Distribution:

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Key: Use all that ApplyLearner = P = Patient FA = Family F= Friend C= Caregiver SO= Signifi cant Other O= OtherOutcomes = V = Verbalizes Understanding of information F = Further Education/Reinforcement needed TB = Learner Able to Teach Back information RD = Leaner able to Return DemonstrateReadiness = R = Readiness to learn B= Barrier to learning Present � Unable due to Condition � no family availableAchieved = No further education necessaryInterpreter/ Interpretive Service

Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSVerbalizes understanding of disease process and reason for hospitalization

Verbalized understanding of purpose and function of equipment and various alarms

Verbalizes understanding of roles and functions of the interdisciplinary team

Verbalizes understanding of referrals made to other members of the healthcare team

Verbalizes understanding of general emergency and safety measures in place in the acute care unit settingVerbalizes personal goal(s) and/or concerns for this hospitalizationGoal Verbalizes understanding that patient and/or family should seek assistance if the patient condition appears to worsen (process for activation of rapid response team by patient/family)At time of transfer to another level of care, verbalizes understanding of rational for transfer and transfer procedureSafety and Protection

Verbalizes understanding of fall risk and agrees to call for help for ambulation/transfers from bed to chair/elimination needsVerbalizes understanding of safety measures used during hospitalization • Fall Prevention • Use of call light • Purpose of side rails • Assistance needed for impaired mobility, cognitive or sensory impairment • Use of red socks, falling star • Use of Crib and importance of side rails to be up when child is not attended • Verbalizes understanding of need to notify nurse when planning to leave child’s

bedsideVerbalizes understanding of abuse cycleVerbalizes understanding of elements of safety plan.Verbalizes understanding of appropriate resources for substance abuse treatmentDemonstrates proper use of Assist Devices

Verbalizes understanding of use of restraints for safety and protection of medical devicesVerbalizes understanding of use of NO NOs for safety and protection of medical devices

*88457*

88457

All documentation must indicate the specifi c date and time of entry and a signature complete with identifying credential, title or classifi cation.

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESS • Provided Patient Education Material: � Patient Restraint and Seclusion GuidelinesVerbalizes understanding of criteria for restraint removal

Verbalizes understanding of Seizure precautions

Verbalizes understanding of relevant symptoms,assessment, planning and expected outcomes for suicide riskVerbalizes knowledge of pertinent follow-up resources.General Infection Prevention Practices/Isolation GuidelinesPatient verbalizes understanding of hospital infection prevention practices that reduces or helps to prevent patients from acquiring infections during their hospital stay including: • MRSA or other MDRO admission screening processPatient verbalizes understanding that patients/family/visitors are encouraged to speak up and remind all healthcare staff to clean their hands before and after patient care or examination if not observed. • Hand Hygiene Practices Policy � On-Demand TV: “Hand Hygiene Saves Lives” viewed• Respiratory Hygiene Practices • Visitors/Family/Visitation PolicyVerbalizes understanding for need of good pericare

Patient/Visitors/Family verbalizes understanding of isolation precautions used in the hospital to prevent transmission of communicable diseases/germs between patients, to visitors and staff.Verbalizes understanding of need for vaccines/ Immunizations • Provided Patient Education Material: � “Flu Fact Sheet” � Childhood Vaccine � Pneumovax � other Multidrug Resistant Organism MDROPatient verbalizes understanding of the diagnosis of the following: � MDRO � MRSA � VRE � Other Other:

Provided with Patient Education Material: � “MRSA FAQ” � “VRE FAQ” �

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSPatient with C diffi cile verbalizes an understanding of infection prevention practices used by healthcare staff/visitors to prevent the spread of C diffi cile including: • Hand Hygiene with soap and water. • Special products used to clean room • Spore PrecautionsPatient Education Material Provided: � “C-Diff FAQ”Patient verbalizes an understanding of isolation precautions/practices being used to prevent the spread of their MDRO, c-diffi cile, or other organism to patients/visitors/healthcare staff. • Contact • Droplet • Airborne • Spore • Patient/Visitors/Family verbalizes an understanding of the isolation precautions/ use of personal protective equipment healthcare staff, family and visitors required before entering a patient’s room

� Infection Prevention PracticesCentral Venous Access Devices/CVADEducation to patient/family member occurs prior to insertion or as soon thereafter as possible. • Patient/family members verbalize an understanding of the need for the device/

central line. • Patient verbalizes understanding how patients acquire blood stream infections with

a Central Line present. • Patient verbalizes understanding of central line infection prevention practices that

help prevent infections including: • Hand Hygiene • Central line insertion practices • Central Line Access and maintenance practices. • Daily Assessment for device removal • Patient Education Materials Provided � Central Line Infection Prevention FAQ Hand out given

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSOther

PHYSIOLOGIC Perception/Cognition Elimination Cardiac Function/Tissue Perfusion Fluid and electrolyte Respiratory Function Physical Regulation Complications of PregnancyPerception/CognitionVerbalizes and demonstrates understanding of the need to report neurological changesVerbalizes understanding of assessing and monitoring for baseline mental status and assessments for monitoring (i.e. LOC, GCS, RASS & CAM-ICU)Verbalizes understanding of the management of delirium and its sequelae

Verbalizes understanding of communication methods used to for patients with an impaired ability to communicate: • Mechanical ventilation • Patient with a tracheostomy • Neurologic impairment • Hearing aides • Use of touch • Picture boards / communication tools • Paper and pencil • Mouthing words/lip reading • Other Patient verbalizes understanding of Pre-Term Labor prevention practices including: • Bed rest in LL position • Signs & symptoms of PTL • Risk factors • Medications/Treatments (purpose, • Importance of fl uids as indicated dosage, schedule, precautions, and • Daily assessment of fetal movement side effects) • Fetal Monitoring • Avoidance of sexual activity/ • Follow-up Appointment Nipple stimulationVerbalizes understanding of associated medications and treatments for increased ICPVerbalize understanding of type, care and maintenance of any neurological monitoring equipment: • ICP monitoring • BIS monitoring • EVD • Other Verbalizes and demonstrates understanding of the need to report neurovascular dysfunction • Pain • Pulses • Pallor • Paresthesia • Paralysis

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSVerbalizes understanding of earliest symptoms of dysrefl exia and the actions that should occur. • Care of bladder • Care of bowel • Care of skinStrokeVerbalizes understanding of stroke management and typical progression in the hospital settingVerbalizes Warning signs of stroke Sudden numbness or weakness of face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known causeVerbalizes understanding of Personal Risk Factors for Stroke HTN, Cigarette smoking, Heart disease, Diabetes, TIA, High cholesterolVerbalizes understanding that stroke is an emergency and need to call 9-1-1 if stroke is suspectedVerbalizes understanding that f/u care is needed after dischargeProvided Patient Education Material � Stroke Care Notes � Self care measures after a stroke Care NoteViewed on demand TV topic: � StrokeCardiac Function/Tissue PerfusionVerbalizes understanding of cardiovascular care and management: • Telemetry monitoring • VTE prophylaxis • DVT care and management • Hemodynamic monitoring • Blood product administrationVerbalizes understanding of cardiac arrhythmia management

Verbalizes side effects of cardiac medications

Verbalizes understanding of signs and symptoms to report • Chest Pain, radiating pain • Shortness of breath • Mental status change • Diaphoresis • Skin color • Infant/child – acroyanosis or TET spellsVerbalizes understanding of assessment and management of the following Cardiac Conditions: • Cardiac-CAD • Cardiac Hypertension • CHF • Cardiac Surgery Pre & Post Op

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSViewed On Demand TV Topic: � “Heart Failure” � “Hypertension” � “Cardiovascular Nutrition”Provided Patient Education Material: � Heart Failure Guide to Hospital Care � Cardiology Discharge Instructions (Clin Path Site) � CABG Care Notes (Inpatient Care) � Valve Replacement Care NotesVerbalizes/Demonstrates understanding of purpose and care of A-V fi stula/Shunt

Respiratory Function

Verbalizes understanding of pulmonary care and management: • General respiratory monitoring • Mode of ventilation/oxygen delivery method • Extubation/weaning plan • Deep breathing/coughing • Incentive spirometryPatient verbalizes understanding of the need for invasive methods of ventilation and strategies to improve ventilation and oxygenationVerbalizes understanding of the role of the ventilator to decrease work of breathing and to facilitate rest for the patientVerbalizes understanding of the weaning plan and typical responses to weaning

Verbalizes understanding of strategies to reduce the risk of aspiration

Verbalizes understanding of strategies to promote a clear airway • Cough/ Splinting Incision if indicated • Positioning • Deep breathing • Suctioning • Incentive spirometry • Continuous lateral rotation therapy • Percussion • Pain managementVerbalizes an understanding of the infection prevention practices that assist in preventing lung infections while the patient is on the ventilator including: • Hand hygiene • Frequent oral care • Daily assessment by the healthcare team to evaluate if the ventilator can be removed.Patient Education Materials Provided � Ventilator Assisted Pneumonia FAQsElimination/ExchangeVerbalizes understanding of urinary/bowel tubes used to facilitate elimination • Foley catheter • Other urinary drainage device • fecal management systemVerbalizes assessment, purpose, plan for skin/incontinence

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSPatient verbalizes the understanding for the need for the device/indwelling foley catheter.

Patient verbalizes understanding how the presence of an indwelling foley catheter can increase the risk of urinary tract infection.Patient verbalizes understanding of infection prevention practices that help prevent urinary tract infection due to an indwelling foley catheter including: • Hand hygiene • Insertion Practices • Maintenance Practices • Daily assessment for device removal • Plan for removal when no longer neededProvided Patient Education Material: � “Catheter Associated-UTI FAQ”Verbalizes understanding of potential causes of and treatment for constipation or diarrhea in the acute care setting.Verbalizes understanding of the reason for an ostomy. Verbalizes type of ostomy. Patient and family demonstrate an ability to provide care for the ostomy including emptying of appliance, changing appliance, skin evaluation and diet & fl uid guidelines and can recognize signs of potential complications.

Type of ostomy: Fluid and Electrolyte

Verbalizes understanding of appropriate diet and fl uid intake, need for measuring accurate intake and output, and measures for optimizing fl uid volume statusVerbalizes understanding and method of hemodialysis/CRRT for the maintenance of fl uid, electrolyte and acid base balance.Verbalizes/Demonstrates understanding of purpose and care of A-V fi stula/Shunt

Verbalizes understanding of signs of bleeding and actions to take if bleeding is noted

Verbalizes understanding of need for blood transfusion Signs and symptoms of transfusion RXN Need for frequent vital signsPhysical Regulation

Verbalizes understanding signs and symptoms of fever and treatment for fever.Verbalizes understanding of temperature regulation methods: • Antipyretics • Cooling • Warming •

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSVerbalizes understanding of blood glucose monitoring and management. (Includes care of the Diabetic patient) • Calories ADA • No concentrated sweets • Sick day guide • Appropriate physical activity • Insulin regimen: • Withdrawal mixing • Injection/Administration • Timing • Peak hours • Site rotation • Storage • Oral hypoglycemic agentsVerbalizes signs and symptoms of hypoglycemia and hyperglycemiaVerbalizes understanding of alc values and desirable valueViewed On Demand TV Topic: � “Blood Sugar Testing” � “Diabetes Mellitus, Type I” � “Diabetes Mellitus, Type II” � “Insulin and Diabetes” � “Obesity and type II Diabetes” � “Kidney Care for People with Diabetes”Verbalizes treatment options and interventions for hepatitis

Verbalizes understanding of signs and symptoms indicative of further complications of liver impairmentFUNCTIONAL Nutrition Growth & Development Comfort Values/Beliefs Sleep/Rest Activity/Exercise Self careNutritionVerbalizes understanding of typical nutrition progression in the acute care setting � Breastfeeding � Bottlefeeding � Oral diet/TF/TPN for patient � NPO � Additional nutritional supplements � Therapeutic Diet restriction � Fluid Restriction � Role of dietician � Role of calorie count in nutrition plan � Room service Program and menu � Speech therapy/swallow evaluation

Patient LabelACUTE CARE TEACHING PLAN

88457 (Rev 2-19-10)

Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSVerbalizes understanding of rationale for food consistencies and choices associated with impaired swallowingVerbalizes Viewed On-Demand TV Topic: � “Exploring the New Food Pyramid” � “Cardiovascular Nutrition” � Provided Patient Education Material: � “Esophagectomy Diet” � “Nissen Fundoplication Diet” � Dietary Care Notes given � Nutrition Care manual � ComfortVerbalized understanding of possible nausea/vomitingVerbalizes understanding of use of antiemetics for nausea/vomiting and other treatments such as relaxation and imageryVerbalizes understanding of promotion of comfort/pain management in the hospital including routine assessment of pain and treatment options • Components of pain assessment, management, and evaluation • Pain scales to assess and monitor pain level • Identifi cation of pain reduction measures • Rationale for type and route of analgesia • Non-pharmacological interventions • Relaxation • Music • Deep breathing • Guided imagery • Heat/cold applicationVerbalizes understanding of sedation and/or paralytic agents used to promote rest and/or decrease metabolic rateSleep & RestVerbalizes understanding of typical sleep/rest pattern in the hospital • Hours designated for uninterrupted sleep • Adjustment of lights, noise, temperature to promote sleep • Rest periods during the day • Use of sleep aid medication • Nap scheduleSelf CareVerbalizes understanding of patient and family role in care activities. • Respiratory care• Feeding• Toileting• Bathing/hygiene activities• Active Range of Motion/Passive Range of Motion

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESS

Values Beliefs

Verbalizes understanding of Pastoral Services, Social Services, Child life.Other Growth and DevelopmentVerbalizes understanding of management of physiologic and neurobehavioral responses of the infant to inhance: attention-interaction, motor system, physiologic system, regulatory system, and sleep-wake systemVerbalizes realistic expectations of growth and development milestones. Expectations and misconceptions addressedActivity and exerciseVerbalizes understanding of typical activity progression during acute care hospitalization and verbalizes understanding of the personalized activity and mobility plan: • Head of bed position • Equipment used for mobility • C-Spine precautions • Role of Physical therapy and Occupational therapy • Progression to ambulation • Benefi ts of Out of Bed to Chair • Bed rotationVerbalizes understanding of ROM, exercises, repositioning, self-care activities, and using devicesVerbalizes understanding of use of oxygen during activity

Verbalizes type of specialty bed in used _____________(list type) and rationale for the use

Verbalizes understanding of type of cast/splint or other type of immobilization devices used and associated care and maintenance • Cast • Spica Cast Care • Splints • Other • CPM Machine Verbalizes understanding/Demonstrates proper use of crutches and/or other ambulatory devicesVerbalizes care and management of amputation site: • Elevation • Pain management • Rewrapping every 8 hours • Signs/symptoms of infection • Demonstrates proper stump wrapping techniqueVerbalizes understanding of care and management of a Total Knee Replacement (follow Total Knee Replacement Clin Path Inpatient Education)Verbalizes understanding of care and management of a Total Hip Replacement (follow Total Hip Replacement Clin Path Inpatient Education

Provided Patient Education Material: � “Hip Personal Recovery Plan” (Clin Path Site) � “Knee Personal Recovery Plan” (Clin Path Site)

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESS

Skin IntegrityVerbalizes understanding of relevant risk factors that contribute to the development of impaired skin integrity (mobility, moisture, nutrition, pressure), measures to reduce the risk, and ways to monitor for impending skin breakdownVerbalizes understanding of skin and wound care including symptoms of infection, complications and healing • Wound type and management • Type of pressure ulcer and management Verbalizes understanding of burn wound injury care and management.

Verbalizes importance of adequate nutrition for wound healing

Verbalizes and demonstrates understanding of the need to report neurovascular dysfunction • Pain • Pulses • Pallor • Paresthesia • ParalysisVerbalizes understanding of measures to regain or maintain intact oral mucous membranes

Verbalizes understanding of measures used for latex allergies

MedicationsVerbalizes understanding of the current medications (purpose, dose, schedule, implications) that the patient is receiving including the reason for use.Verbalizes and demonstrates understanding of proper use of self-medicationsPatient/Family verbalize an understanding of the following medications and any recent changes in medication regimen: • IV access/IV fl uids • Cardiac and vasoactive drips • Respiratory medications • Glucose management • Site Rotation • Peak Hours • Turning • Mixing Insulins • Storage • Diuretics • Stool Softener • Sleep aid • Anti-anxiety/Anti-Depressant • Antibiotics

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESS

Heparin • Patient has received and reviewed heparin education material with RN • Patient verbalizes understanding: • That heparin is a blood thinning medication • That heparin requires regular monitoring of blood test called aPTT • Of risks and signs of bleeding, and actions to take if bleeding is noted • That heparin may be transitioned to warfarin (if long-term anticoagulation is

necessary)Coumadin • Verbalizes understanding of need for continued monitoring and indicates he/she will

follow-up with primary care physician/Coumadin clinic • Verbalizes understanding of risks and signs of bleeding and actions to take if

bleeding is noted • Verbalizes understanding of how Coumadin may be affected by drugs,

including OTC, vitamins/dietary/herbal supplements, diet ( vitamin K) and alcohol

• Verbalizes understanding of how Coumadin may be affected by certain medical conditions and activity levels

Lovenox • Verbalizes understanding of risks and signs of bleeding and actions to take if

bleeding is noted • Verbalizes understanding of how and where to inject Medication • Verbalizes understanding of how to store and dispose of SyringesCardiac Medications and side effects • • • • The following Care Notes given: • • • • • Provided Patient Education Material: � “Your Medicine: Play it Safe” � �

Viewed on Demand TV Topic: � Insulin and Diabetes � Verbalizes understanding of Chemotherapy regimen (medication purpose, possible reactions, side effects, and need to prevent and report infection).

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESS

Operative Procedure (pre & post operative care)Verbalizes understanding any scheduled operative procedures, including preoperative and post operative care procedures

• Procedures: • • • •

Education to patient/family member occurs prior to surgery/procedure or as soon thereafter as possible.Patient verbalizes understanding of the infection prevention practices to prevent surgical site infections including: • Hand hygiene: • showering or bathing with an antiseptic soap (CHG) • Using clippers to remove hair if needed; do not use a razor • Avoid using a razor for hair removal • Administration of prophylactic antibiotic Patient verbalizes understanding of the signs and symptoms of a surgical site infection.Provided Patient Education Material: � “Surgical Site Infection Prevention”

Verbalizes understanding of care and management related to Renal Transplant

PSYCHOSOCIAL Health Promotion Self-Perception Role/Relationship Coping/Stress Tolerance Emotional Values/BeliefsVerbalizes patient and family role in the decision making process and treatment plan • Agrees to treatment plan and agrees to participates in the following: • • • • Verbalizes understanding of the role of family spokes person and ways to promote family support mechanisms for the acutely ill patientVerbalizes understanding of available resources in the acute care setting

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSVerbalizes understanding of potential sources for anxiety and identifi es methods for anxiety reduction and potential coping methodsVerbalizes understanding of physical changes caused by illness or surgery and typical changes in body image, feelings related to hospitalization, injury, or change in health statusVerbalizes knowledge of own strengths and the use of those strengths in coping during acute illness • Identifi ed strengths: • • • Verbalizes how keeping a diary/journal can help patients see their progress

Verbalizes understanding of how talking about fears, concerns & how disease process/hospitalization has impacted their life can help with mental healing.

Viewed on Demand TV Topic: � “Depression”Verbalizes available resources for promotion of psychosocial needs (i.e. Pastoral Services, Social Services, Child Life, Community Resources)Verbalizes understanding of “End of Life Care”

DISCHARGE CARE

Verbalizes understanding of expected length of stay and plan of careVerbalizes understanding of discharge plan

Verbalizes/demonstrates the ability to care for new devices that the patient will be discharged with. Demonstrates ability to use discharge supplies

(list devices)

Verbalizes self care practice in the home environment to reduce the risk of infection

Patient verbalizes an understanding of recommended self-care practices/precautions used at home to prevent the spread of germs for the following MDRO:

• MRSA (written instructions/handout MUST be given before discharge) • VRE • Resistant Acinetobacter baumannii • Resistant Pseudomonas auerginosa • C diffi cile • Other

� Hand out given

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSVerbalizes understanding of self care practices for incision site care or other wound care

Verbalizes understanding of Home Central IV Therapy or Home Peripheral IV Therapy

Verbalizes the signs and symptoms that would prompt a call to the physician

Verbalized understanding of discharge medications. • Reconciled list of medications provided and explained to patient and/or familyVerbalizes understanding of need for lifestyle changes: • Smoking cessation • Care Notes given • Dietary changes • Weight loss • Exercise program (discuss with physician) • Management of diabetes • Compliance with medication regimen

Provided Patient Education material • Cardiology Discharge EducationVerbalizes understanding of available community resources and/or follow-up resources: • PT • OT • Social Services • Free health Education Classes • UCI Website www.ucihealth.com • Toll Free Number (877)UCI-Docs or (877)-824-3627

� Health Education Booklet GivenPostpartum Discharge Care Materials to include: � Postpartum Plan of Care Nursing diagnosis � Congratulations on New Baby booklet � Micromedic Medication instructions sheets � Postpaertum depression education material w/Edinburgh Scale � Prescriptions from MDPostpartum Discharge Care Materials for C/S patients to also include: � Wound Care SheetNewborn CareMother verbalizes understand of Newborn care practices to include: • Cord care • Hyperbilirubinemia • Circumcision care • Carseat • Feeding: Breast vs. Formula • Elimination: void/stool • Follow-up Appointment • Back to sleep

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Date Initial & ✓

When Achieved

InitialsLearner

TEACHING OBJECTIVES OUTCOMES AND READINESSNewborn Discharge Care to include � Cord care � Prescription from MD � Circumcision care � Micromedics Medication instruction sheets � Feeding: Breast vs. Formula � Hyperbilirubinemia � Follow-up Appointment � Elimination: void/stoolLaboring PatientsPatient verbalizes understanding of plan of care during labor to include: • Labor process • Relaxation/distraction techniques • Procedures during fetal distress • LL position • O2 via mask • Increase IV fl uids • Lower head of bed • Trendelenburg as needed • Amnioinfusion • Stages of labor • Induction/Augmentation process • Pain medication options for labor • LL tilt • Frequent position changes • Need for C/S

Date Time Signature Initials Date Time Signature Initials