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Recently, while learning to fly fish, I read a line that made me smile: "If fishing was easy it would be called catching." Those words come back to me in many settings, especially in patient education. It's one thing to teach our clients information we think is vital for their independence, but the true measure of our effectiveness lies in what they learn and are able to implement in their lives.


Therefore, it is essential that the patient education we conduct as skilled interventions in home healthcare nursing is appropriate, effective, and meaningful for each individual. Evidence-based research in education has shown that learning is enhanced if:


* The information is developmentally appropriate and culturally relevant. Verbal and written information must be understood by the client, and medical jargon should be kept to a minimum. Format and font of written material should be uncluttered and large enough for elderly patients to read. Sensory or motor deficits that might impede learning or ability for self-care should be addressed and may indicate a need for altering the method of teaching.


* The learner participates actively in the process of learning. Patients and care-givers need to be included in the planning process and then learn by doing, while discussing their questions, feelings, and attitudes about applying the learning in their lives.


* The content to be learned is broken down into concise, manageable sessions that do not overwhelm with vast amounts of facts and details. Essential information should be presented in a number of formats (verbal, visual, participatory) to address the different learning styles of patients.


* The learner understands the value of the information and procedures being taught for improving quality of his or her life. A thorough assessment of the patient and caregiver's values, attitudes, and readiness for learning should be done before teaching.


* The environment is conducive to learning. Stress, environmental distractions, cultural conflicts, and value judgments all should be eliminated if possible. Timing should be based on the available time, attention span, and readiness for learning without rushing or taking too much time. A positive relationship is important between the teacher and learner, and the nurse needs to be perceived as a credible source of information.


* Finally, client and family successes are positively reinforced. Evaluation of learning can be done by observing return demonstration of skills; by discussions of content, feelings, and attitudes; and by evaluation of expected outcomes and achievement of goals that the plan of care was designed to reach (Walsh et al., 1987).



Developing a Teaching/Learning Plan in Cardiac Care

"At no other time in home care history has the goal of nursing been so clear: to facilitate the patient's transition from acute care to self-care--to promote the patient's independence in care and how to identify the early signs and symptoms of deviations from the normal" (Frantz, 2004).


As nurses today, we face ever-increasing demands on our time and skills. In home health-care, now more than ever, we need to find creative ways of educating patients so they are able to assume self-care. Our effectiveness in interventions depends not only on our ability to care for our patients, but also on their ability to understand and put into practice the teaching we provide.


Developing an effective teaching/learning plan consists of assessment of the learner, designing a plan with him or her to achieve important outcomes, implementing the interventions of interactive teaching/learning, and evaluation of the learning evidenced by actual behavioral outcomes.


Cardiac disease, and specifically heart failure, is a major and growing health problem in our country and is the most common Medicare Diagnosis-Related Grouping. Heart failure (HF) is primarily a condition of the elderly. The number of deaths associated with HF has been steadily increasing, despite advances in care, in part related to our aging population, but also because of better treatment and survival of patients with acute myocardial infarction and cardiac disease earlier in life (Hunt et al., 2005).


Understanding some basic facts about heart disease and its symptoms will better prepare patients and loved ones to manage their condition and make it easier to talk to health-care professionals about their illness. In designing a patient education disease management program, the focus should be on involving patients in their own care so they will be able to take responsibility as soon as possible and prevent hospital readmission.


Important components to include are:


1. Basic information about how the heart works with a simple diagram of the heart and its four chambers for a teaching visual.


* Your heart is a muscle that pumps blood throughout your body. The right side of the heart pumps blood to the lungs. In the lungs, blood receives oxygen. The oxygen-rich blood travels back to the left side of the heart, where it is pumped to your organs, limbs, brain, and all the other parts of your body. After your body uses up the oxygen in the blood, it sends the blood back to the right side of the heart, and the process starts again.


2. Definition of heart failure.


* In heart failure, the heart is not actually failing. It is losing its ability to pump blood effectively, which has a negative effect on most bodily functions. Because a weakened heart moves less blood with each pump, fluid backs up in the lungs and as a result, the body does not receive enough oxygen. The kidneys cannot work properly in removing excess fluid from the body, and fluid may accumulate in parts of the body, particularly the feet and lower legs. Heart failure results from other conditions that weaken the heart, such as heart attack, coronary artery disease, high blood pressure, or diabetes. It does not go away and needs to be treated with medication and daily monitoring.


3. Emergency plan for exacerbations. Urge the patient to call the nurse first when complications arise to reduce hospitalizations.


* Call the home health nurse if you experience more shortness of breath, especially when lying flat; weight gain of 2 pounds overnight or 3 to 5 pounds in a period of 5 days; feet, ankles, or stomach swell more than usual; very fast or very slow heart beat (greater than 120 bpm or less than 50 bpm); dizziness or fainting; cold, sweaty, pale or cyanotic skin; nausea or lack of appetite.


4. Daily self-care calendar.


* Fill out your self-care calendar every day; this will help you and your nurse to monitor your condition from day to day. Pay close attention to your breathing, swelling, energy level, and overall feeling of well-being. When you are participating in any activity, be aware of what your body can tolerate. When you begin to get tired or short of breath, rest and take your time.


5. Practical tips for improving health and emotional outlook.


* Take good care of yourself; your emotional health and physical health strongly affect each other.


* Take your medicine as ordered; if you are on a diuretic (water pill) take it at least 6 to 8 hours before bedtime. This will allow you to sleep better at night and also will help you breathe better.


* Weigh yourself every day; record your weight daily on your self-care calendar. You will soon be able to see how your weight affects your energy level and ability to breathe.


* Conserve your energy for things important to you; you can do anything you want, but rest periods may be necessary.


* Keep your feet elevated at every opportunity; this will reduce swelling in your feet and legs and also help blood return to your heart.


* Watch what you eat and drink; eat healthy and delicious foods that you like and avoid salt and alcohol--they can make your heart failure worse (KHNH, 2005).




The disease management education plan should also include practical skills for patients and caregivers to participate in their own care. Essential skills to include are:


* how to take your own pulse;


* how to weigh yourself accurately (at the same time each day, with the same clothing on);


* how to take your own blood pressure (if appropriate);


* how to manage your medications;


* how to manage food and fluids;


* how to conserve energy; and


* how to deal with stress.



In the end, creative interventions using the science and art of nursing can help many patients and families become more confident and skilled participants in their own care. Returning to the metaphor of fishing, for which catching is the goal, so in teaching, learning and improved quality of life are the prize.




Frantz, A. K. (2004). Breaking down the barriers to heart failure patient self-care. Home Healthcare Nurse, 22 (2), 109-115. [Context Link]


Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., et al. (2005). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Available at: [Context Link]


Keweenaw Home Nursing and Hospice (KHNH). (2005). Patient and family information about heart and lung disease. Calumet, MI: Author. [Context Link]


Walsh, J., Persons, C. B., & Wieck, L. (1987). Manual of home health care nursing. Philadelphia: JB Lippincott. [Context Link]