NR 557 Week 7 Patient Teaching and Follow-Up Plan Example

Teaching and Follow-Up Plan: After a Night in Hospital for Right Lower Lobe Pneumonia, What the Patient and Daughter Can Say Back, What They Can Watch for Without Equipment, and When the Nurse Comes Next

Student Name

College of Nursing, Chamberlain University

NR 557: Health Assessment for Professional Nursing Practice

Instructor Name

Month Day, Year

Teaching and Follow-Up Plan: After a Night in Hospital for Right Lower Lobe Pneumonia, What the Patient and Daughter Can Say Back, What They Can Watch for Without Equipment, and When the Nurse Comes Next

Where Things Stand

The patient, 78 years old and living with COPD and heart failure, was seen in the emergency department on the day of my home visit. A chest radiograph confirmed right lower lobe pneumonia. The patient received oxygen, intravenous fluids and a first dose of antibiotics, was observed overnight after a severity assessment based on confusion, urea, respiratory rate, blood pressure and age (Lim et al., 2003), and was discharged home the next afternoon on oral antibiotics for five more days, a short course of oral steroids for the COPD component and a plan for a home health visit within 48 hours. By discharge, the patient was oriented, oxygen saturation was 92% on room air at rest and the respiratory rate was recorded as 20. I visited the following morning. This plan sets out what was taught at that visit and how follow-up will work.

What Was Found, Said So It Can Be Said Back

The first part of the teaching was the finding itself, in two sentences the patient and daughter could repeat: "You have pneumonia, an infection in the bottom of your right lung. It made your breathing fast, your oxygen low and your thinking muddled, and the antibiotics should make it better over the next week."

I asked the patient to explain, in their own phrasing, what was wrong and why the antibiotics mattered. The patient said, "It's an infection at the bottom of my lung, and I have to finish all the tablets even if I feel better." The daughter added, "And the confusion was from the infection, not dementia." Asking people to say information back in their own words, and correcting it until they can, has been associated with better outcomes for patients with limited health literacy (Schillinger et al., 2003). Instructions with no finding behind them tend to be followed for about a week and then dropped; a finding the family can repeat gives the instructions a reason.

Medicines, With the Reason for Each

Antibiotic tablets: twice a day for five more days, with food, until all are gone. Reason: to clear the lung infection. Steroid tablets: once a day in the morning for four more days. Reason: to calm the airways. Usual inhalers and heart medicines: unchanged. Rescue inhaler: as before, up to four times a day; needing it more often than that is a reason to call. The daughter set up a written chart on the refrigerator with a box to tick for each dose.

Return Triggers the Family Can Observe

Each reason to come back is written as something the patient or daughter can see, feel or count without equipment. The patient does have a pulse oximeter from a previous admission, but it is sometimes misplaced and its readings depend on warm fingers, so the triggers do not depend on it.

Call 911 now: lips or fingertips turning blue or gray; too breathless to say more than two or three words; cannot be woken properly or does not know where they are; chest pain.

Call the nurse or the practice today: breathing faster than at rest this morning, which the daughter will check by counting the patient's breaths for one minute while the patient watches television, and calling if the count is above 24; confusion returning, such as not knowing the day; fever returning after it has gone; unable to keep the antibiotic tablets down; weight rising over a kilogram overnight or two kilograms across the week, because of the heart failure.

Mention at the next visit: cough still producing colored sputum after the antibiotics finish; tiredness that is not improving after a week.

I taught the daughter to count breaths by watching the patient's chest rise for a full minute, and she counted 20 while I counted with her. That skill makes the most important trigger usable at home.

Tonight Against This Week

The triggers are ordered by speed of response: some mean call for help tonight, others mean call during the day, and others can wait for a visit. That order was explained directly: "The top ones mean don't wait until morning." Grouping them this way avoids two errors: calling an ambulance for a cough that is slow to clear, and waiting until the morning with a respiratory rate of 30 and new confusion. Respiratory rate is a sensitive early sign of deterioration (Cretikos et al., 2008), which is why it sits among the same-day triggers.

Follow-Up

Home health visits: tomorrow, then in three days, then weekly for two weeks, each with a counted respiratory rate, saturation seated and again after walking across the room, temperature, lung examination comparing both bases, weight and a brief mental status check. Phone check: the day after the antibiotics finish. Primary care appointment: within seven days of discharge, booked before I left, with transport arranged by the daughter. Pneumococcal vaccination: status to be checked at the primary care visit, since it was unclear. Chest radiograph: follow-up imaging decision to be made at primary care.

Barriers to the Plan

Three barriers could weaken the plan. The patient lives alone, and the daughter cannot stay every night, so the most important triggers must be ones the patient can notice too, such as being too breathless to talk or feeling muddled. The steroid tablets may raise blood sugar and cause poor sleep, which could be mistaken for worsening illness; I told the family to expect some restlessness. And the patient's reluctance to return to the emergency department could delay a call. We agreed that the patient would call the home health agency first for anything in the same-day group, so that a nurse could help decide, rather than weighing a hospital visit alone.

Checking That the Plan Held

At the next visit, I will ask the patient and daughter to repeat the finding, the reason for the antibiotics and the three most important triggers. If either cannot, the teaching will be repeated in a different way, for example with a written card listing the triggers in large print. The goal is not that the family remembers everything, but that they know when to call.

References

Cretikos, M. A., Bellomo, R., Hillman, K., Chen, J., Finfer, S., & Flabouris, A. (2008). Respiratory rate: The neglected vital sign. Medical Journal of Australia, 188(11), 657-659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x

Lim, W. S., van der Eerden, M. M., Laing, R., Boersma, W. G., Karalus, N., Town, G. I., Lewis, S. A., & Macfarlane, J. T. (2003). Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax, 58(5), 377-382. https://doi.org/10.1136/thorax.58.5.377

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., & Bindman, A. B. (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90. https://doi.org/10.1001/archinte.163.1.83