1. 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.

2. • 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

3. 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…)

4. 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

5. 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

6. 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

7. MEASURE/INDICATOR
Veterans 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

8. 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:

9. 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.

10. 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.

11. 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).

12. 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.

13. PAIN ASSESSMENT AND FOLLOW-UP

14. 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.

15. 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.

16. HEALTH EFFECTS OF SMOKING OR USING
TOBACCO PRODUCTS
How 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.

17. SMOKING AND THE FINANCIAL IMPACT
Those 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.

18. 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.

19. 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 information
smokefree.gov/talk-to-an-expert
National Cancer Institute Smoking Quitline: 877-44U-QUIT (877-448-7848)

20. DEPRESSION
Everyone 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.

21. 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

22. 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.

23. 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

24. 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).

25. 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.

26. HIGH BLOOD PRESSURE RISK
FACTORS
 Risk Factors You Can’t Control
Family History
One or both of your parents or
grandparents has had high
blood pressure or heart disease.
Gender and Age
You’re a man over age 55 or a
postmenopausal woman.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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

32. 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.

33. PATIENT EDUCATION
 VAPHS Internet Page : http://www.pittsburgh.va.gov/
 Patients & Visitors
 Patient Information
 Health Education
• Veterans Health Library:
www.veteranshealthlibrary.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

34. INFORMATION COMPILED BY:
TANISHA R. DAVIS, BSN, RN, CCRN
UNIVERSITY OF PITTSBURGH
MSN-CNL
IN COLLABORATION WITH:
MYRA COUCH, MANAGER RAINBOW CLINIC
MELISSA TAYLOR, ASSOCIATE CHIEF OF NURSING RESEARCH, VA
RAINBOW CLINIC STAFF
ROSE HOFFMAN, CNL PROGRAM COORDINATOR, UNIVERSITY OF PITTSBURGH