muscles and helping reduce pain.

Chiropractic adjusts the spine and joints. It may help reduce back, neck, or joint pain. Chiropractic may also use mild electrical stimulation, massage, heat, or ultrasound (sound waves).

Acupuncture uses thin needles to help treat pain. The treatment may release the body’s own painkillers.

Distraction helps you focus on something besides pain. Try reading a book, watching a movie, or talking with family. Or visit a local attraction.

Meditation helps you focus on words, objects, or ideas. Doing this can calm you and decrease stress.

Relaxation includes methods like listening to soothing music or relaxation tapes. You might try slow, deep breathing. Imagine a calm scene, like an ocean or mountain, as you breathe.

HEALTH EFFECTS OF SMOKING OR USING TOBACCO PRODUCTSHow smoking affects your body:

Cigarette smoke contains carbon monoxide. This gas takes the place of oxygen in your blood.

Nicotine raises your blood pressure and heart rate. It reduces blood flow to your arms and legs, and slows digestion.

Tar is what’s left after tobacco is smoked. This sticky brown material gums up your lungs, so less oxygen gets into your bloodstream.

Cigarette smoke contains over 4,000 other chemicals, including formaldehyde, arsenic, and lead. Dozens of these chemicals are known to cause cancer.

Facing facts this can: Increase your risk of lung cancer, bladder

cancer, and cervical cancer. Raise blood pressure, which increases your

risk of heart attack or stroke. Reduce blood flow, which can slow healing,

cause wrinkles and increase signs of aging. In pregnant women, cause bleeding

problems, miscarriage, stillbirth, or birth defects.

In men, cause problems with erections.

SMOKING AND THE FINANCIAL IMPACTThose dollars add up! Do you realize how much money you are spending on

cigarettes per year? ($ _____ per pack) ×( _____ number of packs per day) × (365 days) = $ _____ yearly cost of smoking

Example: $6.75 per pack cigarettes x 1 ppd x 365 days= $2463.75

Besides tobacco, there are other costs, including extra cleaning bills and replacement costs for clothing and furniture; medical expenses for smoking-related illnesses; and higher health, life, and car insurance premiums.

SMOKING CESSATION Set a quit date

If you’re serious about quitting smoking, choose a date within the next 2 to 4 weeks. Mark it in bright, bold letters on a calendar you use often. Tell people about your quit date. Ask for their support. Let your friends and family know how they can help you quit.

Make a contract A quit-smoking contract gives you a goal. Write out the

contract and sign it. Have it witnessed, if you like. Then keep the contract where you’ll see it often, or carry it with you. Read the contract when you’re tempted to smoke.

Take action On the day you quit, reread your quit contract. Think

about the benefits you gain by quitting, such as better health and an improved sense of taste.

Remove cigarettes from your home, car, or any other place where you stash them.

Throw away all smoking materials, including matches, lighters, and ashtrays.

Review your list of triggers and your plan for coping with them.

Stay away from people or settings you link with smoking. Make a survival kit that includes gum, mints, carrot

sticks, and things to keep your hands busy. Talk to your health care provider about using quit-

smoking products, such as medication or a nicotine patch, inhaler, nasal spray, gum, or lozenges.

GETTING SUPPORT FOR QUITTING SMOKING Ask for help

You don’t have to go through the process of quitting smoking without support. Tell people you are quitting. The support of friends, coworkers, and family

members can make a big difference. Face-to-face or telephone counseling can also be helpful, as can a stop-smoking class or an ex-smokers’ group

Sometimes you may just need to talk when you miss smoking. Ex-smokers are good to talk to, because they’re likely to know how you feel. You may need extra support in the first few weeks after you quit. Ask a friend to call you each day to see how you’re doing. Telephone counseling can also help you keep on track. Ask your health care provider, local hospital, or public health department to put you in touch with a phone counselor. You may also have to deal with doubters when you decide to quit. Explain to any doubters why you are quitting. Tell them that quitting is important to you. Ask for their support. Tell your smoking buddies that you can walk together instead of smoking together. If someone thinks you won’t succeed, say that you have a good quit plan. Let him or her know you’re sticking with it.

For more informationsmokefree.gov/talk-to-an-expertNational Cancer Institute Smoking Quitline: 877-44U-QUIT (877-448-7848)

DEPRESSIONEveryone feels sad or “blue” from time to time for a few days or weeks. Depression is when these feelings don't go away and they interfere with daily life. Depression is a real illness. It makes you feel sad and helpless. It gets in the way of your life and relationships. It inhibits your ability to think and act. But, with help, you can feel better again. Depression affects your whole body

Brain chemicals affect your body as well as your mood. So depression may do more than just make you feel low. You may also feel bad physically. Depression can:

Cause trouble with mental tasks such as remembering, concentrating, or making decisions

Make you feel nervous and jumpy Cause trouble sleeping. Or you may sleep too much Change your appetite Cause headaches, stomachaches, or other aches and pains Drain your body of energy

Depression and other illness It is common for people who have chronic health problems to

also have depression. It can often be hard to tell which one caused the other. A person might become depressed after finding out they have a health problem. But some studies suggest being depressed may make certain health problems more likely. And some depressed people stop taking care of themselves. This may make them more likely to get sick.

DEPRESSION SIGNS AND SYMPTOMS Recognizing signs of depression

People who are depressed may: Feel unhappy, sad, blue, down, or miserable nearly

every day Feel helpless, hopeless, or worthless Lose interest in hobbies, friends, and activities that

used to give pleasure Not sleep well or sleep too much Gain or lose weight Feel low on energy or constantly tired Have a hard time concentrating or making

decisions Lose interest in sex Have physical symptoms, such as stomachaches,

headaches, or backaches

WARNING SIGNALS FOR SUICIDE Know the serious signals

Threats or talk of suicide Statements such as “I won’t be a problem much

longer” or “Nothing matters” Giving away possessions or making a will or

funeral arrangements Buying a gun or other weapon Sudden, unexplained cheerfulness or calm after

a period of depression If you notice any of these signs, get

help right away. Call a health care professional, mental health clinic, or suicide hotline and ask what action to take. In an emergency, don’t hesitate to call the police.

DEPRESSION/SUICIDE RESOURCES:Resources: National Institutes of Mental

Health 866-615-6464 www.nimh.nih.gov

National Alliance on Mental Illness 800-950-6264 www.nami.org

Mental Health America 800-969-6642 www.nmha.org

National Suicide Hotline 800-784-2433 (800-SUICIDE)

National Suicide Prevention Lifeline 800-273-8255 (800-273-TALK) www.suicidepreventionlifeline.org

WHAT IS HIGH BLOOD PRESSURE? High blood pressure (also called hypertension) is known as

the “silent killer.” This is because most of the time it doesn’t cause symptoms. In fact, many people don’t know they have it until other problems develop. In most cases, high blood pressure can’t be cured. It’s a disease that requires lifelong treatment. The good news is that it CAN be managed.

Measuring blood pressure High blood pressure is 140/90 or higher

The top number is the pressure of blood against the artery walls during a heartbeat (systolic).

The bottom number is the pressure of blood against artery walls between heartbeats (diastolic).

FACTS ABOUT HIGH BLOOD PRESSURE

Feeling OK does not mean that blood pressure is under control. Likewise, feeling bad doesn’t mean it’s out of control. The only way to know for sure is to check your pressure regularly.

Medication is only one part of controlling high blood pressure. You also need to manage your weight, get regular exercise, and adjust your eating habits.

High blood pressure is usually a lifelong problem. But it can be controlled with healthy lifestyle changes and medication.

Hypertension is not the same as stress. Although stress may be a factor in high blood pressure, it’s only one part of the story.

Blood pressure medications need to be taken every day. Stopping suddenly may cause a dangerous increase in pressure.

HIGH BLOOD PRESSURE RISK FACTORS

Risk Factors You Can’t ControlFamily History

One or both of your parents or grandparents has had high blood pressure or heart disease.

Gender and AgeYou’re a man over age 55 or a postmenopausal woman.

CONTROLLABLE RISK FACTORS OF HIGH BLOOD PRESSURE Choose heart-healthy

foods. Eating healthier meals helps you control your blood pressure. Ask your doctor about the DASH eating plan. This plan helps reduce blood pressure by limiting the amount of sodium (salt) you have in your diet.

Maintain a healthy weight. Being overweight makes you more likely to have high blood pressure. Losing excess weight helps lower blood pressure.

Exercise regularly. Daily exercise helps your heart and blood vessels work better and stay healthier. It can help lower your blood pressure.

Stop smoking. Smoking increases blood pressure and damages blood vessels.

Limit alcohol. Drinking too much alcohol can raise blood pressure. Men should have no more than 2 drinks a day. Women should have no more than 1. (A drink is equal to 1 beer, or a small glass of wine, or a shot of liquor.)

Control stress. Stress makes your heart work harder and beat faster. Controlling stress helps you control your blood pressure.

CHRONIC HEALTH CONDITIONS: TAKING AN ACTIVE ROLE IN YOUR CARE Talk with your doctor

To make the most of your office visits, try these tips: Make a list of things you want to talk about, including new

treatments. Don't be afraid to ask questions. Jot down what your health care provider says.

Keep a diary. Describe changes in your condition and in how you feel. Bring the diary to office visits.

Ask about other health services, such as dietitians or physical therapists.

Ask if complementary care, such as acupuncture or herbs, might help.

Take your medications Learn about the medications you take. For the best results, be sure

to do the following: Ask your pharmacist if there are certain foods or drugs you should

avoid while taking your medication. This could include drugs you buy over the counter, such as aspirin, as well as vitamins and herbs.

Read labels. Use medications only as directed. Don't skip doses or stop taking medications on your own.

Tell your health care provider if you are bothered by side effects. There may be other medications you can try.

Store medications properly. Some are affected by heat or light. Ask your health insurer about buying medications through the mail.

Or check with groups that focus on your condition. They may know other ways to save on costs.

CHRONIC HEALTH CONDITIONS: TAKING AN ACTIVE ROLE IN YOUR CARE Start to deal with emotions

When you're coping with a health problem, it's normal to be sad or depressed at times. Some medications can also affect your mood. Still, if these feelings don't go away, be sure to tell someone. Depression can be treated.

If you choose, share what you learn about your condition with the people in your life. Consider inviting family members along when you attend a support group meeting. Learning more about your condition can ease their concerns.

Learn to relax Listening to music, spending some quiet time alone, or taking a

warm bath can all be relaxing. But there are many other things that can help you feel calm. Choose activities you enjoy and make them part of your daily life. You may also want to try:

Deep breathing. When you feel tense, take a few deep breaths. Meditation, visualization, tai chi, or yoga. You might want to

take a class in these techniques. Or check the public library for books and tapes to help you get started.

CHRONIC HEALTH CONDITIONS: TAKING AN ACTIVE ROLE IN YOUR CARE

Thinking At times, you may want to be alone with your thoughts. At other times, you'll

want to explore new interests. Try some of the following: If you don't already know how, learn to use a computer. Computers can

connect you to a vast amount of information. Many public libraries have systems you can use free of charge.

Read just for pleasure. Try novels, magazines, humor, even cookbooks. Play board or computer games. Plan a trip, listen to music, or start a journal.

Doing Think about what you enjoy doing. Then find ways to make it happen. Your doctor, nurse,

or occupational therapist may be able to help you get started. Consider the following: Take a class in healthy cooking. What you learn can help, whether or not you're on a

special diet. Ask someone to take you to a ball game or on a picnic. Go on a nature walk or work in the garden.

Relating to others Over time, your bonds with some people may grow stronger while some may not last. As

you move forward, keep these tips in mind: Try volunteering. It's a good way to be involved with others. Be open to new people you meet. Find ways to maintain friendships you value. If you have to cancel plans, try to

reschedule. If you can access a computer, use e-mail to stay in touch. Call or text.

CHRONIC DISEASE RESOURCES American Diabetes Association at

800-342-2383, or www.diabetes.org American Heart Association at

800-242-8721, or www.heart.org American Lung Association at

800-586-4872, or www.lung.org Arthritis Foundation at

800-283-7800, or www.arthritis.org Medicare Hotline at

800-633-4227, or www.medicare.gov Phone book listings in the Government section

and the yellow pages To find out about disability benefits and your

rights under the Americans with Disabilities Act (ADA) at 800-949-4232

PREVENTING HOSPITAL READMISSIONS Your health care provider will work with you to

set up a treatment plan. The plan may include medications.

Take medications as prescribed It might also include ways to find emotional

support. To feel more healthy and in control, do your

best to follow your plan. Maintain an active role in your treatment plan

Notify healthcare team if any changes in health occur

Please schedule follow-up appointments with the clerks at the Rainbow clinic so that we are better able to help manage your care. Please verify that we have your correct contact

information.

PATIENT EDUCATION VAPHS Internet Page : http://www.pittsburgh.va.gov/

Patients & Visitors Patient Information

Health Education• Veterans Health Library: www.veteranshealthl

ibrary.org• My HealtheVet:

https://www.myhealth.va.gov/index.html • Krames Online: https://

www.kramesondemand.com/Browse.aspx

Multilingual and very easily understood information Understanding Diagnosis Making Informed Decisions Purpose of Tests and Procedures Medication Information Managing Ongoing Health Health Videos Support Resources

INFORMATION COMPILED BY:TANISHA R. DAVIS, BSN, RN, CCRNUNIVERSITY OF PITTSBURGHMSN-CNL

IN COLLABORATION WITH:MYRA COUCH, MANAGER RAINBOW CLINICMELISSA TAYLOR, ASSOCIATE CHIEF OF NURSING RESEARCH, VARAINBOW CLINIC STAFFROSE HOFFMAN, CNL PROGRAM COORDINATOR, UNIVERSITY OF PITTSBURGH