Running Head: HEALTH PROMOTION PROJECT 1

Older Adult Health Promotion Project

Deborah Hasenfus

Professor Tamara Krukiel

Bon Secours Memorial College of Nursing

NUR4113

Gerontological Concepts

April 9, 2018

“I have neither given nor received aid, other than acknowledged, on this assignment, nor have I

seen anyone else do so.”

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Older Adult Health Promotion Project

Theresa is a 93-year-old widow who lives with her adult daughter and son-in-law.

Physically, she is in good health, with only mild hypertension, hypercholesteremia and arthritis.

Although she lives with her adult children, she is mostly independent in her Activities of Daily

Living (ADLs), only needing help with bathing. She suffers from an anxiety disorder but it is

well controlled with medication. There are no indications of depression. She has no indications

of mental decline or cognitive impairment, performing well on the Folstein Mini-Mental State

Exam. Using the Fulmer SPICES tool, it was determined that Theresa may have issues with

sleep disorders, requiring a follow-up with the Pittsburgh Sleep Quality Index (PSQI). Theresa

has trouble falling and staying asleep, and wakes often during the night. She wakes late in the

morning, sometimes at noon, and takes naps lasting several hours during the day. Theresa

determined that she would like to learn more about healthy sleep and sleep hygiene. Sleep health

is one of the overall topics of Healthy People 2020, with a goal of educating the public on the

importance of sleep and its effects on other aspects of health (Sleep Health, n.d.). One of the

objectives is to “increase the proportion of adults who get sufficient sleep” (Healthy People

citation). Together with her student nurse, Theresa set out to learn more about how to improve

her own sleep.

Nursing Diagnosis

The student nurse developed a nursing diagnosis for Theresa of Insomnia, related to pain,

inadequate physical and mental stimulation, and caffeine intake, as evidenced by Theresa’s

reports of difficulty with falling and staying asleep and a displayed lack of energy during the

daytime (Gulanick & Myers, 2014, p. 109). This diagnosis was important to Theresa, as she and

her family had been distressed by her poor sleep quality. Theresa complained that she never had
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energy to sustain activities or for interactions with friends and family, and her daughter

expressed concern at Theresa’s long hours spent in bed. Both parties wanted Theresa to get better

sleep that left her feeling well rested. Mutually, the student nurse, Theresa and Theresa’s

daughter set a short-term outcome that Theresa would receive adequate sleep over a one-week

period, as evidenced by Theresa’s own reports of feeling rested and an improvement in sleep

patterns, recorded in a daily sleep journal. In the long-term, it was determined that an ideal

outcome would be for Theresa to maintain improved sleep hygiene throughout the month of

March, as evidenced by greater energy levels reported by Theresa and her daughter, and less

frequent reports of sleep difficulties.

Teaching Plan

During the initial assessment visit, the student nurse and Theresa determined that healthy

sleep would be the focus of the teaching plan during future sessions. Before returning, the

student nurse researched nursing diagnoses and scholarly articles about sleep and sleep hygiene

in older adults. These findings were presented to Theresa and her daughter during the subsequent

visit several days later. One review focusing on non-pharmacological interventions for sleep

issues in the elderly reported that there were growing bodies of evidence to support the benefits

of mindfulness training and cognitive-behavioral training (CBT) to restore healthy sleep patterns

in older adults (Macleod, Musich, Kraemer & Wicker, 2018, p. 5). Another study reported that

“interventions involving activities that de-stress mind and body significantly improve sleep

quality in adults without clinical sleep disorders” (Murawski, Wade, Plotnikoff, Lubans &

Duncan, 2017, p. 8). After reviewing these studies with Theresa and her daughter, it was

mutually determined that a CBT approach was most appropriate for Theresa, as she was not

interested in mindfulness or de-stressing activities. The main CBT method Theresa would use is
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sleep hygiene training, which “teaches healthy lifestyle strategies” (Macleod et al, 2018, p. 5)

that are designed to improve sleep quality.

The teaching plan was also carried out during this visit. Theresa, her daughter and the

student nurse discussed methods for improving Theresa’s sleep. At Theresa’s preference, and

because she is an important form of social support, her daughter was present to help reinforce

concepts and ask questions, and to help Theresa remember what was taught. First and foremost,

the group discussed the importance of developing a sleep schedule. This included setting a

bedtime and waking time, and limiting naps during the day. The student nurse taught the

importance of only sleeping in bed and avoiding watching any screens before sleeping. She also

reviewed sleeping positions that could alleviate back pain to prevent pain from waking Theresa

during the night. To address trouble falling asleep, the student nurse discussed limiting caffeine

intake. Theresa was very surprised to learn that coffee acts as a stimulant and seemed resistant to

the idea of limiting her coffee consumption, so the student nurse discussed switching to

decaffeinated coffee with her daughter. This teaching session took about thirty minutes of

discussion, and the student nurse allowed ample time for questions due to occasional

forgetfulness on Theresa’s part. With her daughter’s help, Theresa was able to teach-back by the

end of the session.

During this visit, the student nurse and Theresa perused the internet to find some

teaching tools Theresa could use to reinforce her learning, as Theresa is mainly a visual learner.

A “Sleep Hygiene” checklist was printed for Theresa to be able to review and refer to as

necessary. It was determined that the most appropriate place for this checklist would be at her

bedside so she could regularly review it. During this time, the pair also printed a “Sleep Diary”

so that Theresa could keep track of her sleeping habits, from the times she went to bed during the
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week to how often she napped. This would allow Theresa to see which of her habits were healthy

and keep track of improvements in her sleeping patterns. This was also kept at Theresa’s

bedside. Both aids were simple and easy to understand, and appropriate to Theresa’s high school

education.

Theresa did not fully realize her short-term outcome of adequate sleep over a week’s

period. This was measured through her own reports of feeling rested and an improvement in her

sleep patterns. Although Theresa reported feeling well-rested each day, her sleep diary indicated

that she was still waking frequently at night, and napping during the day over the weeklong

period. Her daughter still expressed concern that she was not sleeping well. To help Theresa

achieve her long-term outcome/goal of improved sleep hygiene, the student nurse reinforced the

teaching at a third visit. She recommended that Theresa continue her sleep journal so that she

could better understand which habits were associated with her feeling better rested. She also

recommended that her daughter help Theresa maintain the sleep journal so that she was fully

involved in helping to improve Theresa’s sleep.

Evaluation

The outcomes of Theresa’s teaching plan were related to tertiary prevention. She had

already developed issues with and disturbances in her sleep pattern, and needed the student

nurse’s help in addressing these problems to limit the effect they are having on her life and

overall health. In a different patient, the interventions used with Theresa could be used as

primary prevention to avoid developing sleep disturbances. Theresa had no problem grasping the

content of the teaching, but she may not have been emotionally or psychologically ready to fully

implement the interventions taught. She was particularly hesitant about reducing her caffeine

consumption, as she disbelievingly stated “Coffee makes you stay awake? No…” This hesitance
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may have been part of the reason why the outcomes were only partially met. At the follow-up to

teaching, she may have been telling the student nurse that she felt well-rested in order to

maintain a socially acceptable stance, as she understood the implication of what she should be

doing versus what she actually was doing, and her sleep diary indicated poor sleep.

In a similar scenario, to improve the outcomes associated with this teaching plan, the

student-nurse (or future student nurses) could allow for more teaching time. When a patient is

hesitant about particular parts of a teaching plan, it could indicate that they are not yet ready to

implement this plan, and thus will not be compliant. More frequent follow-ups, perhaps on a

weekly basis until the patient sees a physical difference in how they feel, could improve

compliance. It is also possible that Theresa did not fully understand why some of the teaching

plan was being implemented, and this may have affected her compliance. In a future scenario, it

may be helpful for the student nurse to allow the patient to ask questions in a less formal manner,

as they occur to her, or to ask questions of someone she considers more intimate, such as her

daughter. This proxy person could then relay questions to the student-nurse to allow for

improved communication, higher compliance and better outcomes.

The Role of the Nurse-Teacher

Overall, this was a very valuable experience for me as a student nurse. It allowed me a

glimpse of the process of geriatric nursing, as well as the process of home nursing. As I normally

operate in a hospital setting, it was interesting to see how this slower environment and multiple

visits allowed for a closer understanding of the patient’s health issues. This project was slightly

complicated by the fact that the patient is my grandmother, and thus the relationship is slightly

different from the professional nurse-patient relationship. It could also have affected how

successful the teaching plan was. This served to highlight the importance of this professional
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relationship in successful outcomes for the patient. I enjoyed this project and all that I learned

from it. I feel more confident in my assessment abilities and ability to develop and implement a

teaching plan.
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References

Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, & outcomes.

St. Louis, MO: Elsevier.

Macleod, S., Musich, S., Kraemer, S., & Wicker, E. (2018). Practical non-pharmacological

intervention approaches for sleep problems among older adults. Geriatric Nursing.

doi:10.1016/j.gerinurse.2018.02.002

Murawski, B., Wade, L., Plotnikoff, R. C., Lubans, D. R., & Duncan, M. J. (2017). A systematic

review and meta-analysis of cognitive and behavioral interventions to improve sleep

health in adults without sleep disorders. Sleep Medicine Reviews.

doi:10.1016/j.smrv.2017.12.003

Sleep Health. (n.d.). Retrieved April 09, 2018, from https://www.healthypeople.gov/2020/topics-

objectives/topic/sleep-health